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Bile Leak
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Related narrative: Bile Leak Significant bile leak (see bile leak) occurs in 1-2% of patients after laparoscopic cholecystectomy (see laparoscopic cholecystectomy and laparoscopic cholecystectomy (video)). Failure to recover promptly after surgery is the typical presentation, and the patient usually manifests right upper quadrant pain, anorexia and/or nausea within a day or two of surgery. The majority (50-75%) of leaks are through the cystic duct. The remainder are divided between the gallbladder bed (ducts of Luschka or injury to an aberrant bile duct lying superficially beneath the gallbladder bed in about 25% of individuals) and major bile duct injury. Cystic duct leak may be precipitated by a retained common duct stone (see common duct stones) that causes common duct obstruction. The increased intrabiliary pressure causes the clips on the cystic duct to blow off. Intraoperative cholangiogram (see cystic duct cholangiogram) is indicated in patients with abnormal liver functions, a history of jaundice, or pancreatitis to identify retained stones. The patient can then undergo post-operative ERCP (see retained common duct stone) for sphincterotomy and duct clearance to prevent complications. In the case of small stones (< 4 mm) observation may be a reasonable option, since most of such stones will pass spontaneously, and the (7%) morbidity of ERCP can be avoided, especially in a high-risk patient. Bile duct injury, while still rare, occurs 4x more commonly after laparoscopic cholecystectomy than after open cholecystectomy. This is postulated to be due to inexperience, failure to open when the landmarks are unclear or there is severe inflammation, or the 24% of biliary ductal/vascular anomalies (see biliary variation). Performance of routine cholangiography has not been shown to prevent bile duct injury since most injuries occur in the dissection prior to performance of cholangiogram. Preliminary diagnostic screening with ultrasound can detect a significant-size biloma. CT scan is also commonly used to make the diagnosis and then to guide percutaneous drainage. Dynamic radionuclide scan (HIDA, see biliary imaging discussion) gives the additional information of whether the leak is active and ongoing. ERCP gives the most definitive information of the status of the biliary system and allows visualization of retained common duct stones. It also allows therapeutic intervention in the form of sphincterotomy, clearance of stones and stenting to prevent build-up of biliary pressure, so the leak can heal. The disadvantage of ERCP is the 7% morbidity and 0.2-1% associated mortality. The great majority of bile leaks (from other than major duct injuries) resolve with such treatment. Major duct injuries most commonly are not recognized at the time of surgery. Only very favorable circumstances mitigate for primary repair of such injuries (sharp injury without crush, partial injury). Primary repair over a T-tube may be attempted, but there is a 40-50% failure rate. Choledochoduodenostomy should be avoided because of the high incidence of stricture. The preferred treatment is Roux-Y choledochojejunostomy. References: Townsend: Sabiston textbook of surgery, 16th ed, 2001, 219, 220. Leaks from laparoscopic cholecystectomy. De Palma GD - Hepatogastroenterology - 01-JUL-2002; 49(46): 924-5 Wind, G Applied laparoscopic anatomy, Williams & Wilkins, Baltimore, 1997, pp. 66-80.
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