An Algorithm for the Management of Bile Leak Following Laparoscopic Cholecystectomy

Abstract

INTRODUCTION The management of bile leaks following laparoscopic cholecystectomy has evolved with increased experience of ERCP and laparoscopy. The purpose of this study was to determine the impact of a minimally invasive management protocol.PATIENTS AND METHODS Twenty-four patients with a bile leak following laparoscopic cholecystectomy were recorded consecutively between 1993 and 2003 . Between 1993-1998, 10 patients were managed on a case-by-case basis. Between 1998-2003, 14 patients were managed according to a minimally invasive protocol utilising ERC/biliary stenting and relaparoscopy if indicated.RESULTS Bile leaks presented as bile in a drain left in situ post laparoscopic cholecystectomy (8/10 versus 10/14) or biliary peritonitis (2/10 versus 4/14). Prior to 1998, neither ERC nor laparoscopy were utilised routinely. During this period, 4/10 patients recovered with conservative management and 6/10 (60%) underwent laparotomy. There was one postoperative death and median hospital stay post laparoscopic cholecystectomy was 10 days (range, 5-30 days). In the protocol era, ERC ±s tenting was performed in 11/14 ( P = 0.01 versus pre-protocol) with the main indication being a persistent bile leak. Relaparoscopy was necessary in 5/14 ( P = 0.05 versus preprotocol). No laparotomies were performed ( P < 0.01 versus pre-protocol) and there were no postoperative deaths. Median hospital stay was 11 days (range, 5-55 days).CONCLUSIONS The introduction of a minimally invasive protocol utilising ERC and re-laparoscopy offers an effective modern algorithm for the management of bile leaks after laparoscopic cholecystectomy.

A non-randomized study in consecutive patients with postcholecystectomy refractory biliary leaks who were managed endoscopically with the use of multiple plastic stents or fully covered self-expandable metal stents (with videos)

“…1,2,8 A variety of ERCP techniques have been used, including biliary stenting, nasobiliary drainage, biliary sphincterotomy, or a combination of these procedures.…”

“…1 ERCP has emerged as a minimally invasive method for the primary treatment for bile leaks. [2][3][4][5][6][7][8][9][10][11] The outcome of sealing the leak can be accomplished by a variety of endoscopic techniques.…”

Jackson Pratt drain fluid-to-serum bilirubin concentration ratio for the diagnosis of bile leaks

“…To further assess patients with a high drain output (O200 mL/day), ERCP or a HIDA scan may be performed. 2 However, JP drain fluid volume may be confounded by ascites from portal hypertension or other causes. A persistent or abruptly increasing JP output may also indicate an ongoing leak.…”

“…1,2 Technetium 99 m-HIDA scintigraphy (HIDA) has a high accuracy for predicting the presence of bile leaks and is often used as a noninvasive guide to determine those in need of endoscopic management. 3 However, it may be difficult to mobilize trauma patients for the transport to the nuclear medicine department, and an occasional unstable patient has difficulty lying flat for the approximate 1 hour required for the study.…”

Management of bile duct injury after laparoscopic cholecystectomy*

“…Since the 1990s, the increase in iatrogenic bile duct injuries has followed the increase in laparoscopic cholecystectomies (LCHE) and is reported as 0.3 to 2.7% [1]. Compared with the early days of LCHE, the learning curve today must be seen as historical and, when an experienced surgeon is available, it can be shorter and involve fewer risks.…”