Bile Leak

A bile leak is abnormal escape of bile from the biliary system after hepatobiliary surgery, trauma or spontaneous bile duct disruption.

After cholecystectomy, common sources are:

• Cystic duct stump
• Duct of Luschka or gallbladder bed
• Partial common hepatic or common bile duct injury
• Complete major bile duct transection

The distinction between a minor leak with preserved duct continuity and a major transection is critical because ERCP can treat most minor leaks but cannot reconstruct complete loss of biliary continuity.

Presentation after surgery includes:

• Persistent bilious drain output
• Right upper quadrant or diffuse abdominal pain
• Fever
• Abdominal distension
• Failure to recover normally
• Bile peritonitis
• Sepsis

A patient without a drain may initially present only with tachycardia, pain and fever from an accumulating biloma.

CT abdomen: identify intra abdominal bile collections requiring drainage.

MRCP: define biliary anatomy when the type of injury is uncertain.

ERCP both demonstrates a leak with preserved distal continuity and allows definitive endoscopic treatment.

First control free intra abdominal bile.

Drain a significant biloma or infected collection percutaneously.

Treat sepsis where present.

A practical regimen for infected postoperative biliary collections is:

Piperacillin tazobactam 4.5 g IV every 8 hours by extended infusion, adjusted for renal function.

Minor bile leak

Cystic duct stump and accessory duct leaks usually respond to ERCP with transpapillary plastic stenting, with or without sphincterotomy. The treatment lowers intrabiliary pressure and preferentially directs bile into the duodenum.

A common approach is a 7 Fr to 10 Fr plastic biliary stent.

Stents are usually removed after approximately 4 to 6 weeks once the leak has healed.

High grade or refractory leaks may require multiple plastic stents or a temporary fully covered self expanding metal stent.

Major bile duct injury

A completely transected or ligated major bile duct with loss of ductal continuity will not be corrected by routine ERCP.

Drain contamination, define the anatomy and refer early to an experienced hepatobiliary reconstruction team.

Definitive repair is usually Roux en Y hepaticojejunostomy.

Do not perform repeated blind repair attempts at the original operation or in a low volume setting when complex hilar anatomy is unclear. Poor initial repair can convert a reconstructable injury into a difficult high biliary stricture.