A 35 year old underwent radical cholecystectomy for large Ca Gallbladder with resection of seg 5 and 4A. HP resection margins and periductal and perivascular tissues negative for tumour. Noticed bile leak on 3rd POD.6th POD it is 200mls. Presently he has no systemic complaints. Subhepatic tube drain is functioning well.
keep draining, use antibiotics to prevent infection, and wait until automatic stop of bile leakage, just for your reference.
After hepatectomy is possible leakage of bile from the resection surface. In the postoperative period, it is necessary antibiotics and prolonged control subhepatic tube drain. There is always the possibility of bad drainage features, its clogging and require "supervision" of the abdominal drain. If there is a smooth passage of bile through the papilla of Vater, after the introduction of oral feeding, and leak from resection surface of the liver will gradually stop. Period of stoped of leakage is individual.
I agree with Charalampos that ERCP & stent helps minimize the back pressure on the biliary tree should the leak be ongoing.
200 ml/24h indicates that there is no distal bile duct obstruction. We do not perform ERCP in such cases. If there is no biloma formation on US/CT there is no need for further interventions. The leak of this magnitude always stop spontaneously. We usually discharged patient with the drain in place. After second postop. week if there is still some leak we repositioned the drain withdrawing 4-5cm every 6-7 days in order to permit healing of the formed fistula tract.
Thanks Alex,I fully agree with you As this pt is an out stationed , ERCP and stenting was done.From 200ml the drain output dropped to 90 mls in 48 hours time.
I agree there is no need to do sphincterotomy if the papilla works well. It is there to avoid duodenal content entering the bile duct. Pressure in the duodenum is high during contraction. And if the patient is treated with gastric acid inhibitors, there can be more bacterial growth.
I always use suction drains, at least until 5-7 days when there is formation of a fibrous tract around the tube, and no collections. I do not use antibiotics unless there are signs of infection.
I also agree for no absolute need of sphincterotomy in the absence of pathology of papilla or when the bile leak is under 150 ml per day. Soft drains left in place (without active suction) for 6-7 days or more and slowly retracted every 3-4 days for 2 cm can be helpful since they work as a foreign bodies and can be helpful for the healing process of the fistula tract. If the drains were remouved and small biloma is present (less than 5 cm) and in the absence of infections we observe without further interventional procedures. With large biloma or infected biloma we always drain the collection by interventional radiology techniques and we performe ERCP sphincterotomy. During adult to adult split liver transplantation bile leak from the cut surface of the liver graft is an ongoing problem: it usually resolves spontaneously by leaving open the T tube (inserted during the bile duct reconstruction). This finding supports the fact that, in the absence of important bile duct injury, the time of healing and and the amount of bile leak is also directly proportional to the intrahepatic biliary pressure.
ERCP is an helpful intervention but may have some complications. If your patient has no sign of infection or peritoneal irritation and your subhepatic drain is functioning well, observation without any intervention is another option. If anything develops in terms of infection, ERCP is the best way...
When the leak does not stop spontaneously, I do first a fistulography, and/or a cholangio-MRI to confirm that there is communication with the main bile duct, to perform a papillotomy. If the leak comes from a periferal duct, so not connected with the main duct, there is no reason for an ERCP.
Thankyou Dr Ignacio,ERCP stenting/papillatomy does redce intra biliary pressure and blle ieaks from the periphery also settles faster.
I guess ERCP decreases overall pressure in biliary tree. It may shorten time to leak stop. But closure can take place without it.
I believe periferal leaks not connected with main duct do not improve with ERCP.
Risk of cholangitis increase with ERCP, mostly in patients with collections and post-ischemic stenosis.
So I just propose thorough evaluation of the biliary tree anatomy and physiopathology to design treatment.