An Elderly Man with a Postcholecystectomy Bile Leak

• Moderator's Introduction
• The Case
• Moderator's Questions
• Guest Discussant's Reply
• Moderator's Comments
• References

Moderator's Introduction

I am pleased to introduce Dr Thierry Ponchon, MD, from Lyon, France, as our guest discussant. Dr Ponchon is a world expert in hepatobiliary and pancreatic disorders.

The Case

A 74-year-old man was referred to Duke University Medical Center 7 days after reportedly uncomplicated laparoscopic cholecystectomy. At 3 days after surgery he returned to the hospital where his operation had been performed, complaining of abdominal pain, fever, and extreme lassitude. His examination was significant for a temperature of 38.5 °C, tachycardia, and abdominal tenderness, especially in the right subcostal and epigastric regions. His blood tests showed several abnormalities, with a white blood cell count (WBC) of 15 300/mm³ and serum transaminases elevated to approximately twice normal levels. The alkaline phosphatase was normal but the serum bilirubin was elevated to 2.3 mg/dl (this is 2.3 times the upper limit of normal; the conversion for SI units is approximately ×17).

A complication of surgery was suspected; endoscopic retrograde cholangiopancreatography (ERCP) was requested, and carried out within 24 hours of hospital admission. The gastroenterologist was unsure of his findings on cholangiography, but suspected a leak arising from the right intrahepatic ductal system. He elected to place a 7-Fr straight biliary endoprosthesis with its tip advanced into the right main intrahepatic duct. The patient was given a broad-spectrum antibiotic and observed. Unfortunately, he continued to be febrile, with a maximum temperature of 39.9 °C, and had a rising WBC. On day 7 of his hospitalization he was transferred to our referral center for further management. On admission he was an unwell-looking elderly white male with tachycardia, tachypnea, hypotension (80/50 mmHg), fever (38.4 °C), and confusion. His abdomen was symmetrically distended and diffusely tender on palpation. Several procedures were performed. At the time of repeat ERCP, the 7-Fr biliary stent was found to have migrated distally; most of the stent was hanging out of the papilla into the duodenum. The stent was removed and cholangiography was performed (Figure [1]). We interpreted the cholangiogram as showing a leak arising from the cystic duct stump, and not from the intrahepatic system. There was no apparent injury to the intrahepatic or extrahepatic ducts. We elected to place a 6-Fr nasobiliary drain (Figure [2]), which was put on continuous low wall suction. The procedure was covered by broad-spectrum antibiotics, which were continued, with minor adjustment, to deal with Klebsiella species that were isolated from blood cultures at the referring hospital. Unfortunately, the output from the abdominal drain, which we had placed to manage a bile collection, remained unchanged for 4 days.

Moderator's Questions

Dr Ponchon, could you please give us your overview of this case and management suggestions?

Guest Discussant's Reply

It is my impression from the history, and studying Figure [1], that the patient had a bile leak from the cystic duct stump following laparoscopic cholecystectomy.

To comment on Figure [1]: we can see a short cystic duct stump perpendicular to the common bile duct. The leak seems to arise from the horizontal part of the cystic duct stump and the bile flows towards the subhepatic space. We also see two surgical clips a short distance from the cystic duct stump; these clips may have been dislodged from it. The common bile duct seems to be intact. The intrahepatic bile ducts are not well filled (opacified) because of the leak, but they seem to be complete, although the right lateral segments are not well visualized.

How can we explain the abnormal liver function test results, observed 3 days after surgery, in the absence of common bile duct injury? A possible explanation is the migration of pus or blood clot into the common bile duct from the gallbladder bed, but we need to be sure that a) the bile duct is intact (the ERCP has to be studied closely), and b) that there is no associated vascular injury, such as damage to the hepatic artery, that could produce liver ischemia (Doppler ultrasonography is required to assess arterial patency).

As regards the initial ERCP: first, the first gastroenterologist suspected a leak from the right intrahepatic duct (accessory duct of Luschka). In fact, the leak was seen to be from the cystic duct when the ERCP was repeated at Duke University. This is a common and understandable mistake; I confess that I have made it myself. A pool of contrast medium exiting the biliary tree into the gallbladder bed can be radiologically superimposed over the cystic duct and the right intrahepatic ducts at the same time, making precise identification of the leak site impossible. For this reason, it is imperative to watch for the leak site in “real time” under fluoroscopy from the very start of the contrast injection. In practice, an error in identifying the leak site usually has no significance, as the treatment is the same in any case.

Secondly, a 7-Fr stent was inserted, with its tip advanced into the right intrahepatic duct, without prior papillotomy. Stent insertion has been used to treat 11 patients with accessory bile-duct leaks, seen at Duke University [1]. This procedure is acceptable in a case where the leak is from the cystic duct, provided that the stent has side holes. Several experts have recommended biliary stenting without papillotomy for this indication. This approach has the advantage of being well tolerated by patients who cannot, of course, dislodge the stent (intentionally or unintentionally) as they might a nasobiliary drain. The disadvantages include possible stent migration (encouraged in this case by the small diameter of the stent), inability to confirm the stent's exact position by cholangiography, and a lack of access for suction to decompress the duct (as can be achieved with a nasobiliary drain). The stent migration was probably responsible for the failure of the first endoscopic procedure to deal with the leak.

To deal with the second ERCP: a nasobiliary drain was inserted deep into the left intrahepatic ductal system. This option was used in this case as the situation was grave and the drainage had to be secure.

(i) deep insertion of the curved part of the drain (Figure [2]) prevented migration, even though the drain diameter was small;

(ii) nasobiliary drainage allowed suction to be applied;

(iii) subsequent control of the drain position and function was possible.

During neither ERCP was biliary sphincterotomy (papillotomy) performed. Papillotomy carries its own well known complications and should always be avoided when not absolutely necessary. However, papillotomy does provide permanent biliary drainage and has been proposed as sole therapy - or in combination with stenting or nasobiliary drainage - for this indication (postcholecystectomy bile leak). It could have solved the problem of stent migration after the first ERCP. Personally, I would have performed papillotomy plus nasobiliary drainage at the time of the second ERCP, as the clinical situation was serious and a definitive cure had to be found.

My suggestions for further management are as follows.

(i) The subhepatic space and the peritoneal cavity need to be examined by ultrasonography (and computed tomography (CT) if necessary) following ERCP to look for a bile collection, which may require percutaneous drainage. I suppose that in this case, ultrasonography and CT were performed before the second ERCP. In Figure [2], a percutaneous drain appears to have been placed, although I am puzzled by its location. Abdominal ultrasonography and CT are mandatory in cases of bile leak, as ERCP alone cannot prevent sepsis associated with peribiliary fluid collections. If such a collection is demonstrated, then a decision must be made whether or not to drain it. If the collection is more than 3 cm in diameter and the infection persists despite bile-duct decompression, drainage is indicated (usually by the percutaneous route under ultrasonographic or CT guidance).

(ii) As indicated previously, Doppler ultrasonography is appropriate to check for trauma to the hepatic vasculature in cases of postoperative bile leak.

(iii) In uncomplicated cases, nasobiliary drainage is usually enough to stop the bile leakage. One problem is the timing of drain removal. Injection of contrast medium through the drain would be expected to indicate when the fistula has closed. However, the absence of a fistulous track during nasobiliary cholangiography is unreliable, as the pressure generated by injection may be insufficient to opacify a small but persistent fistula. The duration of nasobiliary drainage is rarely reported in the endoscopic literature. Surgeons typically wait 3 weeks before removing T-tubes so that a fibrous track will form, thus reducing the risk of a subsequent bile leak. I would recommend at least 10 days of drainage, and up to 3 weeks if the patient can tolerate having the tube that long.

(iv) Intravenous antibiotics should be administered for a total of 10 days to deal with the sepsis. The antibiotics need to be broad spectrum to cover Gram-negative bacteria. Until culture data are available (blood and/or bile), the choice of drug(s) has to be empiric. At Duke University Medical Center they use ampicillin and gentamicin, substituting vancomycin when there is penicillin allergy. Gentamicin is unsuitable in those with renal insufficiency and may be replaced with a cephalosporin, for example. Bile sampling for microbiologic analysis should be performed whenever possible during ERCP and when bile is drained externally, by T-tube or nasobiliary drain.

(v) Bile leakage from the cystic duct stump or from peripheral hepatic radicals following cholecystectomy is a common problem. However, a clear distinction between this situation and more serious sources of bile leakage is often not clear in the literature. Bergman et al. [2] identified four types of biliary injury; leakage from the cystic duct stump and from peripheral biliary radicals was classified as type A. The success rate for endoscopic treatment of type A postcholecystectomy bile-duct leaks ranges from 69 % to 100 % [1] [2] [3] [4] . The literature suggests that closure of the fistula is highly predictable when nasobiliary drainage is employed, provided that the drain remains patent and that the lateral side holes are not occluded in the narrow intrahepatic bile ducts. The nasobiliary drain should be flushed every 6 - 12 hours with 10 ml of sterile saline, to prevent blockage. Management of the fistula by endoscopic stenting and/or endoscopic sphincterotomy is also satisfactory.

Moderator's Comments

I appreciate Dr Ponchon's expert overview of this case. I thought we were being smart by placing a nasobiliary drain, as previous experience at Duke University Medical Center suggested that this would be an effective way to seal the leak. Unfortunately, the patient's leak persisted without obvious reduction in output volume over 4 days. The patient was brought back to the Endoscopy Unit, where the nasobiliary drain was removed and a generous sphincterotomy performed. This was followed by an immediate reduction in output through the patient's abdominal (Jackson-Pratt) drain. Within 24 hours the drainage had stopped altogether.

The issue of the biloma is important. There is a school of thought in endoscopic circles that bilomas can be left with impunity. Bile is a highly irritant material, which will cause peritonitis if it finds its way into the peritoneal cavity. At Duke it is our policy to drain all bilomas > 3 cm in diameter that are accessible to percutaneous drainage under ultrasonography or CT. Certainly, free peritoneal fluid should be drained promptly. In cases of established peritonitis, open laparotomy for peritoneal drainage and lavage is necessary to prevent overwhelming infection. Figure [3] shows this patient's abdominal CT scan on arrival at our institution. There is a large (8 cm × 6 cm) irregular fluid collection lying anterior to the pancreas. Over 600 ml of bile were drained from this collection, and the Jackson-Pratt drain put out a further 300 - 500 ml of bile daily thereafter. The choice of management of biliary leaks is depends on personal preference [5] [6] : biliary stenting is usually as effective as sphincterotomy without a stent, and avoids the risks of the latter procedure. Nasobiliary drainage - especially with continuous suction - has been anecdotally reported to be highly effective in sealing off leaks. However, it didn't work its magic in this case! All of the techniques used for leaks are designed to reduce transpapillary pressure. The one that worked in our patient's case was biliary sphincterotomy, although an apologist for Duke might say that nasobiliary drainage was just about to work when we gave up on it! Accessory bile duct leaks are rare, but should always be considered when postcholecystectomy bile leaks fail to respond to standard endoscopic management [7].

References

• 1 Mergener K, Stobel JC, Suhocki P, et al. The role of ERCP in the diagnosis and management of accessory bile duct leaks after cholecystectomy.  Gastrointest Endosc. 1999;  50 527-531
  PubMedSearch in Google Scholar
• 2 Bergman GHM, Van den Brink GR, Rauws EAJ, et al. Treatment of bile duct lesions after laparoscopic cholecystectomy.  Gut. 1996;  38 141-147
  CrossrefPubMedSearch in Google Scholar
• 3 Prat F, Pelltier G, Ponchon T, et al. What role can endoscopy play in the management of biliary complications after laparoscopic cholecystectomy?.  Endoscopy. 1997;  29 341-348
  Search in Google Scholar
• 4 Neidich R, Soper N, Edmundowicz S, et al. Endoscopic management of bile duct leaks after attempted laparoscopic cholecystectomy.  Surg Laparosc Endosc. 1996;  6 348-354
  CrossrefPubMedSearch in Google Scholar
• 5 Chow S, Basco JJ, Heiss FW, et al. Successful treatment of post-cholecystectomy bile leaks using nasobiliary tube drainage and sphincterotomy.  Am J Gastroenterol. 1997;  92 1839-1843
  PubMedSearch in Google Scholar
• 6 Barkun AN, Rezieg M, Mehta SN, et al. Post-cholecystectomy biliary leaks in the laparoscopic era: risk factors, presentation and management. McGill Gallstone Treatment Group.  Gastrointest Endosc. 1997;  45 277-282
  PubMedSearch in Google Scholar
• 7 Suhocki PV, Meyers WC. Injury to aberrant bile ducts during cholecystectomy: a common cause of diagnostic error and treatment delay.  AJR Am J Roentgenol. 1999;  172 955-959
  PubMedSearch in Google Scholar

T. PonchonM.D. 

Hôpital Edouard Herriot

Place d'Arsonval

69437 Lyon Cedex 03

France


Fax: + 33-4-72110147

Email: thierry.ponchon@chu-lyon.fr

J. BaillieM.B., Ch.B., F.R.C.P. 

Dept. of Medicine Division of Gastroenterology Duke University Medical Center

Box 3189, DUMC

Durham, North Carolina 27710

USA


Fax: +1-919-684-4695

Email: baill@mc.duke.edu

References

• 1 Mergener K, Stobel JC, Suhocki P, et al. The role of ERCP in the diagnosis and management of accessory bile duct leaks after cholecystectomy.  Gastrointest Endosc. 1999;  50 527-531
  PubMedSearch in Google Scholar
• 2 Bergman GHM, Van den Brink GR, Rauws EAJ, et al. Treatment of bile duct lesions after laparoscopic cholecystectomy.  Gut. 1996;  38 141-147
  CrossrefPubMedSearch in Google Scholar
• 3 Prat F, Pelltier G, Ponchon T, et al. What role can endoscopy play in the management of biliary complications after laparoscopic cholecystectomy?.  Endoscopy. 1997;  29 341-348
  Search in Google Scholar
• 4 Neidich R, Soper N, Edmundowicz S, et al. Endoscopic management of bile duct leaks after attempted laparoscopic cholecystectomy.  Surg Laparosc Endosc. 1996;  6 348-354
  CrossrefPubMedSearch in Google Scholar
• 5 Chow S, Basco JJ, Heiss FW, et al. Successful treatment of post-cholecystectomy bile leaks using nasobiliary tube drainage and sphincterotomy.  Am J Gastroenterol. 1997;  92 1839-1843
  PubMedSearch in Google Scholar
• 6 Barkun AN, Rezieg M, Mehta SN, et al. Post-cholecystectomy biliary leaks in the laparoscopic era: risk factors, presentation and management. McGill Gallstone Treatment Group.  Gastrointest Endosc. 1997;  45 277-282
  PubMedSearch in Google Scholar
• 7 Suhocki PV, Meyers WC. Injury to aberrant bile ducts during cholecystectomy: a common cause of diagnostic error and treatment delay.  AJR Am J Roentgenol. 1999;  172 955-959
  PubMedSearch in Google Scholar

T. PonchonM.D. 

Hôpital Edouard Herriot

Place d'Arsonval

69437 Lyon Cedex 03

France


Fax: + 33-4-72110147

Email: thierry.ponchon@chu-lyon.fr

J. BaillieM.B., Ch.B., F.R.C.P. 

Dept. of Medicine Division of Gastroenterology Duke University Medical Center

Box 3189, DUMC

Durham, North Carolina 27710

USA


Fax: +1-919-684-4695

Email: baill@mc.duke.edu