Surgical Endoscopy
Surg Endosc (1992) 6:33-35
© Springer-VerlagNew York Inc. 1992
Bile leak after laparoscopic cholecystectomy T. Ralph-Edwards and H.S. Himal Department of Surgery, Toronto Western Hospital, 399 Bathurst Street; and University of Toronto, 399 Bathurst Street, Toronto, Ontario M5T 2S8, Canada
Summary. Laparoscopic cholecystectomy has now become the preferred surgical approach to symptomatic cholelithiasis. With the widespread use of this technique there have appeared reports of complications. We report the case of a patient who developed a cystic duct stump bile leak after laparoscopic cholecystectomy. Percutaneous drainage of the biloma, endoscopic retrograde cholangiopancreatography and papillotomy led to resolution of the problem. The literature on cystic duct stump leaks after laparoscopic cholecystectomy is reviewed and the various therapeutic modalities are outlined.
Computed tomography (CT) scan demonstrated a large right subdiaphragmatic collection (Fig. 1). Under local anaesthesia a #12 Van Sonnenberg catheter was placed to drain the right subphrenic collection. One thousand cubic centimeters of bile was aspirated within the first 60 rain. Catheter drainage per 24-h period was as follows: 100, 300, 130, 30 and 130 m 3. At this time an endoscopic retrograde cholangiopancreatography (ERCP) was carried out. Visualization of the extrahepatic biliary tree demonstrated a leak from the tip of the cystic duct at the site of the clips (Fig. 2). A papillotomy was then performed. Percutaneous catheter drainage decreased to 35 cm ~ within the next 24 h. The catheter was then removed and the patient was discharged from hospital. The patient was seen several weeks later and had no complaints.
Key words: Bile l e a k - L a p a r o s c o p i c cholecystec-
Discussion
tomy - Symptomatic cholelithiasis
Bile leaks and injuries to the extrahepatic biliary tree after cholecystectomy have been well documented in the literature [7, 1, 2, 10]. Minor bile leaks are now initially managed by percutaneous radiologic drainage [18]. An important adjunct to the management of bile leaks after cholecystectomy is the visualization of the extrahepatic biliary tree. ERCP will pinpoint the exact area of leakage and the type of damage. Although surgery plays a role in bile duct injuries, endoscopically or radiologically placed stents within the common bile duct have now become common and successful. Smith and associates [16] reported five cases of non-healing biliary cutaneous fistulas. Endoscopically placed bile duct stents were successful in all five patients. Sauerbruch et al. [15] described four cases of postoperative bile fistulas. Two cases were the result of bile duct injury, one case was the result of the inadvertent removal of a T-tube and one case was a cystic duct stump leak. All were successfully treated by endoscopic stents. Ponchon and associates [13] published the results of treating a series of 24 patients with persistent biliary cutaneous fistulas. One case was a spontaneous fistula, two were due to traumatic liver injuries and the remainder occurred after surgery. Nine patients had sphincterotomy alone and the rest were treated by either nasobiliary drainage or endoprosthesis insertion. Fistulas originating from the gallbladder or cystic duct stump (six cases) were all successfully
Laparoscopic cholecystectomy has now become an accepted method of removing the gallbladder Ill, 4, 14]. Large series have been published outlining the technique and results [12, 17]. It is estimated that by 1992 about 50% of all cholecystectomies done in North America will be through the laparoscopic route. As with other interventionai techniques complications do occur and are being reported in the literature. This publication describes a case of a cystic duct bile leak following laparoscopic cholecystectomy.
Case report Miss 1.G. is a 53-year-old female who was admitted to hospital because of recurrent attacks of biliary colic. Ultrasound of the upper abdomen demonstrated several large stones. On April 3, 1991, she underwent laparoscopic cholecystectomy. She did well in the postoperative period and was discharged 48 h after surgery. Six days later the patient was seen in the Emergency Department because of right-sided abdominal pain and tenderness. Vital signs were as follows: BP 130/80, pulse 108/rain, respiration rate 18/rain and temperature 36.4°C. She was admitted for investigation. An ultrasound test suggested a collection of gallstones in the right upper abdomen. Offprint requests to: H.S. Himal
34
Fig. 1. C.T. scan demonstrating a suprahepatic bile collection Fig. 2. Endoscopic retrograde cholangiopancreatography demonstrating a cystic duct stump bile leak
treated by endoscopic means but only ten of the 18 bile duct fistulas were controlled by endoscopic stents. Goldin et al. [6] reported five patients with biliary cutaneous fistulas. Two bile leaks occurred after abdominal trauma and three after bile duct surgery. All were successfully treated by endoscopic stenting. With the development of laparoscopic cholecystectomy reports began to appear in the literature of bile leaks after surgery. Kozarek and Traverso [9] reported a case of a cystic duct leak following laparoscopic cholecystectomy. A 26-year-old woman underwent laparoscopic cholecystectomy for cholelithiasis and was discharged 24 h later. Over the next week she developed abdominal pain, nausea, fever and right-sided abdominal tenderness. CT scan of the abdomen demonstrated a perihepatic bile collection. Percutaneous drainage evacuated 800 cm 3 bile. External bile drainage persisted at a rate of 600-700 m3/24 h. ERCP demonstrated a leak from the cystic duct. A stent without a papillotomy was placed within the common bile duct. This resulted in rapid decrease in the volume of the percutaneous drainage, and the drain was then removed. Four weeks later the biliary stent was removed. Dion and Morin [3] published a series of 60 cases of laparoscopic cholecystectomy. One of the complications was a patient who developed fever and upper abdominal pain 8 days after surgery. Ultrasonography demonstrated an infrahepatic fluid collection and percutaneous drainage was successful, injection of radioopaque material through the percutaneous drain demonstrated a leak from the sump of the cystic duct. The patient had an uneventful recovery. Voyles and associates [19] reported a series of 453 patients who underwent laparoscopic cholecystectomy. One patient developed a localized leak from the cystic duct stump. Nasobiliary drainage resolved the problem. Zucker and associates [20] reported one cystic duct stump leak in 100 patients who had laparoscopic cholecystectomy. Gadacz and associates [5] reported two cystic duct leaks in 60 patients who had undergone laparo-
scopic cholecystectomy. Re-operation and suture ligation of the cystic duct were carried out. Kozarek and associates [8] reported three cystic duct leaks in 597 patients who had undergone laparoscopic cholecystectomy. The mechanism of injury can be explained in two ways. A cautery or laser burn to the cystic duct stump can result in a bile leak. A poorly applied clip can also result in a bile leak from the cystic duct stump. There is controversy as to the best method of treating cystic duct stump leaks after laparoscopic cholecystectomy. Percutaneous drainage of the bile leak will result in complete recovery in most cases providing there is no bile duct obstruction. Endoscopic papillotomy may be added in these cases. Nasobiliary drainage has also been used with success. Endoscopic stents are also useful and will decrease bile drainage. If a patient has a bile collection because of a cystic duct bile leak percutaneous drainage should be carried out first. If drainage persists then ERCP should be carried out to determine the cause. If there is a retained stone in the common bile duct then papillotomy and stone extraction can be carried out. If the common bile duct is clear, then nasobiliary drainage or endoscopic placement of stents will decrease bile drainage through the cystic duct stump. Endoscopic papillotomy will also decrease cystic duct bile drainage. Nasobiliary drainage or stents are associated with significant problems--infection and blockage. Thus for persistent drainage due to a cystic duct bile leak, endoscopic papillotomy is recommended. References 1. Andren-Sanberg A, Johansson S, Bengmark S (1985) Accidental lesions of the common bile duct at cholecystectomy. Ann Surg 201:452-455 2. Blumgart LH, Kelley C J, Benjamin JS (1984) Benign bile duct structure following cholecystectomy: critical factors in management. Br J Surg 71:836-843 3. Dion YM, Morin J (1990) Laparoscopic cholecystectomy: a report of 60 cases. Can J Surg 33:483-486
35 4. Dubois F, Icard P, Berthelot G, Levard H (1990) Coelioscopic cholecystectomy. Ann Surg 211:60-62 5. Gadacz TR, Talamini MA, Lillemoe KD, Yeo CJ (1990) Laparoscopic cholecystectomy. Surg Clin North Am 70: 12491263 6. Goldin E, Katz E, Wengrower D, Kluger Y, Haskel L, Shiloni E, Libson E (1990) Treatment of fistulas of the biliary tract by endoscopic insertion of endoprosthesis. Surg Gynecol Obstet 170:418-423 7. Hillis TM, Westbrook KC, Caldwell FT, Read RC (1977) Surgical injury of the common bile duct. Am J Surg 134:712-716 8. Kozarek R, Gannon R, Baerg R, Wagonfeld J, Ball T ( 1991 ) Bile leak following laparoscopic cholecystectomy. Gastrointest Endosc 37:248 (A) 9. Kozarek RA, Traverso LW (1991) Endoscopic stent placement for cystic duct leak after laparoscopic cholecystectomy. Gastrointest Endosc 37:71-73 10. McSherry CK, Glenn F (1980) The incidence and causes of death following surgery for non-malignant biliary tract disease. Ann Surg 191:271-276 11. Perissat J, Collet DR, Belliard R (1989) Gallstones: laparoscopic treatment intracorporeal lithotripsy followed by cholecystostomy or cholecystectomy: a personal technique. Endoscopy 21: 373-374 12. Peters JH, Ellison EC, lnnes JT, Liss JL, Nichols KE, Lomano
13. 14. 15. 16. 17. 18. 19. 20.
JM, Roby SR, Front ME, Carey LC (1991) Safety and efficacy of laparoscopic cholecystectomy. Ann Surg 213:1-12 Ponchon T, Gallez JF, Valette PJ, Chavaillon A, Bory R (1989) Endoscopic treatment of biliary tract fistulas. Gastrointest Endosc 35:490-498 Reddick E J, Olsen DO (1989) Laparoscopic laser cho[ecystectomy. Surg Endosc 3:131-133 Sauerbruch T, Weinzieri M, Holl J, Pratschke E (1986) Treatment of postoperative bile fistulas by internal endoscopic biliary drainage. Gastroenterology 90:1998-2003 Smith AC, Schapiro RH, Kelsey PB, Warshaw AL (1986) Successful treatment of non-healing biliary-cutaneous fistulas with biliary stents, Gastroenterology 90:764-769 Southern Surgeons Club (1991) A prospective analysis of 1518 laparoscopic cholecystectomies. N Eng J Med 324:1074-1078 Vansonnerbeng E, Casola G, Wittich GR (1990) The role of interventional radiology for complications of cholccystectomy. Br J Surg 77:826-832 Voyles CR, Petro AB, Meena AL, Haick AJ, Koury AM (1991) A practical approach to laparoscopic cholecystectomy. Am J Surg 161:365-370 Zucker RA, Bailey RW, Gadacz TR, Imbembo AL (1990) Laparoscopic cholecystectomy: a plea for cautious enthusiasm, Presented at the SSAT Plenary Session. San Antonio, Texas May 1990
Surg Endosc (1992) 6:33-35
© Springer-VerlagNew York Inc. 1992
Bile leak after laparoscopic cholecystectomy T. Ralph-Edwards and H.S. Himal Department of Surgery, Toronto Western Hospital, 399 Bathurst Street; and University of Toronto, 399 Bathurst Street, Toronto, Ontario M5T 2S8, Canada
Summary. Laparoscopic cholecystectomy has now become the preferred surgical approach to symptomatic cholelithiasis. With the widespread use of this technique there have appeared reports of complications. We report the case of a patient who developed a cystic duct stump bile leak after laparoscopic cholecystectomy. Percutaneous drainage of the biloma, endoscopic retrograde cholangiopancreatography and papillotomy led to resolution of the problem. The literature on cystic duct stump leaks after laparoscopic cholecystectomy is reviewed and the various therapeutic modalities are outlined.
Computed tomography (CT) scan demonstrated a large right subdiaphragmatic collection (Fig. 1). Under local anaesthesia a #12 Van Sonnenberg catheter was placed to drain the right subphrenic collection. One thousand cubic centimeters of bile was aspirated within the first 60 rain. Catheter drainage per 24-h period was as follows: 100, 300, 130, 30 and 130 m 3. At this time an endoscopic retrograde cholangiopancreatography (ERCP) was carried out. Visualization of the extrahepatic biliary tree demonstrated a leak from the tip of the cystic duct at the site of the clips (Fig. 2). A papillotomy was then performed. Percutaneous catheter drainage decreased to 35 cm ~ within the next 24 h. The catheter was then removed and the patient was discharged from hospital. The patient was seen several weeks later and had no complaints.
Key words: Bile l e a k - L a p a r o s c o p i c cholecystec-
Discussion
tomy - Symptomatic cholelithiasis
Bile leaks and injuries to the extrahepatic biliary tree after cholecystectomy have been well documented in the literature [7, 1, 2, 10]. Minor bile leaks are now initially managed by percutaneous radiologic drainage [18]. An important adjunct to the management of bile leaks after cholecystectomy is the visualization of the extrahepatic biliary tree. ERCP will pinpoint the exact area of leakage and the type of damage. Although surgery plays a role in bile duct injuries, endoscopically or radiologically placed stents within the common bile duct have now become common and successful. Smith and associates [16] reported five cases of non-healing biliary cutaneous fistulas. Endoscopically placed bile duct stents were successful in all five patients. Sauerbruch et al. [15] described four cases of postoperative bile fistulas. Two cases were the result of bile duct injury, one case was the result of the inadvertent removal of a T-tube and one case was a cystic duct stump leak. All were successfully treated by endoscopic stents. Ponchon and associates [13] published the results of treating a series of 24 patients with persistent biliary cutaneous fistulas. One case was a spontaneous fistula, two were due to traumatic liver injuries and the remainder occurred after surgery. Nine patients had sphincterotomy alone and the rest were treated by either nasobiliary drainage or endoprosthesis insertion. Fistulas originating from the gallbladder or cystic duct stump (six cases) were all successfully
Laparoscopic cholecystectomy has now become an accepted method of removing the gallbladder Ill, 4, 14]. Large series have been published outlining the technique and results [12, 17]. It is estimated that by 1992 about 50% of all cholecystectomies done in North America will be through the laparoscopic route. As with other interventionai techniques complications do occur and are being reported in the literature. This publication describes a case of a cystic duct bile leak following laparoscopic cholecystectomy.
Case report Miss 1.G. is a 53-year-old female who was admitted to hospital because of recurrent attacks of biliary colic. Ultrasound of the upper abdomen demonstrated several large stones. On April 3, 1991, she underwent laparoscopic cholecystectomy. She did well in the postoperative period and was discharged 48 h after surgery. Six days later the patient was seen in the Emergency Department because of right-sided abdominal pain and tenderness. Vital signs were as follows: BP 130/80, pulse 108/rain, respiration rate 18/rain and temperature 36.4°C. She was admitted for investigation. An ultrasound test suggested a collection of gallstones in the right upper abdomen. Offprint requests to: H.S. Himal
34
Fig. 1. C.T. scan demonstrating a suprahepatic bile collection Fig. 2. Endoscopic retrograde cholangiopancreatography demonstrating a cystic duct stump bile leak
treated by endoscopic means but only ten of the 18 bile duct fistulas were controlled by endoscopic stents. Goldin et al. [6] reported five patients with biliary cutaneous fistulas. Two bile leaks occurred after abdominal trauma and three after bile duct surgery. All were successfully treated by endoscopic stenting. With the development of laparoscopic cholecystectomy reports began to appear in the literature of bile leaks after surgery. Kozarek and Traverso [9] reported a case of a cystic duct leak following laparoscopic cholecystectomy. A 26-year-old woman underwent laparoscopic cholecystectomy for cholelithiasis and was discharged 24 h later. Over the next week she developed abdominal pain, nausea, fever and right-sided abdominal tenderness. CT scan of the abdomen demonstrated a perihepatic bile collection. Percutaneous drainage evacuated 800 cm 3 bile. External bile drainage persisted at a rate of 600-700 m3/24 h. ERCP demonstrated a leak from the cystic duct. A stent without a papillotomy was placed within the common bile duct. This resulted in rapid decrease in the volume of the percutaneous drainage, and the drain was then removed. Four weeks later the biliary stent was removed. Dion and Morin [3] published a series of 60 cases of laparoscopic cholecystectomy. One of the complications was a patient who developed fever and upper abdominal pain 8 days after surgery. Ultrasonography demonstrated an infrahepatic fluid collection and percutaneous drainage was successful, injection of radioopaque material through the percutaneous drain demonstrated a leak from the sump of the cystic duct. The patient had an uneventful recovery. Voyles and associates [19] reported a series of 453 patients who underwent laparoscopic cholecystectomy. One patient developed a localized leak from the cystic duct stump. Nasobiliary drainage resolved the problem. Zucker and associates [20] reported one cystic duct stump leak in 100 patients who had laparoscopic cholecystectomy. Gadacz and associates [5] reported two cystic duct leaks in 60 patients who had undergone laparo-
scopic cholecystectomy. Re-operation and suture ligation of the cystic duct were carried out. Kozarek and associates [8] reported three cystic duct leaks in 597 patients who had undergone laparoscopic cholecystectomy. The mechanism of injury can be explained in two ways. A cautery or laser burn to the cystic duct stump can result in a bile leak. A poorly applied clip can also result in a bile leak from the cystic duct stump. There is controversy as to the best method of treating cystic duct stump leaks after laparoscopic cholecystectomy. Percutaneous drainage of the bile leak will result in complete recovery in most cases providing there is no bile duct obstruction. Endoscopic papillotomy may be added in these cases. Nasobiliary drainage has also been used with success. Endoscopic stents are also useful and will decrease bile drainage. If a patient has a bile collection because of a cystic duct bile leak percutaneous drainage should be carried out first. If drainage persists then ERCP should be carried out to determine the cause. If there is a retained stone in the common bile duct then papillotomy and stone extraction can be carried out. If the common bile duct is clear, then nasobiliary drainage or endoscopic placement of stents will decrease bile drainage through the cystic duct stump. Endoscopic papillotomy will also decrease cystic duct bile drainage. Nasobiliary drainage or stents are associated with significant problems--infection and blockage. Thus for persistent drainage due to a cystic duct bile leak, endoscopic papillotomy is recommended. References 1. Andren-Sanberg A, Johansson S, Bengmark S (1985) Accidental lesions of the common bile duct at cholecystectomy. Ann Surg 201:452-455 2. Blumgart LH, Kelley C J, Benjamin JS (1984) Benign bile duct structure following cholecystectomy: critical factors in management. Br J Surg 71:836-843 3. Dion YM, Morin J (1990) Laparoscopic cholecystectomy: a report of 60 cases. Can J Surg 33:483-486
35 4. Dubois F, Icard P, Berthelot G, Levard H (1990) Coelioscopic cholecystectomy. Ann Surg 211:60-62 5. Gadacz TR, Talamini MA, Lillemoe KD, Yeo CJ (1990) Laparoscopic cholecystectomy. Surg Clin North Am 70: 12491263 6. Goldin E, Katz E, Wengrower D, Kluger Y, Haskel L, Shiloni E, Libson E (1990) Treatment of fistulas of the biliary tract by endoscopic insertion of endoprosthesis. Surg Gynecol Obstet 170:418-423 7. Hillis TM, Westbrook KC, Caldwell FT, Read RC (1977) Surgical injury of the common bile duct. Am J Surg 134:712-716 8. Kozarek R, Gannon R, Baerg R, Wagonfeld J, Ball T ( 1991 ) Bile leak following laparoscopic cholecystectomy. Gastrointest Endosc 37:248 (A) 9. Kozarek RA, Traverso LW (1991) Endoscopic stent placement for cystic duct leak after laparoscopic cholecystectomy. Gastrointest Endosc 37:71-73 10. McSherry CK, Glenn F (1980) The incidence and causes of death following surgery for non-malignant biliary tract disease. Ann Surg 191:271-276 11. Perissat J, Collet DR, Belliard R (1989) Gallstones: laparoscopic treatment intracorporeal lithotripsy followed by cholecystostomy or cholecystectomy: a personal technique. Endoscopy 21: 373-374 12. Peters JH, Ellison EC, lnnes JT, Liss JL, Nichols KE, Lomano
13. 14. 15. 16. 17. 18. 19. 20.
JM, Roby SR, Front ME, Carey LC (1991) Safety and efficacy of laparoscopic cholecystectomy. Ann Surg 213:1-12 Ponchon T, Gallez JF, Valette PJ, Chavaillon A, Bory R (1989) Endoscopic treatment of biliary tract fistulas. Gastrointest Endosc 35:490-498 Reddick E J, Olsen DO (1989) Laparoscopic laser cho[ecystectomy. Surg Endosc 3:131-133 Sauerbruch T, Weinzieri M, Holl J, Pratschke E (1986) Treatment of postoperative bile fistulas by internal endoscopic biliary drainage. Gastroenterology 90:1998-2003 Smith AC, Schapiro RH, Kelsey PB, Warshaw AL (1986) Successful treatment of non-healing biliary-cutaneous fistulas with biliary stents, Gastroenterology 90:764-769 Southern Surgeons Club (1991) A prospective analysis of 1518 laparoscopic cholecystectomies. N Eng J Med 324:1074-1078 Vansonnerbeng E, Casola G, Wittich GR (1990) The role of interventional radiology for complications of cholccystectomy. Br J Surg 77:826-832 Voyles CR, Petro AB, Meena AL, Haick AJ, Koury AM (1991) A practical approach to laparoscopic cholecystectomy. Am J Surg 161:365-370 Zucker RA, Bailey RW, Gadacz TR, Imbembo AL (1990) Laparoscopic cholecystectomy: a plea for cautious enthusiasm, Presented at the SSAT Plenary Session. San Antonio, Texas May 1990
