WHY DOES A BILE LEAK OCCUR?
Bile leak occurs due to trauma to liver or bile ducts. Trauma can be either iatrogenic or other types. One of the common cause of bile leak is post laparoscopic cholecystectomy. Compared to an open Cholecystectomy, Laparoscopic Cholecystectomy has 10 times more chances of a bile duct injury.
Bile leak can also occur after biliary enteric anastomoses. Other uncommon causes include bile duct injury after liver surgery or ablation procedures.
HOW IS A BILE LEAK PRESENTED?
Postoperative bile leak usually presents within one week. However it may be present in one month. Usually a patient with a bile leak is presented with generalised or localised abdominal pain and tenderness with fever and chills.
Presence of jaundice indicate presence of biliary stricture. Blood reports will show leukocytosis and elevated C-reactive protein which is suggestive of active inflammation. Older patients may lack typical symptoms.
Bile leak may cause bilioma, biliary fistula, biliary peritonitis with subsequent abscess formation and sepsis. So a prompt diagnosis and treatment should be done.
HOW SERIOUS IS A BILE LEAK?
Bile leak is classified into three categories based on how serious it is.
- Stage A are small leaks in which patients usually do not have significant symptoms. These do not require any significant intervention.
- Stage B are significant leaks and patient is symptomatic.
- Stage C patients are also symptomatic and require intervention.
HOW DO WE MANAGE A BILE LEAK?
- Stage A bile leak is managed by keeping surgical drain in situ till the leak heals by itself gradually. If surgical drain has been removed, we can put percutaneous USG guided drain and keep it in situ till it heals.
- Stage B and C require intervention or surgery.
For management – leaks can be divided into two types, one in which leaking segment is connected with the biliary system and one in which it is not connected with the biliary system.
LEAKING SEGMENT CONNECTED WITH BILIARY SYSTEM
- Cystic duct injury – require endoscopic or percutaneous drainage. Leak will stop gradually.
- Intra-hepatic biliary radicle injury – require percutaneous or endoscopic drainage of hepatic duct draining this injured biliary radicle. If there is large bilioma or fistula formation, embolization of leak may be helpful.
- Duct of Lushka injury – these ducts drain into right hepatic system, so the percutaneous or endoscopic drainage of the right hepatic system helps in healing of the leak.
- Bile duct injury – management depends on severity of the injury.
A) If continuity of bile duct is maintained – in such cases endoscopic or percutaneous drainage suffice. In this if injury is near hilum, it is good to place two (one right and one left) or three stents (one right anterior, one right posterior and one left).
B) If there is complete transection of the duct, drain is placed using both percutaneous and endoscopic approach. For this, the wire is passed from the percutaneous access to the hepatic duct -> bile duct -> collection and it is caught down endoscopically and brought down into duodenum. Then one or preferably two or three stents are placed across the transection.
In both the cases (A & B), putting PTBD catheter preoperatively from right to left or left to right also may suffice. It will help in healing the leak. Once the leak stops and area is healed, the injury can be treated by definitive surgery.
5. Biliary-enteric anastomoses leak – In this type of leak, endoscopy is difficult, so percutaneous drainage is the treatment of choice. Unilateral or preferably bilateral internal-external biliary drain is placed. Once leak stops, the drain can be removed.
In types 4 and 5 if there is an associated stricture, it can be dilated once the leaking stops.
LEAKING SEGMENT IS NOT CONNECTED WITH BILIARY SYSTEM
- Isolated Intrahepatic biliary radicle leak with bilioma or fistula formation – this should be drained percutaneously and then embolized or treated surgically.
- Cystohepatic duct injury – these ducts drain liver parenchyma directly into the gall bladder and are not connected to the biliary system. So, this should be treated surgically.
- Bile duct injury with lower down obstruction – This should be drained percutaneously. Once the leak stops and the area is healed, definitive surgery can be performed.
Bile leaks are a surgeon’s nightmare and they should be treated promptly. While small leaks resolve by themselves with the help of a simple drainage, significant leaks and bile duct injuries require endoscopic or percutaneous drainage with or without surgery. Early endoscopic or percutaneous interventions helps in decreasing morbidity and mortality rates significantly.