resolve or persist. Uncontained or persistent bili­ary leaks that require additional intervention to control are labeled Grade B or C. A precise defi­nition for persistent bile leak has not been estab­lished. However, the ISGLS classified a biliary leak that persists for > 1 week as Grade B. Given its relatively recent publication, the proposed definitions and grading system of a biliary leak have not been validated widely.

A controlled biliary leak occurs when there is no communication with an intraperitoneal col­lection. In contrast, an uncontrolled biliary leak communicates with an intraperitoneal collection or flows freely throughout the peritoneal cavity. An uncontrolled biliary leak generally requires further drainage or manipulation of extant drains to establish control and prevent secondary infec­tion.

To prevent cystic duct stump leaks, one must en­sure the cystic duct stump is appropriately identi­fied and secured. A variety of methods of secur­ing the cystic duct stump have been described. These include use of titanium clips, locking clips, harmonic scalpel, suture ligature, and endovascu­lar stapling devices. There is no evidence-based data to suggest that any one method is vastly superior. The technique used should ensure that the clip or device is securely fastened, will not be dislodged, and should span the entire cystic duct. The cystic duct wall must be vascularized and free of significant inflammation. For a wide cystic duct, additional clips, ligature, or an endo­vascular stapler may be used after confirming the anatomy. Cautery injury proximal to the site of ligation should be avoided by careful dissection and use of cautery. Gentle traction should be used to avoid avulsion of the cystic duct from the com­mon hepatic duct. Leakage from ducts of Lusch­ka or from the fossa is likely related to dissec­tion into the liver parenchyma. Efforts to stay in the correct plane and ligation of accessory ducts entering the gallbladder from the fossa should decrease peripheral biliary leaks. Preventing bili­ary leaks from major bile duct injuries requires correct identification of the anatomy. The critical view of safety in which the cystic duct and cystic artery are isolated and the cystic plate is exposed has been shown to decrease the rate of major biliary injuries [8]. The role of routine cholan­giography to prevent injury is controversial [9]. Clearly cholangiography can define anatomy and unsuspected injury intraoperatively. Selective in­traoperative cholangiography based on operative conditions and lack of anatomic clarity is utilized most frequently but such use does not address misidentification errors.

was above the confluence. In another retrospec­tive review from India, 270 patients underwent side-to-side choledochoduodenostomy with a biliary leak documented in 2 % of patients [13]. Sump syndrome was not observed in any of these patients, the majority of whom underwent preop­erative endoscopic retrograde cholangiography (ERC) and papillotomy. While retrospective, these studies suggest the frequency of biliary leaks may be comparable to Roux-en-Y recon­struction with low incidence of sump syndrome.

% of patients. Multivari-

repeat hepatectomy, a