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Chapter 29 / Bile Leak and Bile Duct Injury 361
of radionuclide from the biliary system; however, these studies always
require further investigation to dene the true nature of the leak and to
perform biliary drainage.
Management of Minor Bile Leaks after Cholecystectomy
Minor bile leakage following laparoscopic cholecystectomy is most
commonly due to cystic duct stump leak (60% to 75%) or from a duct of
Luschka (10% to 20%). The same basic management strategy applies to
any minor bile leak, which includes decompression of the biliary tree,
usually via endoscopic means, and drainage of the intra-abdominal col-
lections to control sepsis. The most effective method of decompressing
the biliary tree is lowering the pressure gradient across the sphincter
of Oddi. This may be accomplished endoscopically via sphincterotomy
with or without transampullary stenting. These techniques decompress
the biliary tree and allow bile to take the path of least resistance into
the duodenum, which usually allows healing of the upstream pathology.
The endoscopic route with or without stenting is preferred as the endo-
scopic approach is easier, particularly as the intrahepatic bile ducts are
often not dilated, and it is better tolerated by patients. Percutaneous
transhepatic drainage is another option although is seldom necessary
FIGURE 29.5 An ERCP performed in a patient with a major BDI. Contrast does not ll the
proximal biliary tree due to operatively placed clips.
Section III / Biliary362
since most minor bile leaks following cholecystectomy involve intact
biliary anatomy. An increasingly common indication for PTC is a bile
leak or injury following cholecystectomy after gastric bypass proce-
dures. While the success in healing minor bile leaks using various meth-
ods have not been compared to each other using randomized studies,
most series quote success rates of nonoperative decompression greater
than 90%. A recent study by Pitt et al. analyzed 528 patients with biliary
leak or duct injury managed by endoscopists, interventional radiolo-
gists, and surgeons. They concluded that bile leaks from the cystic duct
or a duct of Luschka were managed almost exclusively by endoscopists
with excellent results.
Management of Bile Leak after Liver Resection
Bile leak after liver resection continues to be a fairly common problem
complicating 5% to 10% of cases. e majority of cases are minor leaks
from the transected liver parenchymal surface that do not cause signi-
cant morbidity. However, major biliary complications may occur and
cause signicant morbidity and even mortality. Such injuries include
injury to the common bile or hepatic duct, from the stump of a ligated
main biliary trunk or from a biliary–enteric anastomosis. Bile may also
leak from an immature T tube or transhepatic stent tract. Many investiga-
tors have tried to determine risk factors for bile leak after liver surgery.
ere does not seem to be a signicant correlation with the preoperative
condition of the patient, liver pathology, or technique used to divide the
hepatic parenchyma. Some studies have suggested that longer operative
times and the removal of Couinaud segment 4 may be independent risk
factors for bile leak.
FIGURE 29.6 Percutaneous transhepatic cholangiogram demonstrates complete obstruc-
tion of the biliary tree at the site of bile duct transection.
FIGURE 29.7 A: MRCP demonstrates intact biliary anatomy with a small leak from the
cystic duct. In such a case, a therapeutic ERCP would be indicated. B: MRCP demonstrates
complete transection of the common hepatic duct. In this case, ERCP would be of no value,
and a percutaneous approach would be necessary to access the biliary tree should drain-
age be necessary. Alternatively, if appropriate, the patient could be taken directly to the
operating room for reconstruction as the anatomy is nicely dened.
Section III / Biliary364
Bile leaks after hepatectomy may present in the early postopera-
tive period (days 2 to 4) with bile detectable in surgically placed drains.
However, since drains are not routinely used by many liver surgeons, there
may be signicant delay in recognition of bile leak in patients who do not
have drains in place. ese patients often present 6 to 8 days postopera-
tively with one or more of the following: abdominal pain, low-grade fever,
leukocytosis, hyperbilirubinemia, ileus, or protracted hiccups. Rarely, a bili-
ary leak may present as a severe septic or hemorrhagic event.
e workup of bile leak after hepatic resection is similar to that for
postcholecystectomy bile leak. e most likely source of bile leak after
hepatic resection is leakage from the parenchyma, which tends to be low
volume and will often resolve with external drainage of the collection and
antibiotics. If the bile leak persists, decompression of the biliary tree usu-
ally via endoscopic techniques is appropriate if native anatomy is present.
Management of Bile Leak after Liver Transplantation
Biliary complications continue to be a major source of morbidity in hepatic
transplantation. e major biliary complications are bile leak and stricture,
occurring in 5% to 25% of transplants. While there are exceptions, most bile
leakage after transplant occurs at the biliary anastomosis. Currently, the
most common anastomotic techniques are direct choledochocholedochos-
tomy (end-to-end or side-to-side) with or without T-tube stenting or Roux-
en-Y choledochojejunostomy with no clear dierence in the incidence of
biliary leak.
Bile leakage in transplant patients presents similar to other patient
populations discussed earlier. However, due to a suppressed immune
response, these patients may not mount the same magnitude of response
mostly with respect to fever, leukocytosis, and abdominal pain. As such,
a high awareness of the potential for bile leak in the early postoperative
period is important.
Treatment strategies for bile leak after liver transplant are essentially
the same as discussed for other types of bile leaks. e use of nonopera-
tive strategies has nearly obviated the need to return to the operating room
for anastomotic revision except in the most drastic situations. In patients
with direct choledochocholedochostomy, ERCP with sphincterotomy and
stenting is the treatment of choice with a frequency of success approaching
90%. However, in patients with Roux-en-Y choledochojejunostomy, ERCP
is more dicult and requires a highly skilled interventional biliary endos-
copist. Percutaneous transhepatic stenting of the biliary anastomosis may
also be technically dicult in patients who do not have intrahepatic biliary
ductal dilation and often the transplant surgeon wishes to avoid this route.
Management of Bile Leak after Trauma
e liver is the most frequently injured abdominal organ in both penetrat-
ing and blunt trauma. Nonoperative management has become well estab-
lished as the standard of care for treatment of patients who have blunt liver
injury. is development has resulted, in large part, from the widespread
use of abdominal CT, which allows more precise denition of the extent of
injury, and from the increased availability and application of angiography/
embolization to control hemorrhage in these patients. Currently, 60% to
85% of all patients who have blunt hepatic trauma are managed success-
fully without operation. As a result of this paradigm change, it is dicult
to estimate accurately the true incidence of bile leak after hepatic trauma.
Biloma or bile ascites has been reported in as few as 0.5% to as many as
20% of all patients suering blunt liver injury. In the most comprehensive
study of bile leak after blunt liver trauma, Wahl et al. reported 24 bile leaks
Chapter 29 / Bile Leak and Bile Duct Injury 365
in 258 patients for an overall incidence of 9%. Several reviews have found an
increased incidence of bile leak in patients who have more complex injuries
and in those undergoing angiographic embolization, with an overall inci-
dence of 30% to 40% in these populations.
e diagnosis of bile leak may prove particularly dicult in patients
who have blunt trauma managed nonoperatively. Associated injuries may
mask the typical symptoms and physical signs of bile peritonitis. Conversely,
nonspecic symptoms or abnormal laboratory values may be attributed to
other known or suspected injuries. Routine imaging studies (CT and ultra-
sound) can demonstrate intra-abdominal and perihepatic uid collections.
Such screening of patients managed nonoperatively at high risk for bile leak
(those who have complex injuries or are undergoing angiographic emboli-
zation) may prove particularly useful in the trauma population.
As may be expected, with the paucity of data in the literature, no clear
treatment strategy has evolved for managing bile leaks after liver injury.
Several authors have reported success with simply percutaneous drain-
age of bile collections. Like with other causes of bile leak, draining the bili-
ary tree using ERCP +/− sphincterotomy, or endoscopic stent placement,
are options for persistent leaks. In some cases with major ductal injuries,
operative management including reconstruction or even resection may be
necessary.
Recently, laparoscopy with peritoneal lavage and operative drain
placement has been suggested as a useful modality for treating patients
who have hepatic trauma. Wahl noted that patients who were diagnosed as
having a bile leak and were treated early by laparoscopic peritoneal lavage
made more rapid recovery and had earlier hospital discharge than those
diagnosed and treated later in the postinjury course. is nding prompted
them to recommend early (postinjury day 3 or 4) screening for bile leak with
HIDA scan in patients at high risk for bile leak, with laparoscopic peritoneal
lavage applied to patients who had positive scans. Although early laparo-
scopic peritoneal lavage has not been studied in a randomized fashion, it
may hold promise for this specic group of patients.
Most penetrating liver injuries continue to be managed operatively.
Furthermore, a small percentage of patients who have blunt liver injury still
require operative intervention. Diagnosis and management of bile leaks
in these cases is similar to the management of bile leaks following other
operative procedures on the liver or biliary tree. Biliary leak in these cases
generally is suggested by the presence of bile in an operatively placed drain.
Clinical ndings of low-grade fevers, tachycardia, ileus, increased serum
bilirubin, or leukocytosis may prompt abdominal CT and reveal an und-
rained uid collection. External drainage of bile collections (by CT-guided
percutaneous drainage), control of sepsis with tailored antibiotic treat-
ment, and subsequent endoscopic or percutaneous transhepatic decom-
pression of the biliary tree generally leads to resolution of bile leak in these
situations.
Management of Major Bile Duct Injury
Most major bile duct injuries in the United States occur during laparo-
scopic cholecystectomy. Optimal management depends on timing of recog-
nition of the injury. Most of these injuries (60% to 70%) go unrecognized at
the time of laparoscopic cholecystectomy. Figure 29.8 shows the suggested
management of injuries associated with laparoscopic cholecystectomy.
If the injury is recognized at the time of cholecystectomy, the rst
step is to determine if the operating surgeon is technically capable of per-
forming the necessary repair. If he or she is not, we suggest consulting
another surgeon at the original hospital who is experienced in biliary tract
Section III / Biliary366
reconstruction. If there is no one available who can perform such a repair,
the patient should be transferred to a tertiary care center for further man-
agement. Once an injury is recognized, it is usually best to avoid further
dissection or clipping of the proximal ducts. It is, however, mandatory to
create a controlled biliary stula prior to closing. is can be easily accom-
plished by placing a small drainage catheter retrograde into the biliary duc-
tal system as well as placing a closed suction drain into the gallbladder bed.
At this point, the patient should be closed and transferred to a center with
skilled multidisciplinary teams to manage the injury.
A few specic scenarios deserve further discussion. One such situa-
tion is the placement of a clip across the CBD without cutting or dividing
the duct (Fig. 29.9). In such cases, the clip can be removed, the gallbladder is
removed, and no further treatment is necessary. If a small choledochotomy
has been made to perform a cholangiogram, it should be closed with simple
ne absorbable sutures and a drain should be placed in the gallbladder bed.
e procedures can be performed laparoscopically; however, conversion
to open operation is advisable for most surgeons. e patient is at risk to
develop a late stricture, but in most cases, endoscopic balloon dilation and
stenting will result in successful management.
e other situation in which minimal intervention is appropriate is
when a minor bile duct is transected. In such cases, if the duct is less than
4mm in diameter and cholangiography demonstrates only subsegmental
liver drainage with the remainder of biliary anatomy intact, simple ligation
is preferable than an attempt at reconstruction.
If a major duct injury is suspected and the surgeon is capable of repair-
ing the injured duct, the rst step is to convert to an open procedure and
use gross anatomic identication combined with cholangiography to bet-
ter dene the nature of the injury. As discussed above, if the combination
of exploration and cholangiography reveal an injured duct less than 4mm,
which drains subsegmental hepatic parenchyma, simple ligation is accept-
able. If the injured duct is larger than 4mm, it likely drains a larger area of
hepatic parenchyma and will typically require operative repair.
L
APAROSCOPIC CHOLECYSTECTOMY
MAJOR BILE DUCT INJURY
RECOGNIZED AT TIME OF
LAPAROSCOPIC CHOLECYSTECTOMY (30%)
RECOGNIZED IN THE EARLY
POSTOPERATIVE PERIOD
PRIMARY REPAIR TRANSFER TO
HEPATOBILIARY CENTER
E
ND-TO-END
REPAIR
HEPATICOJEJUNOSTOMY
(PREFERRED IN MOST SETTINGS)
PERCUTANEOUS TRANSHEPATIC
CHOLANGIOGRAPHY WITH BILIAR
Y
DRAINAGE
DEFINE ANATOMY/CONTROL BILE
LEAK
4 to 6 WEEKS
DEFINITIVE REPAIR
HEPATICOJEJUNOSTOMY
CT SCAN
(DRAIN COLLECTIONS)
FIGURE 29.8 Algorithm for diagnosis and management of BDI associated with laparo-
scopic cholecystectomy.
Chapter 29 / Bile Leak and Bile Duct Injury 367
If the injury is to the common hepatic or CBD, it should be repaired
immediately. e two most common methods of repair are primary end-to-
end repair or a bilioenteric anastomosis, typically a Roux-en-Y hepaticoje-
junostomy. If a primary end-to-end repair is to be undertaken, the injured
segment of the bile duct should be less than 1cm and the ends must be able
to be approximated without tension. is is usually accomplished by per-
forming a generous Kocher maneuver (mobilizing the duodenum by taking
down the lateral attachments from the retroperitoneum). After the Kocher
FIGURE 29.9 Intraoperative cholangiogram demonstrating a normal distal bile duct with
drainage into the duodenum. The proximal biliary tree cannot be visualized due to a clip
placed across the duct. Such a cholangiogram should alert the surgeon that a major BDI will
occur unless steps are taken to redene anatomy before transecting the duct.
Section III / Biliary368
maneuver, there is typically enough length to facilitate approximation of
the injured ends. e anastomosis should be decompressed with a T tube
placed either above or below the suture line. If the end-to-end repair is con-
traindicated, the distal bile duct should be oversewn and repair undertaken
with a bilioenteric anastomosis.
e long-term results of end-to-end repair have often been criticized
for having a high failure rate with late stricture occurring in over half of
reported cases. However, by keeping normal biliary anatomy intact, endo-
scopic balloon dilatation with stenting is an option for treatment of such
strictures. e results for such treatment are excellent and spare the patient
the need for percutaneous procedures that are often painful and associ-
ated with the need for long-term external stents, which are unpopular with
patients.
Most major bile duct injuries, however, will require a bilioenteric anas-
tomosis with a Roux-en-Y limb of jejunum. e jejunum is divided about
25cm from the ligament of Treitz. A 60-cm tension-free Roux limb is pre-
pared in standard fashion with a stapled functional end-to-side enteroen-
terostomy. e stapled end of the jejunum is then pulled up through a rent
made in the transverse mesocolon to the right of the middle colic vessels.
Reconstruction is performed using a hand-sewn end-to-side anastomosis
ensuring that the mucosa of the bile duct is brought into contact with the
mucosa of the jejunum (Fig. 29.10). Many hepatobiliary surgeons believe
that external biliary drainage preferably by an operatively placed transhe-
patic stent is necessary in all cases of biliary reconstruction after BDI. is
catheter provides decompression of the biliary tree as well as allows rec-
ognition of and protection against the consequences of an anastomotic
Silastic
biliary stent
Silastic
biliar
y stent
in jejunum
Transverse
colon
Hepaticojejunostomy
End-to-side
jejunostom
y
FIGURE 29.10 Schematic representation of a Roux-en-Y hepaticojejunostomy with trans-
anastomotic stent to repair a BDI. (From Mulholland MW, Lillemoe KD, Doherty GM,
et al., eds. Greeneld’s surgery: scientic principles and practice, 4th ed. Philadelphia, PA:
Lippincott Williams & Wilkins, 2006.)
Chapter 29 / Bile Leak and Bile Duct Injury 369
leak. is can be easily accomplished intraoperatively by placing a silastic
stent retrograde through the hepatic parenchyma and externalized prior to
completing the anastomosis. Another benet of the catheter is the ability
to easily study the repair and biliary anatomy postoperatively with cholan-
giography (Fig. 29.11).
Unfortunately, most patients who sustain a major BDI are not recog-
nized during cholecystectomy. ese patients usually present with pain,
nausea, vomiting, bloating, and fever early in their postoperative course
(days 2 to 5). ese symptoms necessitate further diagnostic evaluation as
described previously. A CT should be performed to evaluate for bile ascites
or a bile collection. Such studies should also include arterial phase contrast,
as up to 20% of major BDI may have an associated hepatic arterial injury.
Assuming there is evidence of bile leak, decompression and external drain-
age of the biliary system is mandated. In cases in which there is evidence of
a bile duct transection, the only reliable route for biliary drainage is using
a percutaneous transhepatic approach. If there are drainable collections,
these should also be drained by interventional radiology (IR). Although
most patients with a bile leak do not have “infected bile,” broad-spectrum
antibiotics to cover typical biliary pathogens should be started as well as
used to provide prophylaxis for various procedures. Once the leak is con-
trolled via external drainage (often allowing operatively placed or IR-placed
drains to be removed), and the biliary system is decompressed, there is no
immediate rush to repair. It is clearly benecial to allow resolution of the
inammatory process prior to performing denitive repair. An adequately
FIGURE 29.11 Postoperative cholangiogram after immediate reconstruction of a major
BDI.
Section III / Biliary370
controlled bile leak with total bile diversion is well tolerated for several
weeks; however, both electrolytes and volume status must be monitored
and optimized. e temptation to reexplore patients early with a major BDI
associated with a bile leak should be avoided as the associated inamma-
tion makes dissection and anastomosis quite dicult. Usually 4 to 6 weeks
is a suitable time to plan denitive reconstruction. In those patients with a
major bile duct transection presenting with obstruction without a bile leak,
repair can be completed early after dening the anatomy.
OUTCOMES/FOLLOW-UP
Management of both postoperative bile leaks and bile duct injuries requires
a multidisciplinary team. Minor bile leaks that are appropriately man-
aged have excellent outcomes with nonoperative success rates over 90%.
Bile duct injuries even when treated at major centers still are associated
with signicant morbidity and even mortality. Delay in diagnosis, failure to
control the bile leak, and uncontrolled sepsis can lead to a fatal outcome
particularly in elderly patients. Multiple series reporting outcomes follow-
ing repair have reported postoperative morbidity rates from 25% to 40%
and mortality rates of less than 2%. Complications include postoperative
wound infections, cholangitis, septicemia, intra-abdominal abscess, anas-
tomotic leak, biliary stula, and hepatic insuciency. In most patients, IR
plays an important role in managing complications without the need for
reoperation.
Fortunately, the long-term results for BDI following biliary reconstruc-
tion at major referral centers are generally excellent with successful out-
comes reported in 85% to 95% of cases with follow-up in excess of 5 years.
e development of liver failure or the need for liver transplantation is very
rare for isolated bile duct injuries (without associated vascular injuries) if
timely and appropriate treatment is provided. Finally, for most patients,
quality of life following BDI with successful repair eventually returns to lev-
els of healthy controls, which is particularly important as the majority of
patients in most series are middle-aged women.
CONCLUSION
Biliary leakage is a complication that usually occurs after interventions
on the gallbladder, bile ducts, and liver as well as after abdominal trauma.
e overwhelming majority of biliary leaks are minor and will resolve with
minimal intervention and morbidity. Advances in imaging and minimally
invasive techniques permit nonoperative treatment in most cases. A BDI is
a major complication with signicant deleterious eects to the patient with
respect to morbidity, cost of medical care, and disruption of short-term
quality of life. Prompt recognition, appropriate management, and denitive
repair are necessary to ensure the best possible outcome.
Suggested Readings
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laparoscopic cholecystectomy. Ann Surg 1993;217:532.
Flum DR, Cheadle A, Prela C, et al. Bile duct injury during cholecystectomy and sur-
vival in Medicare beneciaries. JAMA 2003;290:2168–2173.
Flum DR, Dellinger EP, Dheadle A, et al. Intraoperative cholangiography and risk of
common bile duct injury during cholecystectomy. JAMA 2003;289:1639–1644.
Lillemoe KD, Melton GB, Cameron JL, et al. Postoperative bile duct strictures: man-
agement and outcome in the 1990s. Ann Surg 2000;232:430.
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duct injury. J Am Coll Surg 2007;204:656.