Surg Endosc (1992) 6:33-35
Surgical
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 symptom-
atic cholelithiasis. With the widespread use of this
technique there have appeared reports of complica-
tions. We report the case of a patient who developed a
cystic duct stump bile leak after laparoscopic chole-
cystectomy. Percutaneous drainage of the biloma, en-
doscopic retrograde cholangiopancreatography and
papillotomy led to resolution of the problem. The liter-
ature on cystic duct stump leaks after laparoscopic
cholecystectomy is reviewed and the various thera-
peutic modalities are outlined.
Key words: Bile l e a k - L a p a r o s c o p i c cholecystec-
tomy - Symptomatic cholelithiasis
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 post-
operative 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 fol-
lows: BP 130/80, pulse 108/rain, respiration rate 18/rain and temper-
ature 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
Endoscopy
© Springer-VerlagNew York Inc. 1992
Computed tomography (CT) scan demonstrated a large right sub-
diaphragmatic 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. Vi-
sualization of the extrahepatic biliary tree demonstrated a leak from
the tip of the cystic duct at the site of the clips (Fig. 2). A papillo-
tomy was then performed. Percutaneous catheter drainage de-
creased to 35 cm ~ within the next 24 h. The catheter was then re-
moved and the patient was discharged from hospital. The patient
was seen several weeks later and had no complaints.
Discussion
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 sur-
gery 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 postop-
erative 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 endo-
scopic stents. Ponchon and associates [13] published
the results of treating a series of 24 patients with per-
sistent biliary cutaneous fistulas. One case was a spon-
taneous fistula, two were due to traumatic liver inju-
ries and the remainder occurred after surgery. Nine
patients had sphincterotomy alone and the rest were
treated by either nasobiliary drainage or endoprosthe-
sis insertion. Fistulas originating from the gallbladder
or cystic duct stump (six cases) were all successfully
34
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 cuta-
neous fistulas. Two bile leaks occurred after abdomi-
nal trauma and three after bile duct surgery. All were
successfully treated by endoscopic stenting.
With the development of laparoscopic cholecystec-
tomy 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 cho-
lecystectomy. A 26-year-old woman underwent la-
paroscopic cholecystectomy for cholelithiasis and was
discharged 24 h later. Over the next week she devel-
oped abdominal pain, nausea, fever and right-sided ab-
dominal tenderness. CT scan of the abdomen demon-
strated a perihepatic bile collection. Percutaneous
drainage evacuated 800 cm 3 bile. External bile drain-
age persisted at a rate of 600-700 m3/24 h. ERCP dem-
onstrated 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 re-
moved. Four weeks later the biliary stent was re-
moved.
Dion and Morin [3] published a series of 60 cases of
laparoscopic cholecystectomy. One of the complica-
tions was a patient who developed fever and upper
abdominal pain 8 days after surgery. Ultrasonography
demonstrated an infrahepatic fluid collection and per-
cutaneous drainage was successful, injection of radio-
opaque material through the percutaneous drain dem-
onstrated a leak from the sump of the cystic duct. The
patient had an uneventful recovery. Voyles and asso-
ciates [19] reported a series of 453 patients who under-
went laparoscopic cholecystectomy. One patient de-
veloped 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 cholecystec-
tomy. Gadacz and associates [5] reported two cystic
duct leaks in 60 patients who had undergone laparo-
Fig. 1. C.T. scan demonstrating a
suprahepatic bile collection
Fig. 2. Endoscopic retrograde
cholangiopancreatography
demonstrating a cystic duct stump
bile leak
scopic cholecystectomy. Re-operation and suture liga-
tion of the cystic duct were carried out. Kozarek and
associates [8] reported three cystic duct leaks in 597
patients who had undergone laparoscopic cholecystec-
tomy.
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 treat-
ing cystic duct stump leaks after laparoscopic chole-
cystectomy. Percutaneous drainage of the bile leak
will result in complete recovery in most cases provid-
ing there is no bile duct obstruction. Endoscopic papil-
lotomy 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 re-
tained 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 endo-
scopic placement of stents will decrease bile drainage
through the cystic duct stump. Endoscopic papillot-
omy will also decrease cystic duct bile drainage. Na-
sobiliary drainage or stents are associated with signifi-
cant problems--infection and blockage. Thus for
persistent drainage due to a cystic duct bile leak, endo-
scopic papillotomy is recommended.
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Presented at the SSAT Plenary Session. San Antonio, Texas
May 1990