Diagnosis and management of bile leaks following laparoscopic cholecystectomy

Laparoscopic cholecystectomy is now the standard of care for the elective management of gallstone disease. Recent studies have shown the morbidity of laparoscopic cholecystectomy to be similar to that of open cholecystectomy. Postoperative bile leaks have been recognized to be a troublesome problem following laparoscopic cholecystectomy. We present a retrospective review of 854 patients undergoing laparoscopic cholecystectomy at a single institution. Records were reviewed of all patients identified as having postoperative bile leaks. Between January 1990 and April 1991, we have cared for, or been referred, 15 patients with postlaparoscopic cholecystectomy bile leaks (9/854, 1.1% index patients and 6 referred). The location of bile leakage was determined to be the common bile duct (CBD) in two, cystic duct in five, and small accessory ducts located close to the gallbladder bed in the remaining eight. Most patients presented in the first week following laparoscopic cholecystectomy (mean 4.3 ± 0.7 days, range 2–10) with worsening abdominal pain (13/13, 100%), nausea, and low-grade fever (mean 99.6 ± 0.3°F, range 96.8–102.2). Eleven of fifteen (66.7%) patients underwent technicium-99m imidodiacetic acid scanning (Tc-99m IDA) to determine the presence of a possible bile leak. All eleven scans were positive, indicating the presence of a bile leak. Thirteen patients underwent endoscopic cholangiography confirming the presence of biliary leakage (the remaining two patients underwent prompt laparotomy). Five patients were taken to the operating room for management of their leaks (two with common bile duct injuries, two cystic duct leaks, one accessory duct leak). Nine patients (two cystic duct leaks, seven accessory duct leaks) were managed endoscopically, with placement of an indwelling biliary stent (7/9) or endoscopic sphincterotomy alone (2/9). A single patient cholangiogram was normal, when studied 2 weeks following identification of the leak by Tc-99m IDA scan. Mean hospital time for endoscopic treatment of the bile leakage was 5.5 ± 1.2 days. All patients managed endoscopically were discharged well. Mean hospital stay for the operative group was 23 days. Two patients died following operative management. Symptomatic bile leakage occurs relatively commonly postlaparoscopic cholecystectomy. Tc-99m IDA cholescintigraphy is a useful test to screen for the presence of bile leakage following laparoscopic cholecystectomy. Most patients can be managed successfully endoscopically. Although the identification of the ideal treatment of bile leaks following laparoscopic cholecystectomy will require further study, noninvasive testing coupled with endoscopic management may allow rapid evaluation and prompt appropriate treatment, minimizing further morbidity.