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Handling Post-Operative Common Bile Duct Leaks
This middle-aged patient with diabetes mellitus underwent open cholecystectomy for an emphysematous gallbladder and presented 72-hours later with abdominal pain.
How would you treat this bile leak?
The most common recommendation is to perform a biliary sphincterotomy. Many experts also use a plastic stent alone or in combination with biliary sphincterotomy. Although it is commonly believed that placing a short-length stent is enough, we always take a good look at the type of leak, it’s size and location, and then decide on the length of the plastic stent. High volume leaks, or those associated with a big defect, tortuous bile duct or proximal location require a stent to be extending from proximal location, and extending across the papilla.
I encourage you to read the expert commentary by Interventional Endoscopist Thomas Kröner, MD from the USA.
The key to handling biliary leaks lies in thinking about the fact that bile will always flows through the path of least resistance. Bearing this in mind, we consider the “four pressure systems” that factor into a leak:
a) the biliary ductal system’s (with an intact ampulla is ~15mmHg),
b) the intra-abdominal (~6mmHg),
c) the bowel’s (~5mmHg), and
d) the outside world’s (technically 0mmHg).
This means that in a bile leak scenario we have “bilio-athmospheric” (between the bile duct and outside world through the drain), the “bilio-abdominal or peritionel” (between the bile ducts and the intraabdominal cavity through the leak), and “bilio-enteric” (between the bile duct and the bowel through the ampulla) pressure gradients.
The objective of a leak treatment will be for the bilioenteric gradient to be favored by “equalizing” the pressures between the biliary ductal system and the bowel, which is performed doing a sphincterotomy +/- stenting, as suggested by our colleagues in the discussion. This new gradient or “assistance to the bilioenteric drainage” would in theory be more favorable than the “bilioabdominal” gradient.
However, another important point is to never forget the importance of the role the external drain plays. If this drain is still wide-open and immediately adjacent to the leak, the most favorable gradient for bile flow could still be the “bilio-athmospheric” one, even after sphincterotomy and possible stenting. Therefore, careful retraction of the drain a good 4-6cm from the site of the leak is recommended. This will theoretically now favor the bilioenteric route once again.
More on Post-Operative Bile Duct Leaks
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