Biliary Surgery Adverse Events, Including Liver Transplantation

Bile Leak

Minor and clinically insignificant or unapparent bile leaks are common after cholecystectomy; they arise from ducts in the gallbladder bed and occur in up to 24% of patients. These are associated with low output through a surgical drain (if not unapparent) and usually resolve without intervention.

Significant and clinically relevant postoperative bile leaks occur in approximately 0.8% to 1.1% of patients. Bile leaks can be classified into two categories using an ERCP-based assessment of severity:

• Low-grade leaks are present if leakage from the biliary tract is observed only after complete filling of the intrahepatic bile ducts with contrast (i.e., injecting contrast under pressure).

• High-grade leaks are present if a large amount of contrast extravasation occurs before filling of the intrahepatic bile ducts.

Most low-grade leaks occur from the cystic duct or duct of Luschka (types A and C) and can be treated definitively by an endoscopic approach. The endoscopic approach to bile leaks has been reviewed. The aim is to decrease the transpapillary pressure gradient; an increase in transpapillary bile flow diverts bile from the leak site.

Whether to perform biliary sphincterotomy alone without placement of a biliary stent for bile leaks remains debatable, but most endoscopists agree that sphincterotomy alone is not adequate unless there are obstructing stones as an additional factor or if a very large sphincterotomy can be done (which usually necessitates a dilated duct, often absent in the setting of a leak in a young patient). It is usually not necessary to place a stent beyond the site of leak, and we insert a 10-Fr plastic stent after biliary sphincterotomy.

Insertion of a biliary stent across the papilla without sphincterotomy is generally desirable to preserve the biliary sphincter in younger patients. However, when 10-Fr stents are placed without sphincterotomy, it is associated with a higher rate of post-ERCP pancreatitis (PEP). This study was published before the use of prophylactic measures to reduce PEP, such as pancreatic stent placement or administration of rectally administered nonsteroidal antiinflammatory drugs. After successful stent placement, the stent remains in place for approximately 4 to 6 weeks and is not replaced if follow-up ERCP shows resolution of the leakage. Some authors have shown that follow-up ERCP may be unnecessary for patients with cystic duct and duct of Luschka leaks when the initial ERCP is otherwise normal, and a standard upper endoscopy with stent removal can be safely performed. The same approach can be used for minor lateral injuries of the right or CBD (type D). However, whenever the main duct is involved, follow-up ERCP is mandatory to assess complete leak closure and to detect development of a stricture, which occurs more often with main duct injuries.

When a percutaneous drain has been placed during management of the leak (e.g., patients who developed a biloma), the drainage output should be less than 10 mL/day (preferably the drain has been removed) before removing the stent. With minor bile leaks, we advise placing the external drain to gravity drainage rather than to suction, to decrease the resistance of flow through the leak site and promote bile flow through the stent into the duodenum.

An alternative approach is to combine biliary sphincterotomy with nasobiliary drainage (NBD). NBD allows for suction and irrigation and noninvasive cholangiograms, and it is easily removed. Unfortunately, NBD is uncomfortable and frequently becomes dislodged. Biliary stenting has advantages of larger-bore drainage and better comfort for the patient but does not allow for interval cholangiography and requires endoscopic removal.

In 10% of patients, bile leaks do not respond to sphincterotomy and/or placement of a single large-bore plastic stent: such cases can be managed by placement of multiple plastic stents or placement of a fully covered self-expandable metal stent (FCSEMS), which may be removed up to 6 months later. In such cases biliary sphincterotomy is recommended to minimize the risk of PEP. In one nonrandomized trial, multiple plastic stents were found to be superior to an FCSEMS. Refractory biliary leaks have been treated with injection at the distal takeoff of the leaking duct with cyanoacrylate glue.

In patients with refractory bile leaks, one must always consider the possibility that the lesion is coming from transection of an anomalous aberrant right hepatic duct from which the cystic duct arose. Diagnosis may require MRCP; this lesion often requires surgical repair with hepaticojejunostomy. Injuries to main common bile or common hepatic ducts are the most serious and are similar to the injuries most commonly seen in open cholecystectomy. Clinical presentations are highly variable and the patient can deteriorate rapidly, depending on the type of injury: the main duct may be completely transected or clipped with or without bile leak. Patients with bile leak have early symptoms (sepsis, bile peritonitis) at a median of 3 days, whereas patients developing strictures without associated bile leak have a significant longer symptom-free interval. Early diagnosis can be obtained by computed tomography scan and transabdominal ultrasonography; MRCP is useful to define biliary anatomy, particularly in patients with complete biliary transection (type E) where the proximal extent of the injury cannot be assessed by ERCP. The presence of concomitant right hepatic artery injury should also be assessed, because it is a prognostic factor of late complications. Primary surgical repair of the bile ducts in the presence of an acute local inflammatory response should be avoided because of the high rate of breakdown and stricture formation. Injuries involving the biliary bifurcation have a high risk of early and late complications; surgery involves a bilioenteric anastomosis in all cases, usually a proximal hepaticojejunostomy with Roux-en-Y for the prevention of ascending cholangitis. These operations can be difficult and time-consuming. A complex biliary injury recognized at the time of operation by a surgeon with minimal experience in complex biliary reconstruction should not be repaired at that time. Instead, the patient should be stabilized and transferred as soon as possible (ideally within 24 hours) to an institution with hepatobiliary expertise. Major damage to the bile ducts (e.g., complete transection) not amenable to treatment with endoscopic stent placement should be treated by a surgeon with sufficient experience in advanced biliary surgery.

In patients with severe gangrenous cholecystitis, subtotal cholecystectomy is often performed because the severe inflammation prevents dissection down to the cystic duct. The patient is therefore left with an open cystic duct leading into surgical drains. In these cases, we believe that placement of a fully covered stent is preferable to placement of a plastic stent.

Biloma

In the case of an established biloma after successful endoscopic closure of a postcholecystectomy biliary leak, percutaneous drainage is the treatment of choice. Most patients will have rapid reabsorption, and only a small percentage of patients (up to 6%) require open surgical drainage. Endoscopic ultrasonography (EUS)–guided drainage of bilomas that are close to the gastric or duodenal wall is also an option.