Causes, clinical features and non-operative management of bile leaks

This paper evaluates the management of 31 patients with bile leaks identified over a 7-year period. Leaks complicated cholecystectomy in 19 patients (11 laparoscopic, 8 open), interventional procedures in 10 (including surgery in 1), trauma in one and was spontaneous in one case. Confirmation of the diagnosis typically lagged behind the onset of symptoms (mean for the group 4.2 days), indicating that a high index of suspicion is required in at-risk patients with typical symptoms. These include abdominal pain or distension, fever, bile leaking along a drain, jaundice, abnormal liver function tests and elevated white cell count. Two post-surgical bile leaks required surgical drainage of abdominal cellections. The remainder were successfully managed by non-operative methods including percutaneous drainage, endoscopic retrograde cholangiography with or without sphincterotomy or stent placement and percutaneous stenting. The spontaneous leak and all bile leaks complicating interventional procedures were managed non-operatively, although six patients in this group died due to the underlying malignant pathology. Only the patient with self-inflicted transection of the bile duct died directly from the complications of the bile leak. Although this is a varied, small series, we conclude that the majority of bile leaks can be managed by non-operative techniques. Whilst endoscopy is the primary modality for treatment, percutaneous techniques are crucially important for the management of complex cases and endoscopic failure.