Case Report
A 62-year-old female was referred to our surgical clinic for evaluation of recurrent bile leak following an uneventful laparoscopic cholecystectomy 7-years ago, at an outside hospital. The patient had remained asymptomatic for about two years post-cholecystectomy when she developed right upper quadrant abdominal pain. A perihepatic fluid collection was percutaneously drained and was consistent with a bile leak. She then underwent an endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy and biliary stent placement. Additionally, percutaneous transhepatic biliary drainage was performed due to the persistence of bile leak in the external drain (images from the outside hospital were not available). After several weeks, she had an eventual resolution of the bile leak followed by the removal of all the drains and the stent. The patient remained asymptomatic for another 5 years before presenting to our gastroenterology department with a recurrent bile leak for which a percutaneous drain had been placed.
The patient presenting symptoms included sharp right upper quadrant abdominal pain radiating to right lower quadrant and shoulders. Associated symptoms included abdominal distension, diarrhea, nausea, and low-grade fever. At initial presentation, liver function tests showed an AST of 269 units/L, ALT of 210 units/L, alkaline phosphatase of 146 units/L, and bilirubin (total) of 1.5 mg/dL (conjugated of 0.7 mg/dL). CBC demonstrated an initial leukocytosis (14.1 10e9/L). The WBC count was normal (9.7 10e9/L) on repeat draw after 24 hours. The patient's treatment included prophylactic antibiotics course.
She underwent an initial ERCP which showed irregular contrast filling in the gallbladder fossa consistent with a leak possibly from an isolated right posterior sectoral duct (Figure 1A). An internal biliary stent was placed to create an alternative path for bile flow and promote spontaneous closure of the leak. A repeat ERCP two months later showed persistent leakage from the right posterior sectoral duct, and the patient continued to have 20 - 40 ml/d of bilious output in her percutaneous drain, indicating a failure of conservative management. An abdominal CT performed at this time demonstrated an appropriately placed biliary stent traversing the common bile duct, and a right upper quadrant drainage catheter terminating in the gallbladder fossa (Figure 2 A&B). Amorphous complex fluid attenuation was also visible in the gallbladder fossa and a continued leak was suspected. The patient consented to an exploratory laparotomy for possible isolation and ligation or reconstruction of the leaking bile duct versus a partial wedge hepatic resection if the leaking duct was not identified.
Exploration was performed via a right subcostal incision. The percutaneous catheter was tracked into a chronic abscess cavity along the inferior edge of the liver and overlying the gallbladder fossa. The cavity was de-roofed and about 10 ml of bilio-purulent fluid was drained. The common bile duct was identified. After debridement of the abscess cavity and irrigation with copious amounts of neomycin/bacitracin antibiotic solution, a pinpoint (3 mm diameter) area of bile leak was identified in the gallbladder fossa. This was probed with coronary dilators and confirmed to be the offending bile duct branch. The overlying scar tissue was excised and the freshened edges of the duct were oversewn using multiple interrupted 5-0 Polydioxanone sutures. The percutaneous drain was removed and a 19-Fr surgical drain was placed.
The patient had an uncomplicated recovery. The surgical drain was removed on postoperative day 10 in the clinic. An ERCP was performed 6-weeks after surgery and the biliary stent was removed (Figure 1B). 24 months after surgery, the patient continues to do well without any evidence of bile leak, (serum total bilirubin of 0.6 mg/dL and serum ALP 100 units/L).