Management of Bile Leak Post Minimally Invasive Subtotal Cholecystectomy: A Review

Abstract

Objective: Minimally invasive subtotal cholecystectomy is safe alternative to minimally invasive cholecystectomy that prevents bile duct injury. Nonetheless, it is associated with higher rates of other complications, namely post-operative bile leak and symptomatic remnant cholelithiasis.

Summary background data: Bile leak presents as biloma requiring drainage and subsequently high bilious drain output. It is more strongly associated with fenestrating subtotal cholecystectomy. Fortunately, the majority are self-limited and do not require endoscopic intervention. Symptomatic remnant cholelithiasis presents as recurrent gallstone disease post-operative cholecystectomy.

Methods: In this paper, we review available literature on these two complications and share our institutional algorithm on the management of bile leak.

Results: Our approach to bile leak advocates for intra-operative drain placement, early characterization of the leak, watchful waiting, the use of sinogram, and reserving ERCP and stenting for high-grade leaks or refractory cases. Symptomatic remnant cholelithiasis is more strongly associated with reconstituting subtotal cholecystectomy, particularly in cases where the gallbladder stump is long or stones are not completely evacuated from the remnant. This complication should be treated with completion cholecystectomy when possible, but can also be managed with gallbladder-preserving choleystolithomy in patients with aberrant biliary anatomy and/or significant comorbidities. Completion cholecystectomy is a technically challenging operation that benefits from hepatopancreaticbiliary expertise and intra-operative adjuncts such as near-infrared fluorescent cholangiography or intra-operative cholangiogram.

Conclusions: Minimally invasive subtotal cholecystectomy effectively prevents bile duct injury but at the expense of increased post-operative morbidity; it is a bailout strategy that should be used judiciously.

Keywords: ERCP; bile leak; completion cholecystectomy; fenestrating; reconstituting; sinogram; subtotal cholecystectomy; symptomatic remnant cholelithiasis; watchful waiting.