From the Guidelines
An enterotomy with bile leak is a serious surgical complication that requires prompt intervention to prevent morbidity and mortality, and the best approach is to follow the 2020 WSES guidelines for the detection and management of bile duct injury during cholecystectomy, as outlined in the study published in the World Journal of Emergency Surgery in 2021 1.
Definition and Causes
An enterotomy with bile leak is a condition where an incision or perforation in the intestine results in leakage of bile into the abdominal cavity, typically occurring during gastrointestinal surgery when the intestinal wall or biliary tract is inadvertently injured or when a surgical repair fails to heal properly.
Diagnosis and Management
According to the 2020 WSES guidelines, patients with suspected bile duct injury (BDI) should undergo prompt investigation, including liver function tests and abdominal triphasic CT, which may be complemented with CE-MRCP to obtain exact visualization, localization, and classification of BDI 1.
- The assessment of liver function tests, including serum levels of direct and indirect bilirubin, AST, ALT, ALP, GGT, and albumin, is suggested in patients with clinical signs and symptoms suggestive of BDI after LC, as stated in the guidelines 1.
- Abdominal triphasic CT is suggested as the first-line diagnostic imaging investigation to detect intra-abdominal fluid collections and ductal dilation, which may be complemented with the addition of CE-MRCP to obtain the exact visualization, localization, and classification of BDI 1.
Treatment
Treatment of enterotomy with bile leak generally involves surgical intervention to repair the leak, which may include primary closure of the defect, placement of drains to control the leakage, or creation of a diversion to redirect bile flow, as recommended in the guidelines for postoperatively detected BDI management 1.
- For minor BDIs, if no improvements or worsening of symptoms occurs during the clinical observation period after percutaneous drain placement, endoscopic management (by ERCP with biliary sphincterotomy and stent placement) becomes mandatory, as stated in the guidelines 1.
- Patients typically require intravenous antibiotics and nutritional support, often through parenteral nutrition, while the intestine heals.
Prognosis
The prognosis depends on the size of the leak, timing of diagnosis, patient's overall health, and effectiveness of treatment, and it is essential to follow the guidelines to achieve the best possible outcome and reduce the risk of morbidity and mortality, as supported by the study 1.
From the Research
Definition of Enterotomy with Bile Leak
- An enterotomy is a surgical incision into the intestine, and when it involves the bile duct, it can lead to a bile leak 2, 3, 4, 5, 6.
- A bile leak is an abnormal connection between the bile duct and another organ or the skin, allowing bile to escape into the surrounding tissue or cavity 2, 3, 4, 5, 6.
Causes of Enterotomy with Bile Leak
- Enterotomy with bile leak can occur after various surgical procedures, including laparoscopic cholecystectomy 2, liver resection 4, and complex hepatic trauma 5.
- Other causes of bile leak include ruptured liver abscess, hydatid cyst, and trauma 3.
Management of Enterotomy with Bile Leak
- Endoscopic retrograde cholangiopancreatography (ERCP) is a common treatment approach for bile leaks, involving sphincterotomy, stent placement, or a combination of both 2, 3, 4, 5, 6.
- The choice of treatment depends on the location and severity of the bile leak, as well as the patient's overall condition 6.
- Percutaneous or surgical drainage of biliary fluid collections may be necessary in some cases 2, 5.
Outcomes of Enterotomy with Bile Leak Treatment
- The success rate of endoscopic treatment for bile leaks is generally high, ranging from 77% to 91.5% 3, 4.
- Most patients can be successfully managed with ERCP, even when performed on an elective basis 3.
- However, some patients may require additional interventions, such as percutaneous drainage or surgical reintervention 2, 4, 5.