From the Guidelines
Bile leaks after posterior sectionectomy of the right liver should be treated with a stepwise approach, starting with endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy and stent placement, as this approach resolves approximately 90% of cases, as supported by the 2020 WSES guidelines 1. The etiology of bile leaks after posterior sectionectomy of the right liver typically involves injury to bile ducts during surgery, inadequate identification of biliary anatomy, or failure to secure small bile radicles at the resection surface. Key considerations in the treatment of bile leaks include:
- The location and severity of the leak
- The patient's overall clinical condition
- The availability of resources and institutional preferences Treatment options for bile leaks after posterior sectionectomy of the right liver include:
- Endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy and stent placement
- Percutaneous transhepatic biliary drainage (PTBD)
- Conservative management with external drainage via surgically placed drains
- Surgical reintervention The most recent and highest quality study, the 2020 WSES guidelines 1, recommends ERCP with sphincterotomy and stent placement as the first-line treatment for bile leaks, with a success rate of approximately 90%. For ERCP, a 7-10 Fr plastic biliary stent is typically placed for 4-6 weeks to reduce transpapillary pressure gradient and facilitate bile flow into the duodenum rather than through the leak, as supported by the study 1. If ERCP fails, PTBD can be attempted, placing an external or internal-external drain to divert bile flow, as recommended by the study 1. Conservative management with external drainage via surgically placed drains may be sufficient for low-output leaks (<200 mL/day), combined with somatostatin analogs like octreotide (100-200 mcg subcutaneously three times daily for 5-7 days) to reduce bile production, as suggested by the study 1. Surgical reintervention is reserved for high-output persistent leaks or when less invasive approaches fail, and may involve direct suturing of the leak site, bilioenteric anastomosis, or rarely, additional liver resection. The management approach should be tailored to the patient's clinical condition, with close monitoring of drain output, bile characteristics, and signs of peritonitis or sepsis to guide escalation of therapy, as recommended by the studies 1.
From the Research
Etiology of Persistent Bile Leak
- A persistent bile leak following a posterior sectionectomy of the right liver can be caused by various factors, including injury to the bile duct, insufficient closure of the bile duct stump, or division and exclusion of a bile duct 2.
- Anatomic variations of the right biliary system, such as a supra-portal pattern with a long right biliary duct, can increase the risk of sectoral bile duct injury and subsequent bile leak 3.
- The bile leak can originate from the resected duct stump or ablated surface of the liver, as seen in patients undergoing major liver resection, cryosurgery, or radiofrequency ablation 4.
Treatment Options for Persistent Bile Leak
- Endoscopic retrograde cholangiopancreatography (ERCP) with stent placement is a common treatment option for bile leaks, with a high success rate of 91.5% in achieving complete symptomatic resolution 5.
- Percutaneous drain placement and biliary stenting can also be used to manage bile leaks, with most leaks closing with time, although a drain may be required for several months 4.
- In cases where conservative treatment fails, surgical intervention may be necessary, such as repeat resection of the independent liver parenchyma containing the fistula 2.
- A Roux-en-Y hepaticojejunostomy may also be performed to treat persistent bile leaks, especially in cases of isolated right posterior sectoral bile duct injury 6.