What is the most appropriate management for a post-laparoscopic cholecystectomy (surgical removal of the gallbladder using a minimally invasive technique) patient with a 10x15 cm subhepatic biloma (collection of bile in the abdominal cavity below the liver) and elevated total and direct bilirubin (hyperbilirubinemia) levels?

Management of Large Post-Laparoscopic Cholecystectomy Biloma

The most appropriate management is image-guided percutaneous drainage (Option B) combined with endoscopic biliary decompression via ERCP. This dual approach addresses both the symptomatic biloma collection and the underlying bile leak, representing the standard of care for post-cholecystectomy bilomas.

Immediate Management Strategy

Percutaneous Drainage as First-Line Therapy

• Image-guided percutaneous drainage should be performed immediately for this 10x15 cm symptomatic biloma, as management of biloma requires percutaneous drainage according to the World Society of Emergency Surgery (WSES) 2020 guidelines 1.

• The large size of this collection (10x15 cm) makes it symptomatic and requires source control to prevent progression to biliary peritonitis or abscess formation 1.

• Percutaneous drainage under ultrasound or CT guidance has proven successful in treating post-cholecystectomy bilomas in multiple studies, with resolution achieved in the majority of cases 2, 3, 4.

Why Not Conservative Management (Option D)?

Conservative management is inappropriate for a biloma of this size. The WSES guidelines recommend observation only for minor bile duct injuries when a drain is already placed and bile output is noted, with a short observation period of hours—not for established large bilomas 1. This patient presents 2 weeks post-operatively with a massive collection requiring active intervention.

Sequential Endoscopic Management

• Following percutaneous drainage, ERCP with biliary sphincterotomy and stent placement becomes mandatory if symptoms persist or worsen, or if drainage output remains high 1.

• ERCP is the key tool in bile duct injury management, allowing identification of the leak site and providing internal biliary drainage with success rates of 87.1-100% 1.

• The goal of endoscopic therapy is to reduce transpapillary pressure gradient, facilitating preferential bile flow through the papilla rather than the leak site, allowing time for healing 1.

• Endoscopic sphincterotomy combined with plastic stent placement is the most frequent and effective approach, particularly for cystic duct stump leaks or ducts of Luschka injuries 1, 4.

Why MRCP Alone (Option A) is Insufficient

While MRCP provides excellent anatomic detail for visualizing and localizing bile duct injuries 1, it does not provide therapeutic intervention. This patient requires immediate source control of the biloma, not just diagnostic imaging. The CT scan has already identified the collection; MRCP would only delay definitive treatment. MRCP is complementary to CT for surgical planning but should not precede drainage in a symptomatic patient 1.

Why Open Drainage (Option C) is Inappropriate

• Open surgical drainage is reserved only for major bile duct injuries (complete transection) or cases where endoscopic and percutaneous approaches have failed 1, 2.

• The WSES guidelines explicitly state that for minor bile duct injuries detected postoperatively, percutaneous treatment with drain placement is the appropriate initial approach 1.

• Surgery carries higher morbidity and should be avoided when minimally invasive options are effective 2, 3.

Antibiotic Coverage

• Broad-spectrum antibiotics should be initiated immediately using piperacillin/tazobactam, imipenem/cilastatin, meropenem, or ertapenem 1.

• Add amikacin if the patient shows signs of shock or sepsis 1.

• Continue antibiotics for 5-7 days for biloma management 1.

Clinical Algorithm Summary

1. Immediate percutaneous drainage of the biloma under imaging guidance
2. Broad-spectrum antibiotics started within 1 hour
3. ERCP within 24-48 hours if drainage output remains high or symptoms persist, with sphincterotomy and plastic stent placement
4. Monitor drainage output and clinical response over 7-10 days
5. Stent removal at 4-8 weeks after confirming leak resolution on follow-up cholangiography 1

Common Pitfalls to Avoid

• Do not delay drainage waiting for MRCP—the CT has already confirmed the diagnosis and percutaneous drainage is both diagnostic and therapeutic 2, 3.

• Do not proceed directly to surgery—minimally invasive approaches are successful in >90% of cases 2, 4.

• Do not observe large bilomas conservatively—this risks progression to biliary peritonitis, abscess formation, or sepsis 1.

• Do not forget endoscopic decompression—percutaneous drainage alone may be insufficient if the underlying bile leak is not addressed 2, 4.