What are the causes and management of bile leak after hepatico(hepatic)-jejunostomy?

From the Guidelines

Bile leaks after hepaticojejunostomy should be managed with a stepwise approach, starting with percutaneous drainage and broad-spectrum antibiotics, and considering endoscopic retrograde cholangiopancreatography (ERCP) with stent placement for larger or persistent leaks, as recommended by the 2020 WSES guidelines 1.

Initial Management

The initial treatment involves adequate drainage of the leak, which can be achieved through percutaneous drainage catheters placed radiologically. Patients should receive broad-spectrum antibiotics such as piperacillin-tazobactam 4.5g IV every 8 hours or meropenem 1g IV every 8 hours to prevent cholangitis and sepsis.

• Nutritional support is essential, typically through parenteral nutrition initially, transitioning to enteral feeding when tolerated.
• Monitoring liver function tests, inflammatory markers, and serial imaging helps assess treatment response and guides the duration of therapy.

Interventional Management

For small leaks, conservative management with drainage and antibiotics for 1-2 weeks is often sufficient. Larger or persistent leaks may require ERCP with stent placement, though this can be technically challenging after hepaticojejunostomy and may require percutaneous transhepatic approaches.

• The use of ERCP with sphincterotomy is recommended for biliary anastomosis leakage in the post-transplantation period, as stated in the EASL clinical practice guidelines 1.
• In cases of stenosis of the biliary anastomosis without improvement after conservative treatment, it is recommended to perform a hepatico-jejunostomy, as mentioned in the EASL guidelines 1.

Surgical Revision

Surgical revision is reserved for cases that fail conservative and interventional management, typically after 2-4 weeks of unsuccessful treatment.

• The underlying cause of bile leaks is usually technical, including inadequate anastomotic technique, tissue ischemia, or excessive tension at the anastomosis, as discussed in the 2020 WSES guidelines 1.
• Early recognition and management are crucial as prolonged bile leaks can lead to peritonitis, sepsis, and significant morbidity.

From the Research

Bile Leak after Hepaticojejunostomy

• Bile leaks after hepaticojejunostomy represent a major complication carrying a high risk for prolonged hospital stay, biliary peritonitis, and the need for placing interventional drains or even conducting a re-laparotomy 2.
• The incidence of clinically relevant bile leaks after hepaticojejunostomy was significantly associated with simultaneous liver resection, preoperative biliary drainage (PBD), and the placement of stents through the anastomosis 2.

Risk Factors for Bile Leaks

• Preoperative radiochemotherapy, preoperative low cholinesterase levels, biliary complications after liver transplantation necessitating a hepaticojejunostomy, and simultaneous liver resection are risk factors for bile leakages 3.
• A body mass index greater than 35 kg/m2, endoscopic biliary drainage, and an anastomosis on the segmental bile ducts are independent predictors of leakage 4.

Management of Bile Leaks

• Management of bile leaks after hepaticojejunostomy can be safely done with percutaneous transhepatic biliary drainage 4.
• Early bile leaks as well as failed interventional therapy are indications for reoperation 5.
• Reoperation technique can only be discussed on a low evidence level due to the lack of comparative studies 5.

Long-term Follow-up

• Long-term follow-up is essential for assessment of success of the surgical repair of post-cholecystectomy bile duct injuries 6.
• Post-ERCP pancreatitis, number of anastomosis, operative time, post-operative early complications, and post-operative bile leak were predictors for poor outcome 6.