Bile leaks from the intrahepatic biliary tree are an important cause of morbidity following hepatic surgery and trauma. Despite reduction in mortality for hepatic surgery in the last 2 decades, bile leaks rates have not changed significantly. In addition to posted operative bile leaks, leaks may occur following drainage of liver abscess and tumor ablation. Most bile leaks from the intrahepatic biliary tree are transient and managed conservatively by drainage alone or endoscopic biliary decompression. Selected cases may require reoperation and enteric drainage or liver resection for management. 1. Introduction Bile leaks mainly result from injury to the extrahepatic bile duct during cholecystectomy [1–3]. A bile leak from the intrahepatic biliary tree is less frequent and generally follows liver surgery and after blunt or penetrating abdominal trauma [4–6]. Less commonly, bile leaks from the liver may result following drainage of a liver abscess or nonsurgical ablation of liver lesions. The majority of leaks are transient and resolve spontaneously or after nonsurgical interventions like endoscopic retrograde cholangiography and pancreatography (ERCP) with sphincterotomy and/or stenting [6–8]. A few will need operative correction. However, these intrahepatic bile duct leaks result in significant patient morbidity leading to a prolongation of hospital stay and increase in healthcare costs. Bile leaks following liver resection also increase mortality rates [7, 9]. In this paper we will discuss how bile leaks are defined paper classified, what their causes are, and how they should be managed. 2. Definition The most common accepted definition of a bile leak requires the presence of the following:(1)bile discharge from an abdominal wound and/or drain, with a total bilirubin level of >5？mg/mL or three times the serum level,(2)intra-abdominal collections of bile confirmed by percutaneous aspiration,(3)cholangiographic evidence of dye leaking from the opacified bile ducts [10]. 3. Classification Nagano et al. have classified postoperative bile leaks into four types [10]: Type A: minor leaks from small bile radicles on the surface of the liver which are usually self-limiting, Type B: leaks from inadequate closure of the major bile duct branches on the liver’s surface, Type C: injury to the main duct commonly near the hilum, Type D: leakage due to a transected duct disconnected from the main duct. Type A leaks usually close spontaneously with external drainage although sometimes ERCP and sphincterotomy may be required. Types B and C can be managed by ERCP and
References
[1]
S. Connor and O. J. Garden, “Bile duct injury in the era of laparoscopic cholecystectomy,” British Journal of Surgery, vol. 93, no. 2, pp. 158–168, 2006.
[2]
A. M. Hogan, E. Hoti, D. C. Winter et al., “Quality of life after iatrogenic bile duct injury: a case control study,” Annals of Surgery, vol. 249, no. 2, pp. 292–295, 2009.
[3]
G. Nuzzo, F. Giuliante, I. Giovannini et al., “Bile duct injury during laparoscopic cholecystectomy: results of an Italian National Survey on 56 591 cholecystectomies,” Archives of Surgery, vol. 140, no. 10, pp. 986–992, 2005.
[4]
H. L. Pachter and S. R. Hofstetter, “The current status of nonoperative management of adult blunt hepatic injuries,” American Journal of Surgery, vol. 169, no. 4, pp. 442–454, 1995.
[5]
E. H. Carrillo, D. A. Spain, C. D. Wohltmann et al., “Interventional techniques are useful adjuncts in nonoperative management of hepatic injuries,” Journal of Trauma, vol. 46, no. 4, pp. 619–624, 1999.
[6]
L. Capussotti, A. Ferrero, L. Viganò, E. Sgotto, A. Muratore, and R. Polastri, “Bile leakage and liver resection: where is the risk?” Archives of Surgery, vol. 141, no. 7, pp. 690–694, 2006.
[7]
Y. I. Yamashita, T. Hamatsu, T. Rikimaru et al., “Bile leakage after hepatic resection,” Annals of Surgery, vol. 233, no. 1, pp. 45–50, 2001.
[8]
S. Tanaka, K. Hirohashi, H. Tanaka, et al., “Incidence and management of bile leakage after hepatic resection for malignant hepatic tumors,” Journal of the American College of Surgeons, vol. 195, no. 4, pp. 484–489, 2002.
[9]
C. M. Lo, S. T. Fan, C. L. Liu, E. C. S. Lai, and J. Wong, “Biliary complications after hepatic resection: risk factors, management, and outcome,” Archives of Surgery, vol. 133, no. 2, pp. 156–161, 1998.
[10]
Y. Nagano, S. Togo, K. Tanaka et al., “Risk factors and management of bile leakage after hepatic resection,” World Journal of Surgery, vol. 27, no. 6, pp. 695–698, 2003.
[11]
A. K. Pujahari, “Prevention of bile leak after liver surgery: a fool-proof method,” Saudi Journal of Gastroenterology, vol. 15, no. 2, pp. 128–130, 2009.
[12]
S. Agarwal, S. S. Sikora, A. Kumar, R. Saxena, and V. K. Kapoor, “Bile leaks following surgery for hepatic hydatid disease,” Indian Journal of Gastroenterology, vol. 24, no. 2, pp. 55–58, 2005.
[13]
A. Puliga, R. Sulis, M. Pala, R. Sechi, and M. Pietrangeli, “Surgical treatment of hydatid liver cysts: 20 more years of experience,” Chirurgia Italiana, vol. 55, no. 4, pp. 533–540, 2003.
[14]
H. R. Unalp, B. Baydar, E. Kamer, Y. Yilmaz, H. Issever, and E. Tarcan, “Asymptomatic occult cysto-biliary communication without bile into cavity of the liver hydatid cyst: a pitfall in conservative surgery,” International Journal of Surgery, vol. 7, no. 4, pp. 387–391, 2009.
[15]
M. A. Silva, D. F. Mirza, S. R. Bramhall, A. D. Mayer, P. McMaster, and J. A. C. Buckels, “Treatment of hydatid disease of the liver: evaluation of a UK experience,” Digestive Surgery, vol. 21, no. 3, pp. 227–233, 2004.
[16]
A. A. Balik, M. Ba？o？lu, F. ？debi et al., “Surgical treatment of hydatid disease of the liver: review of 304？cases,” Archives of Surgery, vol. 134, no. 2, pp. 166–169, 1999.
[17]
Y. Bilsel, T. Bulut, S. Yamaner et al., “ERCP in the diagnosis and management of complications after surgery for hepatic echinococcosis,” Gastrointestinal Endoscopy, vol. 57, no. 2, pp. 210–213, 2003.
[18]
G. Skroubis, C. Vagianos, A. Polydorou, E. Tzoracoleftherakis, and J. Androulakis, “Significance of bile leaks complicating conservative surgery for liver hydatidosis,” World Journal of Surgery, vol. 26, no. 6, pp. 704–708, 2002.
[19]
M. L. Vignote, G. Mino, M. De la Mata, J. F. De Dios, and F. Gomez, “Endoscopic sphincterotomy in hepatic hydatid disease open to the biliary tree,” British Journal of Surgery, vol. 77, no. 1, pp. 30–31, 1990.
[20]
R. Dumas, R. Le Gall, P. Hastier, M. J. M. Buckley, M. Conio, and J. P. Delmont, “The role of endoscopic retrograde cholangiopancreatography in the management of hepatic hydatid disease,” Endoscopy, vol. 31, no. 3, pp. 242–247, 1999.
[21]
A. Naranjo Rodriguez, A. L. Sanchez del Rio, L. Vignote Alguacil, J. F. De Dios Vega, and G. Mino Fugarolas, “Effectiveness of endoscopic sphincterotomy in complicated hepatic hydatid disease,” Gastrointestinal Endoscopy, vol. 48, no. 6, pp. 593–597, 1998.
[22]
J. B. Dimick, R. M. Wainess, J. A. Cowan, G. R. Upchurch, J. A. Knol, and L. M. Colletti, “National trends in the use and outcomes of hepatic resection,” Journal of the American College of Surgeons, vol. 199, no. 1, pp. 31–38, 2004.
[23]
J. B. Dimick, J. A. Cowan, J. A. Knol, and G. R. Upchurch, “Hepatic resection in the United States: indications, outcomes, and hospital procedural volumes from a nationally representative database,” Archives of Surgery, vol. 138, no. 2, pp. 185–191, 2003.
[24]
J. Belghiti, K. Hiramatsu, S. Benoist, P. P. Massault, A. Sauvanet, and O. Farges, “Seven hundred forty-seven hepatectomies in the 1990s: an update to evaluate the actual risk of liver resection,” Journal of the American College of Surgeons, vol. 191, no. 1, pp. 38–46, 2000.
[25]
W. R. Jarnagin, M. Gonen, Y. Fong et al., “Improvement in perioperative outcome after hepatic resection: analysis of 1,803 consecutive cases over the past decade,” Annals of Surgery, vol. 236, no. 4, pp. 397–407, 2002.
[26]
R. T. Poon, S. T. Fan, C. M. Lo et al., “Improving perioperative outcome expands the role of hepatectomy in management of benign and malignant hepatobiliary diseases: analysis of 1222 consecutive patients from a prospective database,” Annals of Surgery, vol. 240, no. 4, pp. 698–710, 2004.
[27]
H. C. Sun, L. X. Qin, L. Wang et al., “Risk factors for postoperative complications after liver resection,” Hepatobiliary and Pancreatic Diseases International, vol. 4, no. 3, pp. 370–374, 2005.
[28]
A. C. Wei, R. T. P. Poon, S. T. Fan, and J. Wong, “Risk factors for perioperative morbidity and mortality after extended hepatectomy for hepatocellular carcinoma,” British Journal of Surgery, vol. 90, no. 1, pp. 33–41, 2003.
[29]
S. Virani, J. S. Michaelson, M. M. Hutter et al., “Morbidity and mortality after liver resection: results of the patient safety in surgery study,” Journal of the American College of Surgeons, vol. 204, no. 6, pp. 1284–1292, 2007.
[30]
H. Imamura, Y. Seyama, N. Kokudo et al., “One thousand fifty-six hepatectomies without mortality in 8 years,” Archives of Surgery, vol. 138, no. 11, pp. 1198–1206, 2003.
[31]
D. Erdogan, O. R. C. Busch, D. J. Gouma, and T. M. Van Gulik, “Morbidity and mortality after liver resection for benign and malignant hepatobiliary lesions,” Liver International, vol. 29, no. 2, pp. 175–180, 2009.
[32]
D. L. Clarke, E. J. Currie, K. K. Madhavan, R. W. Parks, and O. J. Garden, “Hepatic resection for benign non-cystic liver lesions,” HPB, vol. 6, no. 2, pp. 115–119, 2004.
[33]
R. K. Singh, S. Kapoor, P. Sahni, and T. K. Chattopadhyay, “Giant haemangioma of the liver: is enucleation better than resection?” Annals of the Royal College of Surgeons of England, vol. 89, no. 5, pp. 490–493, 2007.
[34]
A. Zimmermann and H. U. Baer, “Fibrous tumor-liver interface in large hepatic neoplasms: its significance for tumor resection and enucleation,” Liver Transplantation and Surgery, vol. 2, no. 3, pp. 192–199, 1996.
[35]
E. Hamaloglu, H. Altun, A. Ozdemir, and A. Ozenc, “Giant liver hemangioma: therapy by enucleation or liver resection,” World Journal of Surgery, vol. 29, no. 7, pp. 890–893, 2005.
[36]
S. M. Lerner, J. R. Hiatt, J. Salamandra et al., “Giant cavernous liver hemangiomas: effect of operative approach on outcome,” Archives of Surgery, vol. 139, no. 8, pp. 818–823, 2004.
[37]
S. C. Chan, S. T. Fan, C. M. Lo, C. L. Liu, and J. Wong, “Toward current standards of donor right hepatectomy for adult-to-adult live donor liver transplantation through the experience of 200 cases,” Annals of Surgery, vol. 245, no. 1, pp. 110–117, 2007.
[38]
G. Cipe, A. Tuzuner, V. Genc et al., “Living-donor hepatectomy,” Transplantation Proceedings, vol. 43, no. 3, pp. 888–891, 2011.
[39]
T. Iida, Y. Ogura, F. Oike et al., “Surgery-related morbidity in living donors for liver transplantation,” Transplantation, vol. 89, no. 10, pp. 1276–1282, 2010.
[40]
D. LaPointe Rudow, R. S. Brown Jr., J. C. Emond, D. Marratta, S. Bellemare, and M. Kinkhabwala, “One-year morbidity after donor right hepatectomy,” Liver Transplantation, vol. 10, no. 11, pp. 1428–1431, 2004.
[41]
R. M. Ghobrial, C. E. Freise, J. F. Trotter et al., “Donor morbidity after living donation for liver transplantation,” Gastroenterology, vol. 135, no. 2, pp. 468–476, 2008.
[42]
V. Smyrniotis, N. Arkadopoulos, K. Theodoraki et al., “Association between biliary complications and technique for hilar division (extrahepatic vs. intrahepatic) in major liver resections,” World Journal of Surgical Oncology, vol. 4, article no. 59, 2006.
[43]
E. T. Castaldo, T. M. Earl, R. S. Chari et al., “A clinical comparative analysis of crush/clamp, stapler, and dissecting sealer hepatic transection methods,” HPB, vol. 10, no. 5, pp. 321–326, 2008.
[44]
D. A. Geller, A. Tsung, V. Maheshwari, L. A. Rutstein, J. J. Fung, and J. W. Marsh, “Hepatic resection in 170 patients using saline-cooled radiofrequency coagulation,” HPB, vol. 7, no. 3, pp. 208–213, 2005.
[45]
A. Saiura, J. Yamamoto, R. Koga et al., “Usefulness of LigaSure for liver resection: analysis by randomized clinical trial,” American Journal of Surgery, vol. 192, no. 1, pp. 41–45, 2006.
[46]
S. Delis, A. Bakoyiannis, N. Tassopoulos et al., “Clamp-crush technique vs. radiofrequency-assisted liver resection for primary and metastatic liver neoplasms,” HPB, vol. 11, no. 4, pp. 339–344, 2009.
[47]
M. Stojanovi？, M. Radojkovi？, and G. Stanojevi？, “Use of linear radiofrequency device in liver resection,” Vojnosanitetski Pregled, vol. 67, no. 11, pp. 910–915, 2010.
[48]
K. S. Gurusamy, V. Pamecha, D. Sharma, and B. R. Davidson, “Techniques for liver parenchymal transection in liver resection,” Cochrane Database of Systematic Reviews, no. 1, Article ID CD006880, 2009.
[49]
S. G. Delis, A. Bakoyiannis, D. Karakaxas et al., “Hepatic parenchyma resection using stapling devices: peri-operative and long-term outcome,” HPB, vol. 11, no. 1, pp. 38–44, 2009.
[50]
F. K. Balaa, T. C. Gamblin, A. Tsung, J. W. Marsh, and D. A. Geller, “Right hepatic lobectomy using the staple technique in 101 patients,” Journal of Gastrointestinal Surgery, vol. 12, no. 2, pp. 338–343, 2008.
[51]
P. Schemmer, H. Friess, U. Hinz et al., “Stapler hepatectomy is a safe dissection technique: analysis of 300？patients,” World Journal of Surgery, vol. 30, no. 3, pp. 419–430, 2006.
[52]
K. T. Nguyen, T. C. Gamblin, and D. A. Geller, “World review of laparoscopic liver resection-2,804 patients,” Annals of Surgery, vol. 250, no. 5, pp. 831–841, 2009.
[53]
C. Kayaalp, C. Aydin, A. Olmez, S. Isik, and S. Yilmaz, “Leakage tests reduce the frequency of biliary fistulas following hydatid liver cyst surgery,” Clinics, vol. 66, no. 3, pp. 421–424, 2011.
[54]
C. Honoré, E. Vibert, E. Hoti, D. Azoulay, R. Adam, and D. Castaing, “Management of excluded segmental bile duct leakage following liver resection,” HPB, vol. 11, no. 4, pp. 364–369, 2009.
[55]
T. Kyokane, M. Nagino, T. Sano, and Y. Nimura, “Ethanol ablation for segmental bile duct leakage after hepatobiliary resection,” Surgery, vol. 131, no. 1, pp. 111–113, 2002.
[56]
K. Yamakado, A. Nakatsuka, M. Iwata et al., “Refractory biliary leak from intrahepatic biliary-enteric anastomosis treated by selective portal vein embolization,” Journal of Vascular and Interventional Radiology, vol. 13, no. 12, pp. 1279–1281, 2002.
[57]
M. Ijichi, T. Tahayama, H. Toyoda, K. Sano, K. Kubota, and M. Makuuchi, “Randomized trial of the usefulness of a bile leakage test during hepatic resection,” Archives of Surgery, vol. 135, no. 12, pp. 1395–1400, 2000.
[58]
T. Sakaguchi, A. Suzuki, N. Unno et al., “Bile leak test by indocyanine green fluorescence images after hepatectomy,” American Journal of Surgery, vol. 200, no. 1, pp. e19–e23, 2010.
[59]
M. Kaibori, M. Ishizaki, K. Matsui, and A. Hon Kwon, “Intraoperative indocyanine green fluorescent imaging for prevention of bile leakage after hepatic resection,” Surgery, vol. 150, no. 1, pp. 91–98, 2011.
[60]
K. J. Zuzak, S. C. Naik, G. Alexandrakis, D. Hawkins, K. Behbehani, and E. Livingston, “Intraoperative bile duct visualization using near-infrared hyperspectral video imaging,” American Journal of Surgery, vol. 195, no. 4, pp. 491–497, 2008.
[61]
A. Frena and F. Martin, “How to improve bilio-stasis in liver surgery,” Chirurgia Italiana, vol. 58, no. 6, pp. 793–795, 2006.
[62]
A. Hayashibe, K. Sakamoto, M. Shinbo, S. Makimoto, and T. Nakamoto, “New method for prevention of bile leakage after hepatic resection,” Journal of Surgical Oncology, vol. 94, no. 1, pp. 57–60, 2006.
[63]
R. Noun, D. Elias, P. Balladur et al., “Fibrin glue effectiveness and tolerance after elective liver resection: a randomized trial,” Hepato-Gastroenterology, vol. 43, no. 7, pp. 221–224, 1996.
[64]
E. A. Boonstra, I. Q. Molenaar, R. J. Porte, and M. T. de Boer, “Topical haemostatic agents in liver surgery: do we need them?” HPB, vol. 11, no. 4, pp. 306–310, 2009.
[65]
E. A. Boonstra, M. T. De Boer, E. Sieders et al., “Risk factors for central bile duct injury complicating partial liver resection,” British Journal of Surgery, vol. 99, no. 2, pp. 256–262, 2012.
[66]
Y. Fu, W. Yang, J.-Y. Wu et al., “Intrahepatic biliary injuries associated with radiofrequency ablation of hepatic malignancies,” Chinese Medical Journal, vol. 124, no. 13, pp. 1957–1963, 2011.
[67]
H. Kasugai, Y. Osaki, H. Oka, M. Kudo, and T. Seki, “Severe complications of radiofrequency ablation therapy for hepatocellular carcinoma: an analysis of 3,891？ablations in 2,614？patients,” Oncology, vol. 72, supplement 1, pp. 72–75, 2007.
[68]
J. Machi, S. Uchida, K. Sumida et al., “Ultrasound-guided radiofrequency thermal ablation of liver tumors: percutaneous, laparoscopic, and open surgical approache,” Journal of Gastrointestinal Surgery, vol. 5, no. 5, pp. 477–489, 2001.
[69]
W. T. Kong, W. W. Zhang, Y. D. Qiu et al., “Major complications after radiofrequency ablation for liver tumors: analysis of 255？patients,” World Journal of Gastroenterology, vol. 15, no. 21, pp. 2651–2656, 2009.
[70]
D. K. Agarwal, S. S. Baijal, S. Roy, B. R. Mittal, R. Gupta, and G. Choudhuri, “Percutaneous catheter drainage of amebic liver abscesses with and without intrahepatic biliary communication: a comparative study,” European Journal of Radiology, vol. 20, no. 1, pp. 61–64, 1995.
[71]
S. M. Sandeep, V. S. Banait, S. K. Thakur, M. R. Bapat, P. M. Rathi, and P. Abraham, “Endoscopic biliary drainage in patients with amebic liver abscess and biliary communication,” Indian Journal of Gastroenterology, vol. 25, no. 3, pp. 125–127, 2006.
[72]
B. C. Sharma, N. Agarwal, S. Garg, R. Kumar, and S. K. Sarin, “Endoscopic management of liver abscesses and cysts that communicate with intrahepatic bile ducts,” Endoscopy, vol. 38, no. 3, pp. 249–253, 2006.
[73]
B. C. Sharma, V. Garg, and R. Reddy, “Endoscopic management of liver abscess with biliary communication,” Digestive Diseases and Sciences, vol. 57, no. 2, pp. 524–527, 2012.
[74]
K. Sugimoto, Y. Asari, T. Sakaguchi, T. Owada, and K. Maekawa, “Endoscopic retrograde cholangiography in the nonsurgical management of blunt liver injury,” Journal of Trauma, vol. 35, no. 2, pp. 192–199, 1993.
[75]
M. Bala, S. Abu Gazalla, M. Faroja, et al., “Complications of high grade liver injuries: management and outcome with focus on bile leaks,” Journal of Trauma Resuscitation and Emergency Medicine, vol. 20, no. 1, 2012.
[76]
E. H. Carrillo and J. D. Richardson, “Delayed surgery and interventional procedures in complex liver injuries,” Journal of Trauma, vol. 46, no. 5, p. 978, 1999.
[77]
A. De Backer, H. Fierens, A. De Schepper, P. Pelckmans, P. G. Jorens, and W. Vaneerdeweg, “Diagnosis and nonsurgical management of bile leak complicated by biloma after blunt liver injury: report of two cases,” European Radiology, vol. 8, no. 9, pp. 1619–1622, 1998.
[78]
A. Bridges, C. M. Wilcox, S. Varadarajulu, et al., “Endoscopic management of traumatic bile leaks,” Gastrointestinal Endoscopy, vol. 65, no. 7, pp. 1081–1085, 2007.
[79]
W. L. Wahl, M. M. Brandt, M. R. Hemmila, and S. Arbabi, “Diagnosis and management of bile leaks after blunt liver injury,” Surgery, vol. 138, no. 4, pp. 742–748, 2005.
[80]
S. K. D'Amours, R. K. Simons, C. H. Scudamore, A. G. Nagy, and D. R. G. Brown, “Major intrahepatic bile duct injuries detected after laparotomy: selective nonoperative management,” Journal of Trauma, vol. 50, no. 3, pp. 480–484, 2001.
[81]
M. Griffen, J. Ochoa, and B. R. Boulanger, “A minimally invasive approach to bile peritonitis after blunt liver injury,” American Surgeon, vol. 66, no. 3, pp. 309–312, 2000.
[82]
W. Yoon, Y. J. Yong, K. K. Jae et al., “CT in blunt liver trauma,” Radiographics, vol. 25, no. 1, pp. 87–104, 2005.
