title: An algorithm for the management of bile leak following laparoscopic cholecystectomy.
abstract: BACKGROUND
  The management of bile leaks following laparoscopic cholecystectomy has evolved with increased experience of ERCP and laparoscopy. The purpose of this study was to determine the impact of a minimally invasive management protocol.
  
  
  METHODS
  Twenty-four patients with a bile leak following laparoscopic cholecystectomy were recorded consecutively between 1993 and 2003. Between 1993-1998, 10 patients were managed on a case-by-case basis. Between 1998-2003, 14 patients were managed according to a minimally invasive protocol utilising ERC/biliary stenting and re-laparoscopy if indicated.
  
  
  RESULTS
  Bile leaks presented as bile in a drain left in situ post laparoscopic cholecystectomy (8/10 versus 10/14) or biliary peritonitis (2/10 versus 4/14). Prior to 1998, neither ERC nor laparoscopy were utilised routinely. During this period, 4/10 patients recovered with conservative management and 6/10 (60%) underwent laparotomy. There was one postoperative death and median hospital stay post laparoscopic cholecystectomy was 10 days (range, 5-30 days). In the protocol era, ERC +/- stenting was performed in 11/14 (P = 0.01 versus pre-protocol) with the main indication being a persistent bile leak. Re-laparoscopy was necessary in 5/14 (P = 0.05 versus preprotocol). No laparotomies were performed (P < 0.01 versus pre-protocol) and there were no postoperative deaths. Median hospital stay was 11 days (range, 5-55 days).
  
  
  CONCLUSIONS
  The introduction of a minimally invasive protocol utilising ERC and re-laparoscopy offers an effective modern algorithm for the management of bile leaks after laparoscopic cholecystectomy.
authors.affiliation: Department of Hepatobiliary and Laparoscopic Surgery, Leicester Royal Infirmary, Leicester, UK. fateh3@tiscali.co.uk
authors.forename: F
authors.initials: F
authors.lastname: Ahmad
authors.forename: R N
authors.initials: RN
authors.lastname: Saunders
authors.forename: G M
authors.initials: GM
authors.lastname: Lloyd
authors.forename: D M
authors.initials: DM
authors.lastname: Lloyd
authors.forename: G S M
authors.initials: GS
authors.lastname: Robertson
mesh_terms: D000328:Adult; D000368:Aged; D000465:Algorithms; D001646:Bile; D002760:Cholangiopancreatography, Endoscopic Retrograde; D017081:Cholecystectomy, Laparoscopic; D002985:Clinical Protocols; D004322:Drainage / Q000379:methods; D004653:Empyema / Q000601:surgery; D005260:Female; D042882:Gallstones / Q000601:surgery*; D006801:Humans; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D010195:Pancreatitis / Q000601:surgery; D011182:Postoperative Care / Q000379:methods*; D011183:Postoperative Complications / Q000628:therapy*; D016896:Treatment Outcome