Laparoscopic Cholecystectomy Complicated With Bile Leak Four Months Postoperative

Introduction: Laparoscopic cholecystectomy is associated with complications mostly due to peri-cholecystitis, transection of the common bile duct, biliary fistulas, and complex adhesions. Complication rates of laparoscopic cholecystectomy include bile duct injury (0.26%-0.6%), vascular injury or hemorrhage (0.11%-1.97%), abscess (0.14%-0.3%), retained gallstones (0.81%-5.71%), bowel injury (0.14%-0.35%), bile leak (0.3%-0.9%), and port site hernia (0.77%). We present a rare case of bile leak that occurred 4 months after laparoscopic cholecystectomy. The rarity lies in timing, as common bile leaks appear within the first week of surgery and occasionally appear up to 30 days later. Case Description/Methods: A 67-year-old woman with a history of diabetes mellitus type II, hyperlipidemia, and cholecystectomy 4 months earlier presented to the emergency room complaining of abdominal pain. Upon surgical exploration, purulent bile (1.5 liters) was observed within the abdomen. Washout occurred and 2 Jackson-Pratt drains were placed. An initial cholangiogram was performed that confirmed the location of the leak was originating from the cystic duct stump (Figure 1A). The following day, an endoscopic retrograde cholangiopancreatography was performed. Sphincterotomy was performed due to findings of papillary stenosis and the sludge was removed using a biliary stone extraction balloon. A straight plastic biliary stent was placed in the common bile duct to divert bile (Figure 1B). Subsequently, the Jackson-Pratt drain was collecting minimal of bilious fluid during the hospital stay which confirmed the treatment of bile leak. Discussion: Biliary leaks are rare complications that occur in 0.3-0.9% of patients after laparoscopic cholecystectomy. They commonly occur due to surgical injury to a bile duct, which can be attributed to variations in the anatomy of the biliary duct, unsecure clips or ligatures, obstruction, or stricture of a biliary stump. The entirety of cases reported observe a cystic duct stump leak occur within 30 days of cholecystectomy, meaning a presentation occurring 4 months after surgery particularly rare. Based on the findings of papillary stenosis in the endoscopic retrograde cholangiopancreatography, possible etiology of bile leak in this situation could be due to inflammation-induced stump dehiscence, trauma, and/or increased intraductal pressure.Figure 1.: (A) Endoscopic retrograde cholangiopancreatography presenting cystic duct stump leak (red circle). (B) Endoscopic retrograde cholangiopancreatography 2 months post stent placement.