Bile Leak Post Laparoscopy Cholecystectomy -...
Transcript of Bile Leak Post Laparoscopy Cholecystectomy -...
Introduction
SMD is a 58 year old male who was admitted on September 13, 2011, with gall stones
and received surgery via a closed cholecystectomy which became an open surgery. Three days
status post cholecystectomy, SMD’s condition worsened. The patient had several
complications in his hospital stay in the intensive care unit (ICU) and the intermediate care
(IMC) floor before finally being discharged to in house rehabilitation unit.
Patient Profile
As mentioned, SMD is a 58 year old male who was married. He had worked for the IRS
for thirty-three years and was retired. The patient’s wife still is employed and they dad three
children with one that was a thirty year old disabled son who still lived at home. The patient
denied any tobacco or alcohol use.
Medical/Surgical History
SMD had a past medical history of obesity, diabetes mellitus (DM), hypertension (HTN),
sleep apnea, back pain, and a prior anterior wall myocardial infarction (MI) with stenting in
2007. He had no significant past surgical history.
On September 13, 2011, SMD was suppose to have a laparoscopic cholecystectomy,
which turned into an open cholecystectomy. Three days status post the open cholecystectomy,
SDM experienced worsening respiratory status and hypotension and required intubation and
use of pressors. A nasogastric tube was placed, and a coffee ground substance was removed
from the patient’s stomach. A computed topography scan was performed.
There was an exploratory laparoscopy which showed lots of bile. The total parenteral
nutrition (TPN) was initiated. The patient continued on mechanical vent. The TPN was
advanced to goal with the use of 11 units of insulin added to it on September 18th. The patient
did have exploratory surgery on the September 18th showing a bile leak. The patient appeared
to be improving. A failed attempt at a placement of a biliary drain happened on September 19th
with the placement of a small bowel feeding tube (SB FT) and advanced to goal. TPN was
discontinued after the current bag was emptied.
September 20th, a bile leak was found from the cystic duct. An endoscopic retrograde
cholangiopancreatogram (ERCP) was performed of which the feeding tube (FT), running at 40
ml/hr, was held. A common bile duct (CBD) stent was placed on the 20th. The patient was still
on ventilator support as of September 21st and the FT was at goal, then later decreased. Colace
was initiated due to being negative for stool over the previous two days. Ventilator support
continued still on September 22nd and patient received an abdominal computed topography
scan with oral contrast which showed a collection of fluid. FT was advance to goal of 75 ml/hr,
and the patient was still negative for stool.
September 23rd, the patient continued on vent support and was hemodynamically
unstable, which improved after there was drainage of the perisplenic fluid that was found to be
bile. The patient was positive for stool. The FT was held previous night due to a drain
puncturing the stomach, but it was restarted and was advancing slowly. The following day the
patient remained on ventilator support with the FT at 50 ml/hr and D5 solution was stopped.
As of September 26th, the patient was on vent support and was found to be Clostridium
difficile (C-diff) negative. FT was increased to 75 ml/hr and patient was having multiple liquid
stools. The patient continued on vent support and was edematous on September 27th. Per the
physician, the enteral formula was changed to Nepro and beneprotein was added and patient
received a rectal tube. The patient continued with diarrhea on September 28th, but was C-diff
negative a second time. September 29th SMD started to have some excoriation of the skin
surrounding his drain sites. The patient’s rectal tube was then discontinued on September 30th.
On October 3rd, SMD’s tube feedings were held for a test, but were restarted and the
doctor wanted it to be increased due to the patient’s low prealbumin. The patient went to
interventional radiology (IR) on October 4th in order to convert the current Jackson-Pratt (JP)
drain in the stomach into a percutaneous endoscopic gastrostomy (PEG) tube, which then had
the pigtail removed to convert into a gastrostomy jejunostomy tube on October 5th. On
October 5th the patient’s wounds were noticed to be much improved and he continued to have
severe diarrhea. The patient was being weaned off of the ventilator on October 7th, and he had
3 abdominal drains removed, but the CBD remained.
Due to the continuation of SMD’s diarrhea, culturelle was started on October 8th. They
were continuing to wean him off of the ventilator, and it was recommended by the registered
dietitian (RD) to change the enteral formula to Impact Peptide 1.5 due to the patients
continued wounds and low prealbumin. The patient did pass a swallow evaluation on October
5th and was started on a pureed diet, but continuing with the feeding tube running at 55 ml/hr.
The patient appeared to tolerate the pureed diet as of the 11th, but he did not eat much and
had little appetite, so the FT was changed to night (NOC) feeds. The trach was buttoned on
October 12th along with a diet change to National Dysphagia Diet 3 (NDD3)/chopped, but the
patient continued with poor appetite and inadequate intake. A RT was also placed on the 12th.
The patient returned to the ICU from IMC on October 13th being febrile and tachycardic,
and a CT the following day showed a collection of fluid in the left upper quadrant (LUQ) which
was found to be purulent. The patient was returned to ventilator support. As of October 18th,
SMD was still on the vent, but was being weaned again. The patient continued with a rectal
tube and was once again found to be C-diff negative despite the continuation of diarrhea.
October 20th led to the patient complaining new epigastric pain and a KUB showed that he had
distended bowel areas (primarily in the colon) with a non-obstructive gas pattern. The
patient’s abscess was drained on the 21st and tube feedings were held until after the
procedure. On the 25th, tube feeds were again held due to two more abdominal drains being
placed for multiple abscesses, but were restarted and back at goal.
SMD was able to be weaned off ventilator support on October 29th, but continued with
a trach mask in place. On October 31st, the patient reported he did not like supplements and
his tube feed was held and he was nothing per os (NPO) for an ERCP in which stones were
removed. On November 1st, the patient refused all supplements and had poor intake. NOC
tube feeds were restarted and the speech language pathologist (SLP) noted the patient
tolerated a NDD3 diet. November 3rd, PO varied and patient had only been ordering 700-900
kcals a day the previous 2 days. Trach was buttoned, 1 unit packed red blood cells were
transfused. On November 5th the patients PO remained the same and a CT scan of the right
upper quadrant (RUQ) showed significant improvement with no new collections.
November 7th resulted with no PO that day or the previous day. Labs indicated the use
of a continuous feed of Nepro to meet needs and nephrology was consulted. Patient was to
start hemodialysis if potassium did not improve. It was suspected on November 8th that the
patient experience acute kidney injury (AKI) secondary to tobramycin. The patient still
continued with liquid stool. Blood glucose was being controlled with lantus and sliding scale
insulin. On the 10th the patient was still on Nepro, and Allbee with vitamin C and two scoops of
beneprotein were added to the tube feed. The patient received dialysis for electrolytes tending
to be elevated.
An esophogastroduodenoscopy (EGD) was performed on November 11th. The tube feed
was held for a gastrointestinal (GI) bleed. The patient also was positive for black stool per the
rectal tube. The patient was then transfused with two unites of packed red blood cells (RBC).
Hemodialysis was also performed on the 11th and again on the 12th. The results of the EGD
performed on the 11th showed gastritis.
By November 15th the patient was tolerating room air with the trach out. The tube feed
was running at goal. Hemodialysis was being performed every day and the patient’s diarrhea
was improving. The rectal tube was out and the patient was overall doing better. The patient
was tolerating a consistent carbohydrate and two gram sodium diet, but his appetite was still
poor and patient was not eating much. The patient declined all oral supplements and was
going to try to eat more. The tube feed was turned down per physician to run over 12 hours on
November 16th. The patient was complaining of tremors causing problems with self-feeding
and OT was called to provide weighted silverware.
The patient was still not eating well on the 17th reporting the weighted silverware was
not helping with feeding. Nursing and family reported that the patient did not want chopped
food. November 18th was the day of assessment and the patient was no longer receiving
dialysis and was producing large amounts of fluid. The patient did report an increase in
appetite after the tube feed was reduced.
Bile Leak Post Laparoscopic Cholecystectomy
Bile is defined as a thick, viscid, bitter-tasting fluid secreted by the liver. 1 The path of
bile from the liver is either to the cystic duct of the gall bladder or to the duodenum. 1 The
color of bile depends on its last location. 1 If bile comes from the liver, it is straw colored; if it
comes from the gall bladder it can be yellow to brown to green. 1 It is stored and concentrated
in the gall bladder before it is released into the duodenum when stimulated by the presence of
fatty chime. 1 The bile salts act as emulsifiers of fat. 1 These salts emulsify the ingested fats
which help facilitate the digestion of fat by pancreatic lipase. 1 Bile is also responsible for
helping stimulate peristalsis. 1
The gall bladder contracts and the biliary sphincter relaxes due to the release of gut
hormones and cholinergic stimulation. 2 Approximately seventy-five percent of the bile stored
in the gall bladder are released by the stimulation caused by the intake of an average meal. 2
When fasting, there is an increase in sphincter tone which aids in the storage of bile. 2 Bile
salts are not absorbed passively and generally reach the terminal ileum before being actively
absorbed back into the portal vein. 2 These salts then return to the liver and are modified and
secreted back into the gall bladder. 2
Bile leaks can be a problem with laparoscopic cholecystectomies. 3 Laparoscopic
cholecystectomies are not the only cause of leaks, though. Any abdominal surgery can be
responsible for a leak leading to a biloma. 4 Though it is reported that bile leaks post
laparoschopic cholecystectomy are uncommon. 5 Laparoscopic surgery is preferred in gall
bladder removal due to the benefits of less pain and discomfort, earlier return to normal
activities, and better cosmetic results. 3 The most common site for bile leaks are the cystic duct
stump, and the greater severity of bile leaks tend to be those in closed surgery rather than
open. 3 Though the cystic duct stump is a common site for leaks, other sites include the
accessory ducts of Luschka, the common bile duct, common hepatic duct, or the liver bed. 3
The other ducts that can be involved in bile leaks, do so often due to injury during the severing
of the cystic duct. 3
The pathogenisis of a bile leak is not entirely clear, but factor such as inflammatory
changes in the area, a stone in the common bile duct, or dysfunction of the sphincter of Oddi
may play a role. 3 The fact that it has little pain associated with it makes early diagnosis
difficult subsequently leading to increase in morbidity and mortality. 3 With bile leaks the cost
of hospitalization increases most likely due to medications, increased length of stay, and more
diagnostic and therapeutic procedures. 3 Though several preventative measures are being
researched and discussed, the most important preventative measure seems to remain with the
determination of the biliary anatomy during the operation. 3
Over seventy-five percent of bile duct injuries will not be seen or noticed during surgery.
3 The first warning should be the patient’s continued malaise without improvement in the
postoperative period. 3 Patients often are asymptomatic for three to six days post surgery. 3
Infection or the mechanical effect of a biloma may be signs and symptoms of a leak. 3 The
subhepatic area is the most common area for a biloma, but they can also form in intrahepatic
or retroperitoneal space. 3 Common symptoms include fever, anorexia, malaise, nausea,
vomiting, and jaundice. 3 The mild elevation of serum alanine and aspartate transaminases are
often common post laparoscopic cholecystectomies and is thought to be related to the
increased abdominal pressure from the surgery. 3 Abdominal distention and gradual or sudden
abdominal pain can also be clinical presentations of bile collections. 4 Major output from a bile
drain is indicative of severe ductal injury. 4
The best way to diagnose a bile leak is through an ERCP. 3 One may also identify a bile
leak via ultrasonography (US) or computed topography (CT), or both. 4 The stay for bile leaks
are longer, but those that required the drainage of a biloma are still longer. 3 The placement of
stents and sphincterotomies have been used to close bile leaks. 3 Low-grade leaks are
considered those that can only be seen after the biliary tree has been opacified. 3 A high grade
leak are those that have been seen before the opacification of the biliary tree. 3
The use of endoscopic therapy to treat bile leaks allow for more accurate and less
invasive treatment compared with percutaneous cholangiography and allow for precise
identification of low-level biliary injuries. 4 Favorable outcomes of endotherapy are predicted
for those whose leaks are extrahepatic rather than intrahepatic, whose injuries are <5 mm,
distal obstruction which can be treated with sphincterotomy alone, and the absence of bile in
the peritonitis or intra-abdominal abscess. 4 The insertion of a stent post and endoscopic
spincterotomy is not always advisable, though it is proposed that ERCP with stent placement
should be considered the therapeutic and diagnostic treatment of choice due to the large
success of the treatment for bile leaks. 4 Another recommended treatment is the placement of
a nasobiliary drain (NBD). 4 Christofordis et al. conclude that endoscopic retrograde
cholangiography (ERC) can accurately diagnose the cause of a phostcholecystectomy bile leak
and bilorma formation, and that endoscopic spincterotomy (ES) and selective stent placement
with percutaneous drainage represents the foundation of a definitive treatment. 4 Another
article concluded that stent insertion alone was superior to sphincterotomies alone due to
fewer interventions needed to control leaks. 5
Though bile leaks due to laparoscopic cholecystectomies are uncommon, there is a need
to find preventative measures and more effective and less expensive modes of treatment.
More research is needed before any solid conclusions can be made.
Treatment and Prognosis
The patient was admitted on September 13th with gall stones and had a complicated
cholecystectomy. The patient was treated for his subsequent respiratory distress with
ventilator support and the use of a tracheostomy. When the bile leak was found, the patient
underwent treatment for it with surgery and biliary drains. Abscesses were drained and
cleaned as well in his stay at McKay-Dee. The patient was also fed via feeding tube to help with
nutrition and the treatment of abnormal electrolytes through specialized formulas. Dialysis was
also performed to help with electrolyte balance. The patient’s overall prognosis is good. By
the time of the last assessment the patient was starting to have an increased appetite, required
no respiratory support, and his wounds were healing.
Medications
The patient was on several medications. He did happen to have a GI bleed and gastritis
which are two of the medications possible side effects. The patient’s medications were as
follows:
Acetaminophen 650 mg, q 4 hrs prn
Analgesic/Antipyretic N/A
Aspirin 81 mg, daily Analgesic/Antipyretic/ NSAID/CVA prevention
Anorexia, may cause serious gastric bleeding, N/V, black tarry stools, dyspepsia
Calcium (in elemental Mg) 500 mg q 8 hrs
Calcium supplement Anorexia, dry mouth, decrease diarrhea
Citalopram 40 mg daily
Antidepressant, SSRI Increase wt, increase appetite, anorexia, decrease wt, dry mouth, dysgeusia, N/V/D, abd pain, flatulence
Darbepoetin, 100 ug q 7 days
Antianemic N/V, diarrhea
Fenofibrate 160 mg daily
Antihyperlipidemic N/V, constipation
Heparin 300 units as directed
Anticoagulant N/V, abd pain, constipation, GI bleeding
Lansoprazole 30 mg daily
Antiulcer, antiGERD, antisecretory
Increased gastric pH, nausea, abdominal pain, diarrhea, decrease gastric acid secretion
Lantus Antidiabetic, Hypoglycemic
Hypoglycemia, increase wt,
Miralax 1 ea BID, prn Laxative Nausea, bloating, cramps, flatulence, diarrhea
Novolog Glucose control Increase wt, hypoglycemia
Ondansetron 4 mg q 6 hrs, prn
Antiemetic, antinauseant
Dry mouth, abd pain, constipation, diarrhea
Oxycodone 5 mg q 4 Analgesic, narcotic, Anorexia, dry mouth, dyspepsia,
hrs, prn opioid gastritis, N/V, diarrhea, constipation
Propranolol 80 mg BID
Antiarrhythmic, antiangina, antihypertensive, antimigraine, hypertrophic subaortic stenosis
Dry mouth, N/V, epigastric distress, diarrhea, constipation
Prenisone daily Anti-inflammatory, immunosuppressant
Increased appetite, increased wt, esophagitis, N/V, dyspepsia, peptic ulcer, GI bleed/perforation
Simvastatin 20 mg daily
Antihyperlipidemic Nausea, dyspepsia, abd pain, constipation, diarrhea, flatulence
Theragran-M 1 ea daily
Vitamin and mineral supplement
N/A
Zolpidem 1 ea daily Sleep Aid Dry mouth, pharyngitis, N/V, diarrhea, constipation
Anthropometrics
11/18 05:31
11/17 10:07
11/16 06:00
11/15 06:00
11/14 05:56
11/13 06:06
11/12 05:41
11/11 05:41
11/09 06:24
Wt Kg 124.9 126.8 126.8 125.9 131.4 139.1 140.0 141.8 145.5
Wt lb 247.7 277.2 277.2 276.98 289.1 306.2 308 311.96 320.1
Source Bed Bed Bed Bed Bed Bed Bed Bed Bed
Ht cm 180.3 180.3 180.3 180.3 180.3 180.3 180.3 180.3 180.3
Ht in 70.9 70.9 70.9 70.9 70.9 70.9 70.9 70.9 70.9
BMI 38.42 39.01 39.01 38.73 40.42 42.79 43.07 43.62 44.76
IBW (Kg) 78 78 78 78 78 78 78 78 78
IBW % 160 163 163 161 169 178 180 182 187
The patient was morbidly obese. His wt was documented to be decreased by 70 pounds
over the course of 10 days. The patient did have lots of fluid retention and the majority of his
wt loss was likely due to fluid excretion.
Laboratory Data
Test Date 11/12
Date 11/13
Date 11/14
Date 11/15
Date 11/16
Date 11/17
Date 11/18
Normal Reference Range
Alb 2.7 L 2.5 L 3.0 L 3.0 L 3.1 L 3.0 L 3.5-5.0 mg/dL
PALB 38.5 20-40 mg/dL
TP 6.2 6.9 6.8 6.7 6.7 6.0-8.5 g/dL
DB 0.0 0.0 0.0 0.0 =/< 0.3 mg/dL BIL 0.0 0.1 0.0 0.1 0.1-1.0 mg/dL
NA 136 L 135 L 134 L 132 L 132 L 133 L 137 134-146 mmol/L
K 3.7 3.5 3.6 3.7 3.2 L 3.3 L 3.8 3.5-5.0 mmol/L
CL 103 101 100 97 L 96 L 98 102 98-109 mmol/L
P 5.7 H 4.9 H 3.8 4.1 4.6 5.4 H 4.9 H 3.5-5.0 mg/L
MG 1.8 1.8 2.1 2.0 1.9 1.9 1.7-2.4 mg/dL
CO2 23 L 24 24 26 25 23 19 L 24-30 mmol/L
GLUC 120 H 121 H 126 H 132 H 120 H 97 102 H 65-99 mg/dL
BUN 93 H 73 H 59 H 51 H 67 H 69 H 63 H 6-21 mg/dL
CREAT 5.43 H 3.82 H 3.09 H 2.50 H 2.35 H 2.29 H 2.03 H .52-.99 mg/dL
ALK 691 H 513 H 415 H 356 H 317 H 40-120 U/L
SGOT 76 H 85 H 91 H 96 H 73 H 9-52 U/L
SGPT 83 H 77 H 95 H 102 H 98 H 16-52 U/L
WBC 15.1 H 17.7 H 20.8 H 28.5 H 27.7 H 23.2 H 23.0 H 4.5-11 x103 / mm3
PLT 447.0 H 392.0 337.0 372.0 476.0 H 527.0 H 553.0 H 150-400 K/mm3
Hgb 8.6 L 7.8 L 7.9 L 8.4 L 8.3 L 8.6 L 8.7 L 42-52%
Hct 24.9 L 22.6 L 23.0 L 24.1 L 24.8 L 25.4 L 25.5 L 14-18 g/dL
MPV 7.2 7.3 7.7 7.9 8.5 8.0 7.7
The labs indicate fluid overload with his low albumin and prealbumin and his kidney
failure with dialysis. Sodium levels and potassium returned to normal limits. Elevated
phosphorus likely due to his renal problems during his stay. Low CO2 is also related to kidney
function and respiratory dysfunction. BUN and creatinine are levels also indicate renal
insufficiency. Liver function labs related to stress of his condition. Elevated white blood cells
indicate infection. The patient was anemic, but his kidneys were in dysfunction and may not
have produced sufficient erythropoietin and the fluid from his dysregulation could further make
his labs falsely low. The patients elevated glucose can be explained by the use of prednisone.
Diet Evaluation
SMD was a patient who had been on nutrition support for the over a month. Originally
the patient started with TPN after his complicated surgery and was weaned from TPN to enteral
nutrition on September 19th, 2011. Tube feedings were monitored and changed as needed
based upon the patient’s condition. The patient reached goal of his first FT on the same day it
was initiated. When regular oral intake was started the patient had poor appetite that left his
PO was not adequate. NOC feeds were initiated to try to aid in the stimulation of hunger. The
patient’s appetite did improve and the TF was further weaned, with the goal of the patient
meeting his needs without nutrition support.
Date & time Diet order PO% Assess tolerance to diet
Is diet adequate to meet patient’s
needs?
11/3/2011 Regular Consistent Carb and Low Na diet
Good No
11/2/2011 NDD3 Consistent Carb and Low Na diet
Fair No
11/1/2011 NPO N/A Good No
10/29/2011 NDD3 Consistent Carb and Low Na Diet
Fair No
10/13/2011 NPO N/A Good No
10/12/2011 NDD3 Consistent Carb and Low Na Diet
Good No
10/10/2011 NDD1 Consisntent Carb and Low Na Diet
Poor No
9/16/2011 NPO N/A Good No
The patient was receiving nutrition support from September 17th through when the last
assessment was completed. His nutrition support orders for the previous month. By the time
of October the patient was able to tolerate tube feeds and goals were met the day the orders
were written. The nutrition support orders were as follows:
Date Nutrition Support Order Goal Met Tolerance
11/18/2011 NOC FT: Nepro @ 80 mls/hr x 8 hrs, 2 scoops beneprotein TID to provide 50% of needs: 1300 kcals (17 kcals/kg), 87 g protiein (1.1 g/kg)
Yes Good
11/16/2011 NOC FT: Nepro 75 ml/hr x 12 hr, 2 scoops beneprotein TID to provide 74% of estimated needs, 1170 kcal (23 kcal/kg), 110 g protein (1.4 g/kg)
Yes Good
11/15/2011 Continuous FT: Nepro 60 ml/hr providing 2376 kcals (30/kg), 107 g protein (1.4 /kg) Now with G-J tube.
Yes Good
11/10/2011 Continuous FT: Nepro 60 ml/hr, 2 scoops beneprotein providing 2426 kcal (31.1/kg), 119 g protein (1.52 g/kg) N-J tube.
Yes Good
11/7/2011 Continuous FT: Nepro 60 ml/hr providing 2376 kcal (30 /kg) 107 g protein (1.5 /kg) GJ tube
Yes Good
10/25/2011 Continuous FT: Impact peptide 1.5 @ 60 ml/hr, glutamine QID providing 2220 kcals (28.5/kg), 164 g protein (2.1/kg) G-J tube
Yes Good
10/18/2011 Continuous FT: Impact peptide 1.5 @ 55 ml/hr, glutamine QID providing 2055 kcals (26.3.2/kg), 154 g protein (2 /kg) G-J tube
Yes Good
10/14/2011 Continous FT: Impact peptide 1.5 @ 50 ml/hr, glutamine QID providing 2890 kcals (24.2/kg), 143 g protein (1.8/kg) G-J tube
Yes Good
Education
No educations were deemed appropriate for the patient.
Nutrition Care Plan
This complicated patient required significant nutrition support. At the time of the last
assessment performed at the time the patient’s condition had greatly improved. The feeding
tube was still running, but only on a NOC schedule. The nutrition care plan as of November
18th, was as follows:
Active problems were as follows:
Increased nutrient needs related to healing as evidenced by small open abdominal
wounds
Inadequate oral intake related to decreased appetite as evidenced by minimal oral
intake
The active goal was:
Meet nutrition needs
The active interventions were as follows:
Regular consistent carbohydrate and low sodium diet
Decrease TF to NOC feed with goal rate of Nepro @ 80 ml/hr x 8 hrs. Continue with
current beneprotein 2 scoops tid to provide 50% of needs: 1300 kcals (17 kcals/kg) 87 g
protein (1.1 g/kg)
Nutrition Note
The following is the follow-up nutrition note using the format dictated by McKay-Dee
Hospital on November 18, 2011.
Pt morbidly obese. Labs improving. 4 wounds active (3 surgical wounds of which 2 are
open and one is closed, and an area of blotchy irritation on right fingers). Increased
appetite with decreased FT. Can continue to wean off of FT as PO increases.
Summary and Conclusion
The patient was an obese person who had a cholecystectomy that ended up being open
instead of closed. The patient went into respiratory failure, was found to have a bile leak that
lead to severe inflammation and infection. Bile was drained and abdominal abscesses found
afterwards were also cleaned and drained. The patient’s condition was improving and it was
expected that the patient would transition to the rehab floor within time. Patient prognosis
was good if his appetite continued to improve and his wounds continued to heal without
infection.
References
1. Taber’s Cyclopedic Medical Dictionary. 21st ed. Philadelphia, P.A.: F.A. Davis Company; 2009.
2. Merck Manual. 18th ed. Whitehouse Station, N.J.: Merk Research Laboratories; 2006.
3. Massoumi H, Kiyici N, Hertan H. Bile Leak After Laparoscopic Cholecystectomy. Jounral of Clinical Gastroenterology. 2007, 41:301-305.
4. Christofordis E, Vasiliadis K, Goulimaris I, et al. A Single Center Experience in Minimally Invasive Treatment of Postcholecystectomy Bile Leak, Complicated With Biloma Formation. Journal of Surgical Research. 2007, 141:171-175.
5. Kaffes A, Hourigan L, De Luca N, et al. Impact of endoscopic intervention in 100 patients with suspected postcholecystectomy bile leak. Gastrointestinal Endoscopy. 2005, 61:269-275.