Bile Leak Post Laparoscopy Cholecystectomy

A Case Study

By: Heather Call

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.