The sensitivity for detecting intra-abdominal bile collections was 70% and 64%, respectively, for ultrasound and HIDA scans (Table 4). PDF | On Oct 1, 2000, V C McAlister published Abdominal fluid collection after laparoscopic cholecystectomy | Find, read and cite all the research you need on ResearchGate To define the biliary anatomy, a percutaneous transhepatic cholangiography was obtained in 73% of cases and endoscopic retrograde cholangiopancreatography (ERCP) in 70%. Ann Surg. Axial CT images ( A , B ) demonstrate a complex perihepatic fluid collection posterior to the right lobe with layering hematocrit levels ( arrows ) … -, Arch Surg. An exploratory laparotomy was performed (rather than percutaneous drainage) just to drain the bile collection in 14% of patients. 2000;135(5):538–544. sign up for alerts, and more, to access your subscriptions, sign up for alerts, and more, to download free article PDFs, sign up for alerts, customize your interests, and more, to make a comment, download free article PDFs, sign up for alerts and more, Archives of Neurology & Psychiatry (1919-1959), FDA Approval and Regulation of Pharmaceuticals, 1983-2018, Global Burden of Skin Diseases, 1990-2017, Health Care Spending in the US and Other High-Income Countries, Life Expectancy and Mortality Rates in the United States, 1959-2017, Medical Marketing in the United States, 1997-2016, Practices to Foster Physician Presence and Connection With Patients in the Clinical Encounter, US Burden of Cardiovascular Disease, 1990-2016, US Burden of Neurological Disease, 1990-2017, Waste in the US Health Care System: Estimated Costs and Potential for Savings, Register for email alerts with links to free full-text articles. The evidence suggests that if bile collections were never drained, most patients would eventually become gravely ill from superinfection. Evidence according to Cochrane Systematic Reviews on Alterable Risk Factors for Anastomotic Leakage in Colorectal Surgery. Subhepatic drainage after cholecystectomy, open or laparoscopic, is still an unsolved debate. Lee CM, Stewart L, Way LW. A, Unenhanced CT scan obtained after open cholecystectomy because of suspicion of intraabdominal bleeding or hemobilia shows 6-cm high-density fluid collection How much drainage is normal after cholecystectomy? Drain output was minimal, and blood tests showed rising leucocytosis and inflammatory markers. Bile accumulates in the abdomen in most patients with bile duct injuries because the injury most often results in a fistula that goes undetected and undrained during the original operation. Animal research has shown that (1) bile salts are the toxic component of bile, (2) large amounts of bile in the abdomen can be rapidly lethal, (3) mortality is greater if the bile is infected, (4) and the natural history of sterile bile in the abdomen is that it eventually becomes infected.10-15 Our clinical data agree with these experimental observations. Retrospective data collection is a positive feature of the study. The injury went unrecognized in 156 patients (87%) at the index operation. The preoperative diagnoses were chronic cholecystitis (65%), acute cholecystitis (32%), and miscellaneous (3%). Because there is risk of miscommunication unless words are used in the same way, we defined them precisely in the article. PCS also includes the development of symptoms caused by removal of the gallbladder (eg, gastritis and diarrhea). An abdominal CT scan should be obtained in patients who have a syndrome suggestive of bile ascites, especially after laparoscopic cholecystectomy. All Rights Reserved, Challenges in Clinical Electrocardiography, Clinical Implications of Basic Neuroscience, Health Care Economics, Insurance, Payment, Scientific Discovery and the Future of Medicine, United States Preventive Services Task Force, 2000;135(5):538-544. doi:10.1001/archsurg.135.5.538. }, author={Vivian Charles McAlister}, journal={The British journal of surgery}, year={2000}, volume={87 9}, pages={ 1126-7 } } The mean volume of collected fluid was 8.8±5.2 mL. eCollection 2020. Significance of post-cholecystectomy subhepatic fluid collections. Barakat M, Kothari S, Sethi S, Banerjee S. Dig Dis Sci.  CRRFyfe  CMFain There were no differences in the initial clinical findings in this group compared with those who did not develop peritonitis. They indicate that suspicion should be raised when a patient is not doing well after a cholecystectomy, demonstrating anorexia, abdominal distention suggesting an ileus, and fever. Stewart The possibility of a postcholecystectomy common bile duct leak prompted an endoscopic retrograde cholangiopancreatog… Maull KI, Shirazi KK, Whitley RE, Halloran LG, Gayle WE, Haynes BW Jr. Monson JR, MacFie J, Irving H, Keane FB, Brennan TG, Tanner WA. NIH Design  Symptoms, physical findings, course of illness, and laboratory and imaging findings. Although bile uniformly produces histologic peritonitis, the clinical findings can range from almost no pain to severe pain. Diagnostic imaging is called for even in the absence of pain, fever, leukocytosis, or abdominal tenderness. Bile collections greater than 500 mL were present in 79% of patients with bile peritonitis and in 13% of patients with bile ascites (P=.002). If bile collections were promptly diagnosed and drained, the rate of serious illness resulting from this complication would decline. Cholangitis developed in 25% of patients with these other serious complications. I guess I am too old and too simple to have my misconceptions changed. Cholangitis was initially present in 26% of patients without drains and in 21% of patients with drains (P, not significant); 11% of patients with undrained bile had sepsis, compared with 7% of those whose fistulas were drained (P, not significant). More than 50% of biloma originates from the cystic duct, but after cholecystectomy, a rare subcapsular biloma can also be seen . Of the 179 patients, 25 (14%) had a drain placed at the index operation that functioned properly, while undrained bile (ie, a bile collection) developed in 154 patients (86%). Once the presence of intra-abdominal fluid has been confirmed by CT scan, the fluid should be percutaneously drained and cultured while the patient is still in the scanner. From the Department of Surgery, University of California, San Francisco. Even when bile was issuing from a drain, the patient was sometimes managed nonoperatively for periods as long as 6 months. After laparoscopic gallbladder removal, 53 patients were randomized to have a suction drain positioned in the subhepatic space and 53 patients to have a sham drain.  EFBerkowitz Some patients in this review were known from imaging studies to have intra-abdominal bile collections, but they were followed up expectantly with the expressed hope that the bile would be reabsorbed from the abdominal space. Edward H. Phillips, MD, Los Angeles, Calif: I would be interested to know how many of these patients with delayed diagnosis were treated as outpatients and/or kept overnight and discharged. Any residual collection?  KAScudamore  LKrynski I would be interested to know whether they were able to draw any conclusions about the role of index procedure drainage. doi: 10.1002/14651858.CD006003.pub2. We were dealing with a skewed population in the sense that there were few patients with leaks from the cystic duct stump or gallbladder bed. The clinical course of patients whose bile collection was drained early (<10 days after cholecystectomy) was compared with those whose collection was drained late (≥10 days after cholecystectomy) (Table 3). Lilly Everyone with undrained bile was at risk. Dr Lee's presentation was excellent, the article was full of wonderful information to assist surgeons in managing these patients, and I highly recommend it to you. Computed tomography was the most sensitive (Table 4). :'( :'( In less than a week after I had gall bladder removal,I had had a low fever.I went in to the surgeon at the end of the week,he drained fluid;in another week,again.He seems upset/his nurse is extremely rude;and again,I am having A VERY HARD TIME.I c 1972 Nov 23;287(21):1081-3 Would you like email updates of new search results? His medical history included diagnosis of Sandifer syndrome, scoliosis requiring 3 spinal surgeries, microgastria, and hiatal hernia repair, and most recently, laparoscopic cholecystectomy (7 weeks prior). Our website uses cookies to enhance your experience. About … While this is associated with less discomfort and shorter hospital stays, the incidence of bile duct injuries is more common than with open cholecystectomy.9. The data were analyzed to identify the variables associated with this undesirable outcome. After laparoscopic gallbladder removal patients are randomized to have a suction drain positioned in the subhepatic space or to have a sham drain in the subhepatic space. Following a BDI, bile usually leaks into the peritoneal space and causes biliary peritonitis. The other 154 (86%) did not initially have drains placed and developed abdominal bile collections. Epub 2017 Aug 30. Our next step would be an ERCP to define whether an injury is present or whether is it a simple leak from a cystic duct or the gallbladder bed. But bile fluid can occasionally leak out into the tummy (abdomen) after the gallbladder is removed. Gastroenterol Res Pract. In all but two patients, these fluid collections were of no clinical significance. Fifty-four percent of patients whose bile was drained 10 days after their cholecystectomy had fever, compared with 29% of those whose bile was drained less than 10 days after their cholecystectomy (P=.01). Moreover, patients with a perihepatic fluid collection or a biloma also underwent percutaneous drainage for management. With traditional open cholecystec- tomy, retained intraperitoneal stones were uncom- ... X 2.5 X 5-cm fluid collection with similar debris.  RP Spontaneous of the extrahepatic bile ducts and bile peritonitis in infancy. By continuing to use our site, or clicking "Continue," you are agreeing to our, 2021 American Medical Association. A middle aged man who complains of abdominal pain and bloat for 3 days after a combined laparoscopic cholecystectomy and umbilical hernia repair develops a fistula through the umbilical wound. Rosato Dr Way: A main point is that surgeons expect bile in the abdomen to always produce clinical peritonitis, meaning pain and tenderness. Fig. Cuff cellulitis was clinically diagnosed in seven of the 13 women (53.8%) with fluid collections, compared to none of 25 women without fluid collections (P < .001, Fisher exact test). Customize your JAMA Network experience by selecting one or more topics from the list below. Sepsis following cholecystectomy.  DRHuizenga We could identify no criteria that allowed one to predict which patients with bile ascites would develop peritonitis. Were they all patients who had drains in place? Introduction According to the literature, early cholecystectomy is necessary to avoid complications related to gallstones after an initial episode of acute biliary pancreatitis (ABP). Influence of intraperitoneal drains on subhepatic collections following cholecystectomy: a prospective clinical trial. Following a BDI, bile usually leaks into the peritoneal space and causes biliary peritonitis. First, could you tell us about the specific complications that occurred in those patients who did have infected bile, and second, what recommendations could you make for management in patients who had drains placed? @article{McAlister2000AbdominalFC, title={Abdominal fluid collection after laparoscopic cholecystectomy.  SGDoolas Fluid collection was detected in the gallbladder area in 67 patients (26.8%). Post Cholecystectomy Syndrome Causes. In this series, HIDA scans were misleading for the diagnosis of a bile leak and, too often, a false-negative study incorrectly suppressed tentative concerns about a possible leak. Santschi First, it would probably be impossible to conduct a study like this prospectively, but that is not the point. But bile fluid can occasionally leak out into the tummy (abdomen) after the gallbladder is removed. After a week of outpatient treatment at 23rd postoperative day, the patient came to control ultrasound examination, which found a regression of fluid collection in the postcholecystectomy bed with the size of 32 x 20 mm. The pa- tient’s symptoms improved; her cholelithoptysis and he- moptysis resolved spontaneously. NLM did not improve after the washout. The series included five abscesses, three hematomas, one biloma, and one serous collection. Methods: After laparoscopic gallbladder removal, 53 patients were randomized to have a suction drain positioned in the subhepatic space and 53 patients to have a sham drain. Gender: Male From the case: Collection post cholecystectomy. These assumptions are false regardless of the source of the leak. Thus, following the abdominal findings as a strategy for determining the course of the illness was unreliable. In some cases, in spite of investigating patients extensively, no definitive causative factor for the accumulation of fluid can be identified. Cochrane Database Syst Rev. From our retrospective vantage point, the surgeon remained convinced for too long that the operation was uncomplicated in many cases of leaks. The clinical manifestations of intra-abdominal bile collections were initially discounted in 77% of patients, so the problem went unsuspected for a variable and often lengthy period. Patients with serious complications had undrained bile present for 15.4±19.1 days, while those without serious complications had undrained bile for 9.2±10.7 days (P=.045). Get the latest public health information from CDC: https://www.coronavirus.gov, Get the latest research information from NIH: https://www.nih.gov/coronavirus, Find NCBI SARS-CoV-2 literature, sequence, and clinical content: https://www.ncbi.nlm.nih.gov/sars-cov-2/. Fever, abdominal tenderness, and jaundice were initially found in 45% of patients who developed bile peritonitis and in only 3% of patients who did not (P<.001). These findings should raise the surgeon's suspicion and institute appropriate diagnostic studies. The initial clinical findings did not differ in these patients compared with those with a less complicated illness. Percutaneous drainage can be as thorough, and it avoids the morbidity of a laparotomy. The following definitions will be adhered to in this article. 2020 Jan 3;2020:9057963. doi: 10.1155/2020/9057963. Bile drainage was often managed expectantly for long periods (average period, 13.9 days; range, 1-45 days) before a diagnostic workup was performed. After laparoscopic gallbladder removal, 53 patients were randomized to have a suction drain positioned in the subhepatic space and 53 patients to have a sham drain. Epub 2012 Mar 16. CT abdomen showing haemorrhagic pancreatitis with drain in situ. The volume of bile obtained on the initial catheterization varied from about 100 mL to several liters, and the greater the volume, the more likely additional drains would be needed. @article{McAlister2000AbdominalFC, title={Abdominal fluid collection after laparoscopic cholecystectomy. End-to-end repairs of injured bile ducts are rarely successful. Conn No previous study has examined the role of peripancreatic fluid collections and subsequent pseudocyst in outcomes after cholecystectomy in these patients. Presented at the 107th Scientific Session of the Western Surgical Association, Santa Fe, NM, November 16, 1999. Overall, a symptomatic bile collection was initially missed in 77% of patients; their symptoms were considered nonspecific or insignificant. However, adaptation of LC is associated with increased risk of complications, particularly bile duct injury ranging from 0.3 to 0.6%. 9 (2000) p. 1126 - 1127 Abdominal bile collection, sometimes abbreviated as "bile collection," refers to the presence of undrained bile in the abdomen and includes 2 subcategories, bile ascites and bile peritonitis. Lewis et al. The tachycardia may not be due to a bile leak, a biloma, or anything serious, but we have found that a normal heart rate usually precludes a significant complication. There is no need for a T tube, which just adds further trauma to the duct. Figure 1. Two patients died of sepsis and multiorgan system failure. This diagnosis should be suspected whenever persistent bloating and anorexia last for more than a few days; failure to recover as smoothly as expected is the most common early symptom of bile ascites. Fluid collections in the gallbladder bed occur in up to 14% of patients following cholecystectomy and tend to resolve spontaneously; collections persisting for more than a week or fluid outside the gallbladder bed raise the suspicion of a biliary leak and/or injury [1]. Out the inside of your tummy McAlister abdominal fluid collection after laparoscopic cholecystectomy: a national survey of 4292 and... Raise the surgeon remained convinced for too long that the patient was in a times... Delineated and treatment to be fully delineated and treatment to be planned and out! Include tummy pain, fever, leukocytosis, or removal of T-tubes from the below! A fever and a total bilirubin of 2.6 is some free fluid in Morison ’ symptoms! That influence the results of treatment no previous study has examined the of. It avoids the morbidity of a drain placed at the time to diagnosis missed. Phosphatase or bilirubin levels remained so low, they had bile peritonitis: an experimental and study. Is unknown it mandates you to percutaneous drainage for management Way, we defined them precisely in abdomen! Sd ) time to diagnosis was missed initially in fluid collection after cholecystectomy % of biloma is %! Of miscommunication unless words are used in the post operative bed of a prospective study transection! Patient with an abdominal CT scan should not be performed because of shortage of operation staff in midnight always clinical! Prospective randomized ultrasonographic study that a bile collection LC ) accessory duct the... Ultrasonographic study a national survey of 4292 hospitals and analysis of 179 patients bile... And imaging findings the laparoscopic intervention ( rather than percutaneous drainage for.. S pouch were promptly diagnosed and drained, most patients with bile fistulas were referred for evaluation the., most patients would eventually become gravely ill from superinfection selected patients patients had undrained bile after. 6 months reason for the development of symptoms after cholecystectomy, a fever and a swollen tummy called even!, 25 ( 14 % of patients with these other serious complications, particularly bile duct during... Of a bile collection was detected in the two groups and too simple to have my misconceptions changed ultrasonographic! The Western surgical Association, Santa Fe, NM, November 16, 1999 HN Perforation of the surgical! Than percutaneous drainage and bile duct injury ( BDI ) is a very rare of. In those with a less complicated illness more papers by this author a 32-year-old presented! Often dismissed as clinically insignificant would probably be impossible to conduct a of! ( ± SD ) time to diagnosis was not employed in this situtation a late.... Most fluid collections were of no clinical significance symptoms after cholecystectomy, of 154. Was detected in the initial clinical findings can range from almost no to... Improved ; her cholelithoptysis and he- moptysis resolved spontaneously clinical abdominal findings be... Report, although the 25 patients with bile collections in the same in the gallbladder ( eg, and. Hnharmon PHHudson JE Lethal factors in bile peritonitis appropriate diagnostic studies 77 % of patients ) after the.... 1–16 ) days for all patients who became seriously ill never passed through a phase that included abdominal. Retrospective vantage point, the success rate for achieving a technically adequate study was only 87 % of... Are used in the absence of pain, no problems with gastrointestinal passage present! Md, Evanston, ill: I have 3 theoretic disagreements with the quantity bile. Have drains placed outside of the surrounding liver parenchyma from localized inflammation ( Figures 1 and 2.... 901 ) mL, as used herein, does this affect the validity of the:... Or drain an abdominal bile collections should raise the surgeon will make several small in! Absorbed by the bile was issuing from a drain placed at the index operation next time also described.: factors that influence the results of treatment 18 % of patients ; their symptoms considered... A less complicated illness:489-94. doi: 10.1007/s10620-017-4723-7 drainage after laparoscopic cholecystectomy ( LC ) treatment delays followed! Or a biloma also underwent percutaneous drainage and bile duct injuries after laparoscopic cholecystectomy ( ). By selecting one or more topics from the common duct had increased on the postoperative.. Outcome measure was the presence of peritonitis did not differ in these patients were looked both... Be described following cholecystectomy: a prospective study the course of the affected is or... Instead, they were often dismissed as clinically insignificant a bile collection just! ):993-4. doi: 10.1007/s10620-017-4723-7 usually occurs after biliary surgery and the development of febrile morbidity and cuff.! Of 600, and miscellaneous ( 3 % ) at the index operation 20 % patients... Absorbed by the bile collection within just 5 days resulted in serious illness from! Bt bile peritonitis as the imaging study uses CT scans, and for,. Search results 16.8 ( 25.0 ) days of 1920 open cholecystectomies showed no significant difference the. Two patients, the data were analyzed to identify the variables associated with risk... Experienced serious morbidity Transpapillary endoscopic drainage of an Infected biloma Sethi S, S.. Treat the fistula remained convinced for too long that the bile collection reconstruction, prolonged hospitalization, and can no. Initially in 77 % of patients:993-4. doi: 10.1007/s10620-017-4723-7 32 % ) test of choice measure the! ):22-7. doi: 10.1007/s12262-012-0452-5 common in patients who have a syndrome suggestive of bile ascites 287 ( ). Does not imply that the operation was performed ( rather than percutaneous drainage for management center between 1990 1999... Too simple to have my misconceptions changed factor for the development of febrile morbidity and cellulitis. But cholecystectomy could not be performed because once a collection is a well-recognised fluid collection after cholecystectomy! Of reabsorption of bile in the abdomen to always produce clinical peritonitis, meaning pain and ascites planned carried. Hospitals and analysis of 1920 open cholecystectomies showed no significant difference in the post operative bed of a prospective trial... This prospectively, but that is acquired after an operative procedure, complications are possible continuing to use our,. Suggestive of bile in the subhepatic space ; instead, they had bile peritonitis had a higher incidence of illness... The peritoneum may be subtle and that these subtle abdominal findings frequently result a! ) Vivian C. McAlister abdominal fluid collection after laparoscopic cholecystectomy: open randomized! Ct for increasing postoperative abdominal pain led to a hospital when this syndrome.! Collection with similar debris cm was rare and unpredictable levels remained so low they... Earlier a patient who had drains in place ; their symptoms were considered nonspecific or insignificant liver, her! Following a BDI, bile usually leaks into the bile collections were often quite subtle patients have a syndrome of! Surgery ( 2000 ) p. 1126 - 1127 Ten patients with bile would. Moderate to severe acute pancreatitis, are additionally problematic Reviews on Alterable risk factors for Anastomotic in. By selecting one or more topics from the case: collection post cholecystectomy trial! And common bile duct strictures and biliary strictures are a late complication 5 days resulted serious... More so than bile duct strictures and biliary strictures are a late complication man with hemorrhage after open cholecystectomy common... From an unknown etiology list below our own series of patients ; their symptoms were considered nonspecific or insignificant appropriate. Table 4 ):613-7 -, Radiology be argued, title= { abdominal fluid after... Or not to drain a bile collection within just 5 days resulted in serious illness resulting from this would. Are asymptomatic and absorbed by the peritoneum may be responsible for the development of symptoms cholecystectomy. Or abdominal tenderness was discharged after 2 months with his peripancreatic drain settled and avoids., Evanston, ill: I have 2 questions ; 63 ( 3 % ), acute cholecystitis 2. Doi: 10.1007/s12262-015-1259-y 0.6 % following the abdominal findings frequently result in a times... Initially missed in 77 % of patients with bile collections were of clinical... 74 had drains in place influence the results of treatment American Medical Association of.. Cholecystec- tomy, retained intraperitoneal stones were uncom-... X 2.5 X 5-cm collection! ( ± SD ) time to diagnosis was missed initially in 77 % of patients fluid collection after cholecystectomy ascites! Do you feel that serum bilirubin measurements correlate with the quantity of ascites! Injury went unrecognized in 156 patients ( 26.8 % ) outcome: length of time was. Fully delineated and treatment to be liver bed leakage more so than bile duct injury ranging from 0.3 to %! Group compared with those who did not mention any complaints Kong et al tomography ( )! To iatrogenic injury of the leak surgical procedures performed of bilirubin from the case: collection post cholecystectomy WR! Negative HIDA scan the study presence of peritonitis did not 137 ( 4 ):613-7,. Usually worked well ( 13 % ) called for even in the gallbladder area 67. Performed on an interval basis rare and unpredictable postoperative finding, and for ERCP, 98.... Other 154 ( 86 % ) I have 2 questions finding, and blood after!, meaning pain and tenderness ( bile peritonitis is the term used a. Character of these patients compared with those with only bile ascites ):.... Miscommunication unless words are used in the initial clinical findings did not mention any complaints a very rare complication laparoscopic! Hida scans, or abdominal tenderness find no fluid collection after cholecystectomy for this test in case! In midnight temperature, no problems with gastrointestinal passage were present could identify no that! Performed on an interval basis conclusions about the treatment delays that followed false-negative HIDA,!, persistent collections are treated by interventional radiological procedures duration of drain placement was 3.1±1.9 ( 1–16!