Refractory Bergmann type A bile leak: effect of gravity and tube sizing

We read with interest the paper by Massimiliano et al [1] which described a technique of “pulling-out of abdominal drain,” which was placed close to the fistula site in patients with refractory Bergmann’s type A leak to facilitate closure of fistula. Bile leak occurs in approximately 1 % to 4 % of patients after laparoscopic cholecystectomy and cystic duct stump is the most common site of leak [2] [3].

Endoscopic retrograde cholangiopancreatography (ERCP) is the preferred therapeutic modality for management of bile duct leaks [4] [5]. Endoscopic stenting with or without sphincterotomy decreases biliary pressure and minimizes flow through the leak. The technique of pulling out the drain tube described by the authors is effective and also a common practice at our center. However, we take two additional measures in patients with persistent leak after adequate endotherapy: 1. Replace the drain tube with a smaller-diameter tube (e. g. 16F nasogastric tube); and 2. Convert gravity-assisted drainage to a colostomy bag drainage to remove the effect of gravity.

These measures help close the fistula in almost all patients. Let’s understand the physical principles of fluid dynamics behind these measures: (i) Fluid or air flows from high pressure zone to low pressure zone; and (ii) Compartments that are contiguous with each other have same pressure.

• References

• 1 Mutignani M, Forti E, Larghi A. et al. Refractory Bergmann type A bile leak: the need to strike a balance. Endosc Int Open 2019; 7: E264-E267
• 2 Shawhan RR, Porta CR, Bingham JR. et al. Biliary leak rates after cholecystectomy and intraoperative cholangiogram in surgical residency. Mil Med 2015; 180: 565-569
• 3 Viste A, Horn A, Øvrebø K. et al. Bile duct injuries following laparoscopic cholecystectomy. Scand J Surg SJS Off Organ Finn Surg Soc Scand Surg Soc 2015; 104: 233-237
• 4 Adler DG, Papachristou GI, Taylor LJ. et al. Clinical outcomes in patients with bile leaks treated via ERCP with regard to the timing of ERCP: a large multicenter study. Gastrointest Endosc 2017; 85: 766-772
• 5 Kim KH, Kim TN. Endoscopic management of bile leakage after cholecystectomy: a single-center experience for 12 years. Clin Endosc 2014; 47: 248-253