The White test

OBJECTIVE: To describe a new intraoperative bile leakage test in patients undergoing a major liver resection aimed to combine the advantages of each of the other standard bile leakage tests (accurate visualization of leaks, reproducibility, and ease of use) without their disadvantages.

METHODS: At the end of the major hepatic resection, 10 to 30 mL of sterile fat emulsion, 5%, is injected via an olive-tip cannula through the cystic duct while manually occluding the distal common bile duct. As the biliary tree fills with fat emulsion solution, leakage of the white fluid is visualized on the raw surface of the liver resection margin. The detected leakages are closed by means of single stitches. Afterwards, the residual fat emulsion on the resection surface is washed off with saline and the White test is repeated to detect and/or exclude additional bile leakages. At the end, residual fat emulsion is washed out from the biliary tract by a low-pressure infusion of saline solution.

RESULTS: Intraoperatively, additional potential bile leakages (not seen using a conventional saline bile leakage test) were identified in 74% of our patients. Postoperative bile leakages (within 30 days) occurred in only 5.1% of patients when the White test was used. No adverse effects related to this technique were observed.

CONCLUSIONS: The White test has clear advantages in comparison with other bile leakage tests: it precisely detects bile leakages, regardless of size; it does not stain the resection surface, allowing it to be washed off and repeated ad infinitum; and it is safe, quick, and inexpensive.