We thank Dr Kayaalp for his insightful comments about the relative advantages and disadvantages to methods of biliary access for intraoperative bile leak testing. In his letter, Dr Kayaalp advocates for direct puncture of the common hepatic duct with a rigid, narrow-bore catheter and tourniquet occlusion of the common bile duct, with subsequent suture repair of the choledochotomy. We would argue that the air leak test (ALT) includes specific technical features, mainly related to the ability to carefully monitor the intrabiliary pressure, that enhance its safety and effectiveness and result in a considerable reduction in bile leak rates at our institution.
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