Impact of endoscopic intervention in 100 patients with suspected postcholecystectomy bile leak

doi:10.1016/S0016-5107(04)02468-X

Gastrointestinal Endoscopy

Volume 61, Issue 2, February 2005, Pages 269-275

https://doi.org/10.1016/S0016-5107(04)02468-X Get rights and content

Background

Bile leak is a recognized complication of cholecystectomy. Endoscopic intervention is widely accepted as a treatment for this complication, but the optimal form is not well defined.

Methods

An ERCP database was reviewed retrospectively to identify all cases of bile leak related to cholecystectomy. Patient records and endoscopy reports were reviewed, and structured telephone interviews were conducted to collect data.

Results

A total of 100 patients (61 women, 39 men; mean age, 53 [17] years) with suspected postcholecystectomy bile leak were referred for ERCP. Cholecystectomy was commenced laparoscopically in 83 patients (with an open conversion rate of 30%). The most common symptoms were pain (n = 62) and fever (n = 37). Cholangiography was obtained in 96 patients. A leak was identified in 80/96 patients, the most common site being the cystic-duct stump (48), followed by ducts of Luschka (15), the T-tube site (7), and other sites (10). Treatment included stent insertion alone (40), sphincterotomy alone (18), combination stent/sphincterotomy (31), none (6), and other (1). Three patients with major bile-duct injuries were excluded from the analysis. Endoscopic therapy was unsuccessful in 7 patients (6 in the sphincterotomy alone group; p = 0.001). Four patients underwent surgery subsequent to ERCP to control the leak. All 4 were in the sphincterotomy alone group (p = 0.001). Post-ERCP pancreatitis developed in 4 patients (3 mild, 1 moderate).

Conclusions

The optimal endoscopic intervention for postcholecystectomy bile leak should include temporary insertion of a biliary stent.

Section snippets

Patients and methods

The endoscopy database of a tertiary referral, university-affiliated hospital was reviewed retrospectively to identify all patients referred for ERCP because of suspected bile leak related to cholecystectomy (open or laparoscopic). Patient records and endoscopy reports were reviewed, and structured telephone interviews were conducted to collect data. Data were collected regarding clinical features of bile leaks, referral time, healing and discharge times, and follow-up. Retrograde

Results

Over 5000 ERCP procedures were performed between 1992 and 2002. There were 125 patients referred for ERCP because of suspected bile leak. The suspicion of a bile leak arose in the setting of cholecystectomy in 100 patients (61 women, 39 men; mean age 53.2 [17.4] years). Open cholecystectomy was performed in 17 patients. Laparoscopic cholecystectomy was undertaken in 83 patients, but, in 25 (30%), the operation was converted to an open procedure. Mean follow-up for the entire patient group was

Discussion

Bile leak as a result of cholecystectomy is uncommon. The frequency in large series is less than 2%.1, 2, 3, 4, 5, 6, 7 There are several possible treatment strategies for such leaks. A large body of data supports the early use of ERCP to exclude significant bile-duct injury and to effect closure of the leak by various endoscopic means.11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21 However, there is no consensus as to the optimal endoscopic intervention. Flow rates are better in vitro through

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Three hundred seventy patients with biliary stricture requiring endoscopic biliary stenting were enrolled and randomly allocated to the ES group (n = 185) or non-ES group (n = 185). All participants were followed up for 30 days after the procedure. The data and occurrence of adverse events were prospectively collected. The primary outcome measure of this study was the incidence of PEP within 2 days of initial transpapillary biliary drainage. Secondary outcome measures were the incidence of other adverse events related to biliary stent/tube placement.
PEP occurred in 36 patients (20.6%) in the non-ES group and in 7 patients (3.9%) in the ES group (P < .001). The difference in the incidence of PEP between the 2 groups in the per-protocol population was 16.7% (95% confidence interval, 10.1%–23.3%), which was not within the noninferiority margin of 6%. Except for bleeding, the incidences of other adverse events were not significantly different between the groups.
ES before endoscopic biliary stenting could have the preventive effect on the occurrence of PEP in patients with biliary stricture. University Hospital Medical Information Network Number, UMIN000025727.University Hospital Medical Information Network Clinical Trial Registry URL: https://www.umin.ac.jp/ctr/index.htm
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Citation Excerpt :
Injury to these ducts can result in bile leak, an undesired surgical complication. Injury to the subvesical ducts are the second most common cause of post-cholecystectomy bile leak after injury to cystic duct.18,19 The cystohepatic duct is a thick aberrant biliary duct that frequently travels in the triangle of Calot with similar implications for bile leak in the event of inadvertent iatrogenic injury.17
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Between 2006 and 2018, consecutive patients who were referred to interventional radiology units of three tertiary referral hospitals were retrospectively identified. Technical success and clinical success were analyzed and evaluated according to surgery type, BL-site and grade, catheter size and biochemical variables. Complications of PTA were reported.
One-hundred-eighty-five patients underwent PTA for BL. Technical success was 100%. Clinical success was 78% with a median (range) resolution time of 21 (5–221) days. Increased clinical success was associated with patients who underwent hepaticresection (86%,p = 0,168) or cholecystectomy (86%,p = 0,112) while low success rate was associated to liver-transplantation (56%,p < 0,001). BL-site,grade, catheter size and AST/ALT levels were not associated with clinical success. ALT/AST high levels were correlated to short time resolution (17 vs 25 days, p = 0,037 and 16 vs 25 day, p = 0,011, respectively) Complications of PTA were documented in 21 (11%) patients.
This study based on a large cohort of patients demonstrated that PTA is a valid and safe approach in BL treatment after HPB surgery.
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Trauma affects all sociodemographic profiles and is a major cause of morbidity and mortality particularly in patients less than forty years of age. A variety of endoscopic tools and techniques initially used for iatrogenic etiologies (post-operative bile or pancreatic duct leaks, intra-procedural perforation) have been adopted for use in the gastrointestinal trauma victim. The purpose of this review is to highlight a variety of gastrointestinal traumatic complications where endoscopy can serve a complement and/or definitive management strategy.

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: Abstract presentation at Australian Gastroenterology Week, October 4-8, 1999 (J Gastroenterol Hepatol 1999;14 Suppl:A137).

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Original ArticleImpact of endoscopic intervention in 100 patients with suspected postcholecystectomy bile leak

Background

Methods

Results

Conclusions

Section snippets

Patients and methods

Results

Discussion

Am J Surg

Am J Surg

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

A prospective analysis of 1518 laparoscopic cholecystectomies. The Southern Surgeons Club

N Engl J Med

Bile duct injury and bile leakage in laparoscopic cholecystectomy

Br J Surg

The learning curve for laparoscopic cholecystectomy. The Southern Surgeon's Club

Am J Surg

Complications during the introduction of laparoscopic cholecystectomy in Norway. A prospective multicentre study in seven hospitals

Eur J Surg

Original Article
Impact of endoscopic intervention in 100 patients with suspected postcholecystectomy bile leak