1292 Combined Postcholecystectomy Bile Leak and Benign Biliary Stricture—Should a Temporary Placement of Fully Covered Self-Expanding Metal Stent Be the First Choice?

Abstract

INTRODUCTION: Bile leaks are common complications seen after cholecystectomy. Endoscopic Retrograde Cholangiopancreatography (ERCP) with the establishment of an enhanced transpapillary flow – through biliary stent placement and/or sphincterotomy – is considered the standard of care and usually has high success rates. Failure of initial endoscopic therapy (complex bile leak) can be managed with the placement of a fully covered self-expanding metal stent (FCSEMS) or surgery. We present a patient in which large postcholecystectomy biloma developed despite the presence of biliary plastic stent in place. CASE DESCRIPTION/METHODS: 48-year-old female with history of chronic pancreatitis and benign distal biliary stricture was admitted with worsening abdominal pain for the last 2 days. One month prior to this episode, the patient was admitted with the diagnosis of acute on chronic pancreatitis. She underwent ERCP with balloon dilatation and placement of plastic biliary (10 Fr × 10 cm) and pancreatic duct (5 Fr × 7 cm) stents. She had cholecystectomy prior to her discharge. Her abdominal pain on readmission was associated with nausea, vomiting, loss of appetite. She has chronic loose stools, which remained unchanged. She denied fevers, chills, or hematemesis. Her vital signs were within normal range. Abdominal exam revealed sluggish bowel sounds and right upper quadrant abdominal tenderness. She had elevated white cell count at 13,900/µL. The rest of the labs including kidney and liver function tests were unremarkable. CT scan of the abdomen showed moderate to large subcapsular and intraperitoneal fluid. There was mild dilatation of the common bile duct with the biliary and pancreatic duct stents in place. Findings were consistent with post-cholecystectomy biliary leak. A right upper quadrant pigtail drain was placed followed by ERCP. Cystic duct stump bile leak was diagnosed and treated with placement of FCSEMS. The patient tolerated the procedure well with improvement of symptoms. Bile leak resolved and FCSEMS was removed after three months. DISCUSSION: Patients with postcholecystectomy bile leak superimposed on a benign biliary stricture are probably appropriate candidates for endoscopic therapy with FCSEMS. Despite their higher costs, initial temporary placement of FCSEMS may obviate additional ERCP sessions in cases of failure of plastic stents. FCSEMS improve drainage since they have larger lumens. They should be considered especially in the presence of biliary prestenotic duct dilatation and high-grade leaks.