3400 Endoscopic management of post-operative bile leak (embl) in 53 patients.

Abstract

With the advent of laparoscopic cholecystectomy, large or persistent bile leaks ahve been encountered more frequently. EMBL has been demonstrated to be safe and efficacious therapy for bile leak. However, resistance to the use of this therapy continues amongst the surgical community. This large audit addresses those concerns. Methods: The ERCP database identified 53 patients (21M,32F, median age 50 yrs; range 20-87 yrs) who had undergone EMBL between 8/92 - 2/99. Endoscopic data was recorded prospectively at the time of ERCP. Patient outcome data and long-term follow-up was obtained by chart review and structured telephone interview. Results: Of the 53 patients, 45 had undergone laparoscopic cholecystectomy and 8 open cholecystectomy. ERCP was performed at a median of 7 days (range 1-48 days) postoperatively. Cholangiography was successful in 100%. The leak site was identified in 47 patients as follows: 32 cystic duct, 8 duct of Luschka, 4 T tube tract, 2 common duct and 1 distal branch of left hepatic duct. Two patients had contrast extravasation without a discrete site identified, 4 patients had no extravasation. Endoscopic intervention (temporary stent placement only for 2-4 weeks: 36 patients; temporary stent placement and sphincterotomy: 7 patients and sphincterotomy alone: 7 patients) to achieve preferential biliary flow was performed in 94%. 3 patients underwent surgery prior to ERCP, but still required endoscopic intervention for persistent bile leak. 2 patients had surgery after ERCP for lesions which were thought to be not amenable to non-operative management alone. (CHD repair, laparoscopic drainage of collection). Both patients had been managed by sphincterotomy alone, early in our experience. No patient who had a stent placed required surgery after ERCP. 16 patients subsequently underwent percutaneous drainage of a biloma. ERCP complications included 3 cases of post ERCP pancreatitis (1 mild and 2 moderate) and 1 biliary stent migration, which was retrieved and not replaced. There were no late complications (median follow-up 43 months; range 1-73 months). Conclusions: EMBL is safe and highly effective providing definitive therapy in 96% of cases. Temporary stent placement appears to be more effective than sphincterotomy alone. With the advent of laparoscopic cholecystectomy, large or persistent bile leaks ahve been encountered more frequently. EMBL has been demonstrated to be safe and efficacious therapy for bile leak. However, resistance to the use of this therapy continues amongst the surgical community. This large audit addresses those concerns. Methods: The ERCP database identified 53 patients (21M,32F, median age 50 yrs; range 20-87 yrs) who had undergone EMBL between 8/92 - 2/99. Endoscopic data was recorded prospectively at the time of ERCP. Patient outcome data and long-term follow-up was obtained by chart review and structured telephone interview. Results: Of the 53 patients, 45 had undergone laparoscopic cholecystectomy and 8 open cholecystectomy. ERCP was performed at a median of 7 days (range 1-48 days) postoperatively. Cholangiography was successful in 100%. The leak site was identified in 47 patients as follows: 32 cystic duct, 8 duct of Luschka, 4 T tube tract, 2 common duct and 1 distal branch of left hepatic duct. Two patients had contrast extravasation without a discrete site identified, 4 patients had no extravasation. Endoscopic intervention (temporary stent placement only for 2-4 weeks: 36 patients; temporary stent placement and sphincterotomy: 7 patients and sphincterotomy alone: 7 patients) to achieve preferential biliary flow was performed in 94%. 3 patients underwent surgery prior to ERCP, but still required endoscopic intervention for persistent bile leak. 2 patients had surgery after ERCP for lesions which were thought to be not amenable to non-operative management alone. (CHD repair, laparoscopic drainage of collection). Both patients had been managed by sphincterotomy alone, early in our experience. No patient who had a stent placed required surgery after ERCP. 16 patients subsequently underwent percutaneous drainage of a biloma. ERCP complications included 3 cases of post ERCP pancreatitis (1 mild and 2 moderate) and 1 biliary stent migration, which was retrieved and not replaced. There were no late complications (median follow-up 43 months; range 1-73 months). Conclusions: EMBL is safe and highly effective providing definitive therapy in 96% of cases. Temporary stent placement appears to be more effective than sphincterotomy alone.