Endoscopic Management of Postcholecystectomy Biliary Leaks

Abstract

Purpose: Biliary leak is a common complication following cholecystectomy. Endotherapy is an established method of treatment. However, the optimal intervention is not known. Methods: Seventy three patients with postcholecystectomy biliary leaks from July 2000 to April 2007 were retrospectively evaluated. Results: There were 19 males and 54 females with a mean age of 43.06 years. Patients presented 17.95 ± 17.09 days (range 1–90 days) following cholecystectomy (46 open and 27 laparoscopic) with pain abdomen (42), jaundice (21), fever (21), and abdominal distension (37). Bilious abdominal drain was present in 55 patients. Endoscopic retrograde cholangiopancreatography detected leak at cystic duct stump in 35, stricture with mid common bile duct (CBD) leak in 4, leak from right hepatic duct in 2 and ligated CBD in 32 patients. Nine patients also had bile duct stones. One patient had broken “T” tube with stone. Endotherapy was possible in 41 patients and 32 patients with ligated CBD underwent surgery. Two patients with stones, one patient with broken “T” tube with stone and 4 patients with stricture common bile duct with leak were managed with sphincterotomy and stent. Seven patients with cystic duct stump leak with stone were managed with sphincterotomy and stone extraction. Three outdoor patients with cystic duct stump leak were managed with sphincterotomy and stent. Eleven patients with cystic duct stump leak admitted in hospital were managed with sphincterotomy and nasobiliary drain. Thirteen patients had coagulopathy hence sphincterotomy could not be done and were managed with only nasobiliary drain (7) and stent (6). Leak closure could be achieved in 100% patients. Mild pancreatitis occurred in 4 patients who were managed conservatively. Conclusion: Endoscopic intervention is a safe and effective method of treatment of postcholecystectomy biliary leaks. However, management of postcholecystectomy biliary leaks should be individualized based on type of leak and should include stent in outdoor patients and nasobiliary drain in indoor patients with simple leak, sphincterotomy and stone extraction in patients with stone, sphincterotomy and stent in patients with stricture with or without leak and those with ligated duct should undergo surgery.