Got a Leak! Letʼs Glue It

Abstract

Introduction: The procedure of choice for management of acute cholecystitis is laparoscopic cholecystectomy (LC). LC has it's distinct advantages; however, post-operative refractory bile leaks present a significant therapeutic challenge. Herein, we report a case of endoscopic occlusion of high grade bile leak from the gall bladder remnant that failed all standard endoscopic maneuvers via the use of human pooled plasma fibrinogen and thrombin (HPF) (Tissel, Baxter, CA) as a sealant. Case: A 65-year-old male presented with abdominal pain and was found to have CT and HIDA scan findings consistent with acute cholecystitis. Laparoscopic evaluation revealed severely inflamed and gangrenous gall bladder, hence he underwent an open subtotal cholecystectomy. Post operatively, patient had increased bilious output from the JP drain, therefore, a CT scan abdomen was done which revealed a biloma in the gall bladder fossa. ERCP revealed a high grade bile leak from the gall bladder remnant and suggestion of ampullary stenosis. Biliary sphincterotomy was performed and a 10 Fr x 5 cm plastic stent was placed in the common bile duct (CBD). Due to persistent high output from the JP drain, a repeat ERCP was done 4 weeks later; occlusion cholangiogram revealed low grade bile leak from the gall bladder remnant. Balloon sweep with clearance of biliary sludge was performed and the plastic stent was interchanged with a 10 mm x 6 cm fully covered self-expanding metal stent (FC-SEMS). Six weeks after placement of the FC-SEMS, patient still had persistent bilious drainage from the JP drain therefore a third ERCP was done. The previously placed biliary stent was removed and cholangiogram revealed a high grade bile leak. No filing defects or stricture were noted in the CBD. The CBD was dilated to 10 mm and the cystic duct stump was successfully cannulated and injected with 3 ml of HPF for the purpose of sealing the leak. Repeat cholangiogram demonstrated no leak. A 10 mm x 80 mm FC-SEMS was placed in the common bile duct. Follow up ERCP 3 months later revealed normal cholangiogram with no evidence of ongoing bile leak and the FC-SEMS was removed. Discussion: To our knowledge this a first report demonstrating use of HPF endoscopically for successful management of refractory bile leak. HPF should note be injected into vascular structures due to concern for vascular thrombosis. Further studies and reports are needed to evaluate the safety and efficacy of this technique.