Management of Refractory Biliary Leak Using Spyglass Cholangioscopy for Better Localization and Grading of Bile Duct Injury

Abstract

The management of refractory bile leaks is not as well delineated resulting in multiple ERCPs and complications. Choosing the right type stent is highly dependent on the size of a biliary leak with recent literature supporting the use of metal stents for high-grade refractory leaks. We describe a case of a refractory bile leak treated successfully using Spyglass cholangioscopy with a placement of a metal stent. A 31-year-old female underwent elective cholecystectomy with positive IOC and complicated by bile leak requiring placement of two (2) JP drains. The patient was hemodynamically stable on presentation. The clinical examination showed mild diffuse abdominal tenderness. Hepatic function test was within normal limit. A HIDA scan confirmed the presence of a bile leak. Initial ERCP with sphincterotomy extracted multiple gallstones and demonstrated extravasation from the cystic duct stump. A plastic biliary stent was placed across with good biliary drainage. Four days after her admission, due to fever, elevated white count, persistent abdominal pain, and distention, a CT abdomen and pelvis showed a new abdominal fluid collection. Following CT guidance drained of 1,200 mL of purulent bilious fluid, repeat ERCP showed a persistent leak. Dual plastic stents were placed in the right and left hepatic duct. The patient was discharged home on day 15 only to return next day with severe abdominal pain, fever, and persistent bilious output. After stabilizing patient, a third ERCP using spyglass cholangioscopy was used to visualize the area of disruption to be 20 mm. A fully covered wall flex stent was used to cross the entire defect and proper placement was visualized by Spyglass cholangioscopy. A final occlusion cholangiography demonstrated resolution of the leak. The patient was discharged home in stable condition. She was seen in the clinic 8 weeks after discharge in stable condition and repeat ERCP with stent removal was completed with no complication. Refractory bile leaks are frequently due to underestimation of the size of the injury, stent occlusion or stent migration and is a and a major source of morbidity and mortality. Cholangiography alone underestimates the extent of biliary duct injury leading to incorrect type and size stents selection. To our knowledge, this is the first description of the use of Spyglass visualization system to accurately visualize and measure bile duct injury allowing for proper stent selection and treatment of refractory bile leak.1312_A.tif Figure 1: cholangiogram showing large bile leak at common bile duct(Black Arrow).1312_B.tif Figure 2: Biliary duct injury visualized with Spyglass1312_C.tif Figure 3: Deployed metal stent (Black Arrow) with occlusion cholangiography showing resolution