Necessity of a Repeat Cholangiogram During Biliary Stent Removal after Post-cholecystectomy Bile Leak?

Abstract

Purpose: To assess the need for repeat ERC (endoscopic retrograde cholangiography) in patients with biliary stent placed for post-cholecystectomy bile leak. Methods: A retrospective analysis of the CORI (Clinical Outcomes Research Initiative) database at Penn State Milton S Hershey Medical Center identified all patients referred for ERC for post-cholecystectomy bile leak from Jan 2001-June 2010. We collected baseline demographics, location of bile leak, size of biliary stent placed, duration of stenting, bile leak persistence, and the presence of stone, sludge or strictures on repeat ERC. Results: Total of 81 patients underwent ERC for management of bile leaks after cholecystectomy. One was excluded as he had a complete transection of the CBD and taken to the OR immediately. Fourteen (17.5%) patients had open cholecystectomy, 46 (57.5%) had laparoscopic and 10 (12.5%) had a laparoscopic converted to open. Of the 80 patients, 47 (58.7 %) had a Cystic duct leak, 11 (13.7 %) had a Right hepatic duct leak, 11 (13.7%) had CBD leak, 5 (6.2%) had a GB fossa leak, 4 (5%) had CHD leak and the other 2 (2.5%) had Left Hepatic duct leak. All 80 patients (100%) had a biliary stent placed. 57 of 80 (71.2%) had a 10F stent placed with the remainder having a 7F placed. Seventy-five (93.7 %) patients also underwent biliary sphincterotomy at the same time. Sixty-nine patients (11 had no repeat cholangiogram but clinically the leak had resolved) underwent repeat ERC after a mean duration of 8.2 weeks. Three had an early ERC due to suspicion for cholangitis and hence excluded from the analysis. Of the 66 included in the final analysis, 61 (92.4 %) had resolution of the bile leak on repeat ERC. All patients had a resolution of their bile leak by the third ERC. Fifteen patients (22.7 %) had an abnormality on repeat cholangiography (persistent leak in 4, stones in 3, sludge in 7, and leak + stone in 1) that required further intervention including balloon sweep, or further stenting. Conclusion: Although the majority of post cholecystectomy bile leaks resolve after biliary stent placement, a sizeable percentage of patients still have abnormalities on the subsequent cholangiogram that requires further endotherapy. These findings support the need for a repeat ERC +/- of balloon sweep at the time of biliary stent removal.