Outcomes of endoscopic management of primary and refractory postcholecystectomy biliary leaks in a multicentre review of 178 patients.

Jorge Canena,Catarina Rodrigues,António Mateus Dias,Diana Carvalho,António Pereira Coutinho,Rafaela Loureiro,Inês Marques,Liliane Meireles,David Horta,Leonel Ricardo,João Coimbra,Gonçalo Ramos,Pedro Mota Veiga,Carlos Romão,Pedro Russo,Tiago Capela

doi:10.1186/s12876-015-0334-y

Abstract

BackgroundBiliary leaks have been treated with endoscopic management using different techniques with conflicting results. Furthermore the appropriate rescue therapy for refractory leaks has not been established. We evaluated the clinical effectiveness of initial endotherapy for postcholecystectomy biliary leaks using an homogenous approach (sphincterotomy + placement of a 10-French plastic stent) in a large series of patients as well as the optimal and efficacy of rescue endotherapy for refractory biliary leaks.MethodsThis was a multicenter, retrospective study of 178 patients who underwent endoscopic management of postcholecystectomy biliary leaks with a combination of biliary sphincterotomy and the placement of a large-bore (10-French) plastic stent. Data were collected to analyze the clinical outcomes and technical success, efficacy of the rescue endotherapy and the need for surgery, adverse events and prognostic factors for clinical success of endotherapy.ResultsFollowing endotherapy, closure of the leak was accomplished in 162/178 patients (91.0 %). The multivariate logistic model showed that the type of leak, namely a high-grade biliary leak, was the only independent prognostic factor associated with treatment failure (OR = 26.78; 95 % CI = 6.59–108.83; P < 0.01). The remaining 16 patients were treated with multiple plastic stents (MPSs) with a success rate of 62.5 % (10 patients). The use of fewer than 3 plastic stents (P = 0.023) and a high-grade biliary leak (P = 0.034) were shown to be significant predictors of treatment failure with MPSs in refractory bile leaks. The 6 patients in whom the placement of MPSs failed were retreated with a fully cover self-expandable metallic stent (FCSEMS), resulting in closure of the leak in all cases.ConclusionsEndotherapy of biliary leaks with a combination of biliary sphincterotomy and the placement of a large-bore plastic stent is associated with a high rate of success (90 %). However in our series there were several failures using MPSs as a strategy for rescue endotherapy suggesting that refractory biliary leaks should be treated with FCSEMS especially in patients with high-grade leaks.

Highlights

Biliary leaks have been treated with endoscopic management using different techniques with conflicting results
The following criteria were used for inclusion in this study: 1) initial treatment of the biliary leak with a combination of biliary sphincterotomy and the placement of a 10-French transpapillary biliary stent; 2) after failure of the initial treatment, the patients were subjected to a new endotherapy with multiple plastic stents (MPS); and 3) after pacing the Multiple plastic stents (MPS), patients with a persistent biliary leak were submitted to the temporary placement of an fully cover self-expandable metallic stent (FCSEMS), and the patients for whom the placement of an FCSEMS did not close the leak were considered for surgery
Patients were referred to Endoscopic retrograde cholangiopancreatography (ERCP) after a median of 7 days if they had a clinical suspicion of a postcholecystectomy biliary complication based on symptoms, abnormal liver-associated enzymes or jaundice, imaging studies (e.g., CT scan, upper abdominal ultrasonography) or biliary leakage from the drains placed during surgery

Summary

Introduction

Biliary leaks have been treated with endoscopic management using different techniques with conflicting results. Despite a large body of data supporting the use of ERCP in this setting, there has been no study of a large series of patients treated using standard and homogeneous approaches to maximize the benefits of the first endoscopic treatment, a combination of biliary sphincterotomy and the placement of a large-bore (10French) plastic stent. It is unclear which type of rescue endotherapy should be used after failure of the initial treatment. We evaluated the prognostic factors associated with clinical success of the initial treatment and different types of rescue endotherapy

Methods

Results

Conclusion