S1690 A Slow Gut Can Hold up Recovery for Cholecystectomy-Induced Bile Leak

Abstract

Introduction: Bile leak (BL) can occur in up to 0.5% of open cholecystectomies (CCY) and up to 2.7% of laparoscopic CCY. Strasberg types A and D post-CCY BL can be treated with endoscopic retrograde cholangiopancreatography (ERCP) with excellent success rates > 90%. ERCP interventions can decrease the pressure gradient between the bile duct and duodenum and facilitate transpapillary flow of bile. Case Description/Methods: An 81-year-old woman with dementia, recurrent deep vein thrombosis and coronary artery disease presented to an outside hospital with severe abdominal pain and was diagnosed with acute cholecystitis. CCY was delayed by 6 days because she was on ticagrelor and rivaroxaban. Intraoperatively, a gangrenous perforated gallbladder was found, and a surgical drain (SD) was left in-situ. Post CCY she had persistent output from her SD and was transferred to our center for ERCP evaluation of suspected BL. On initial ERCP we found a high-grade Strasberg type A BL from the cystic duct (Figure A). Her major papilla was entirely located within a large duodenal diverticulum. Due to difficulty identifying safe cutting margins within the diverticulum, biliary sphincterotomy (Bsc) was not performed, and a 7 Fr plastic biliary stent was placed which resulted in good flow of bile into the duodenum. Her SD output decreased, and she was discharged the next day. Unfortunately, she was re-admitted to another hospital 3 days later with bile leakage around her SD, vomiting and constipation. An upper gastrointestinal (GI) series excluded a gastric outlet obstruction (Figure B). She was transferred back to our center for ERCP. The scout film showed that oral contrast that was ingested 3 days prior was still present within the proximal jejunum (Figure C). The biliary stent was patent and in good position, but a persistent high-grade BL was seen. Bsc was performed, and an 8mm by 6 cm fully covered self-expanding metal stent (FCSEMS) was placed. The patient was started on an aggressive bowel regimen with resolution of ileus. The SD output ceased, and the SD was removed 3 days later. Unfortunately, patient passed away in hospice before her follow-up ERCP from other causes. Discussion: Despite successful diversion of bile to the duodenum via a biliary stent, small bowel ileus can increase the pressure gradient across the major papilla, resulting in a persistent BL. More aggressive ERCP interventions using FCSEMS, along with aggressive medical treatment of ileus, allowed the BL to heal expeditiously.Figure 1.: A: High-grade cystic duct bile leak on initial ERCP evaluation. B: Contrast flowing from stomach to duodenum in upper gastrointestinal series. The plastic biliary stent is in-situ. C: the oral contrast ingested approximately 3 days prior is still visible within the proximal jejunum on ERCP scout film.