Su1571 ENDOSCOPIC MANAGEMENT OF BILE LEAKS IN PATIENTS UNDERGOING SUBTOTAL CHOLECYSTECTOMY FOR ACUTE CHOLECYSTITIS

Abstract

The mainstay of management of acute cholecystitis (AC) is laparoscopic cholecystectomy. Although one of the most commonly performed procedures in the United States, it is not immune to the challenges of hostile anatomy where the relationship between the cystic duct and portal structures cannot be adequately defined despite converting to open cholecystectomy. One option is to perform a subtotal cholecystectomy (SC) to avoid injury to the portal structures. However, SC is associated with a high incidence of bile leak. The aim of this study is to evaluate the efficacy and safety of endoscopic management of bile leaks following SC for AC. A retrospective analysis of a prospectively collected database of all patients undergoing SC for AC at our institution between 7/1/2015 and 11/15/2019 was conducted. Demographics, surgical, endoscopic, clinical management, and follow-up data was analyzed. A total of 36 patients underwent SC for AC during the study period. The primary indication for the procedure was AC in 40% (n=6) of patients, followed by acute on chronic cholecystitis 33.3% (n=5), perforated gallbladders secondary to AC 20% (n=3), and chronic cholecystitis 6.7% (n=1). Surgical drains were placed in all patients. Bile leaks were occurred in 15 (42%) patients (mean age: 51.67±15.12 years; 53.3% males). Mean interval to post-operative ERCP was 0.80±0.94 days. Biliary sphincterotomy and stenting was successful in all cases. Single (n=4) or multiple (n=4) plastic stents were placed in 53% (n=8) patients; whereas the remainder 7 (47%) patients received a fully covered self-expanding metal stent (FCSEMS). One patient was lost to follow-up. Follow-up ERCP was performed after a mean interval of 70.2±53.8 days. Persistent bile leak was noted in 40% patients (4/8 in patients with plastic stents vs 2/6 in FCSEMS group; p=0.63) requiring repeat stent (all FCSEMS) placement. There was no difference in mean stent duration between patients with and without persistent bile leak (69.9±37.3 vs. 63.3±62.9 days; p=0.81). Complete resolution on subsequent ERCP was noted in all patients except 1 patient with additional bile duct injury and leak from hilum and right main duct who underwent 2 further ERCPs with subsequent resolution of leak and stricture. The patients were followed for a mean of 10.8±15.82 months. No procedure related adverse events or recurrent cholecystitis was noted. ERCP with biliary stent placement is an effective modality for endoscopic management of bile leak following SC; however, significant number had persistent bile leak requiring repeat stenting. Given these lower resolution rates with single ERCP (compared to >95% resolution reported for cystic duct leak following LC), FCSEMS should be preferably placed for prolonged duration in patients with bile leak following SC.