Management Of Post-cholecystectomy Biliary Leaks Research Articles

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

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.

A non-randomized study in consecutive patients with postcholecystectomy refractory biliary leaks who were managed endoscopically with the use of multiple plastic stents or fully covered self-expandable metal stents (with videos)

Endoscopic management of postcholecystectomy biliary leaks is widely accepted as the treatment of choice. However, refractory biliary leaks after a combination of biliary sphincterotomy and the placement of alarge-bore (10F) plastic stent can occur, and the optimal rescue endotherapy for this situation is unclear. To compare the clinical effectiveness of the use of a fully covered self-expandable metal stent(FCSEMS) with the placement of multiple plastic stents (MPS) for the treatment of postcholecystectomy refractory biliary leaks. Prospective study. Two tertiary-care referral academic centers and one general district hospital. Forty consecutive patients with refractory biliary leaks who underwent endoscopic management. Temporary placement of MPS (n= 20) or FCSEMSs (n= 20). Clinical outcomes of endotherapy as well as the technical success, adverse events, need for reinterventions, and prognostic factors for clinical success. Endotherapy was possible in all patients. After endotherapy, closure of the leak was accomplished in 13patients (65%) who received MPS and in 20 patients (100%) who received FCSEMSs (P= .004). TheKaplan-Meier (log-rank) leak-free survival analysis showed a statistically significant difference between the 2 patient populations (χ(2) [1]= 8.30; P< .01) in favor of the FCSEMS group. Use of<3 plastic stents (P= .024), a plastic stent diameter<20F (P= .006), and a high-grade biliary leak (P= .015) were shown to be significant predictors oftreatment failure with MPS. The 7 patients in whom placement of MPS failed were retreated with FCSEMSs, resulting in closure of the leaks in all cases. Non-randomized design. In our series, the results of the temporary placement of FCSEMSs for postcholecystectomy refractory biliary leaks were superior to those from the use of MPS. A randomized study is needed to confirm our results before further recommendations.

Endoscopic management of postcholecystectomy biliary leaks

ObjectiveTo evaluate the nature of bile duct injuries following cholecystectomy and the success of endoscopic retrograde cholangiopancreatography (ERCP) in their identification and management.DesignAll patients referred for ERCP with a diagnosis...

Endoscopic Management of Postcholecystectomy Biliary Leaks

Purpose: Biliary leak is a common complication following cholecystectomy. Endotherapy is an established method of treatment. However, the optimal intervention is not known. Methods: Seventy three patients with postcholecystectomy biliary leaks from July 2000 to April 2007 were retrospectively evaluated. Results: There were 19 males and 54 females with a mean age of 43.06 years. Patients presented 17.95 ± 17.09 days (range 1–90 days) following cholecystectomy (46 open and 27 laparoscopic) with pain abdomen (42), jaundice (21), fever (21), and abdominal distension (37). Bilious abdominal drain was present in 55 patients. Endoscopic retrograde cholangiopancreatography detected leak at cystic duct stump in 35, stricture with mid common bile duct (CBD) leak in 4, leak from right hepatic duct in 2 and ligated CBD in 32 patients. Nine patients also had bile duct stones. One patient had broken “T” tube with stone. Endotherapy was possible in 41 patients and 32 patients with ligated CBD underwent surgery. Two patients with stones, one patient with broken “T” tube with stone and 4 patients with stricture common bile duct with leak were managed with sphincterotomy and stent. Seven patients with cystic duct stump leak with stone were managed with sphincterotomy and stone extraction. Three outdoor patients with cystic duct stump leak were managed with sphincterotomy and stent. Eleven patients with cystic duct stump leak admitted in hospital were managed with sphincterotomy and nasobiliary drain. Thirteen patients had coagulopathy hence sphincterotomy could not be done and were managed with only nasobiliary drain (7) and stent (6). Leak closure could be achieved in 100% patients. Mild pancreatitis occurred in 4 patients who were managed conservatively. Conclusion: Endoscopic intervention is a safe and effective method of treatment of postcholecystectomy biliary leaks. However, management of postcholecystectomy biliary leaks should be individualized based on type of leak and should include stent in outdoor patients and nasobiliary drain in indoor patients with simple leak, sphincterotomy and stone extraction in patients with stone, sphincterotomy and stent in patients with stricture with or without leak and those with ligated duct should undergo surgery.

Nasobiliary Tube Management of Postcholecystectomy Bile Leaks

Endobiliary stenting is the traditional form of endoprosthetic drainage for biliary leaks. Nasobiliary tubes offer the advantage of easy removal and interval tube cholangiograms to assess leak resolution. To determine the efficacy of nasobiliary tube drainage in patients with postcholecystectomy biliary leaks and provide our experience with management of biliary leak using nasobiliary drains. Retrospective study of 24 patients who were treated for postcholecystectomy biliary leaks in a tertiary referral center from 1998 to 2002. These patients were managed with either nasobiliary tube (NBT) alone or NBT + endoscopic sphincterotomy (ES). Twenty-four patients (mean age, 57.5 years; 50% women) had postcholecystectomy leak noted on ERCP. Twenty patients were managed by NBT+ES and 4 patients had NBT placement alone. In the NBT+ES group, 2 patients pulled their NBT out, but 18 patients had complete leak resolution in 3 to 9 days. In the NBT group, all patients had complete leak resolution in 4 to 12 days. Using an intention-to-treat analysis, 22 of 24 (92%) patients were successfully treated with NBT treatment over 3 to 12 days. ERCP with NBT placement is an effective and safe treatment modality in the management of postcholecystectomy biliary leaks.

Endoscopic stenting

Endoscopic management of postcholecystectomy biliary leaks is widely accepted as the treatment of choice. However, refractory biliary leaks after a combination of biliary sphincterotomy and the placement of a large-bore (10F) plastic stent can occur, and the optimal rescue endotherapy for this situation is unclear.To compare the clinical effectiveness of the use of a fully covered self-expandable metal stent (FCSEMS) with the placement of multiple plastic stents (MPS) for the treatment of postcholecystectomy refractory biliary leaks.Prospective study.Two tertiary-care referral academic centers and one general district hospital.Forty consecutive patients with refractory biliary leaks who underwent endoscopic management.Temporary placement of MPS (n = 20) or FCSEMSs (n = 20).Clinical outcomes of endotherapy as well as the technical success, adverse events, need for reinterventions, and prognostic factors for clinical success.Endotherapy was possible in all patients. After endotherapy, closure of the leak was accomplished in 13 patients (65%) who received MPS and in 20 patients (100%) who received FCSEMSs (P = .004). The Kaplan-Meier (log-rank) leak-free survival analysis showed a statistically significant difference between the 2 patient populations (χ2 [1] = 8.30; P < .01) in favor of the FCSEMS group. Use of <3 plastic stents (P = .024), a plastic stent diameter <20F (P = .006), and a high-grade biliary leak (P = .015) were shown to be significant predictors of treatment failure with MPS. The 7 patients in whom placement of MPS failed were retreated with FCSEMSs, resulting in closure of the leaks in all cases.Non-randomized design.In our series, the results of the temporary placement of FCSEMSs for postcholecystectomy refractory biliary leaks were superior to those from the use of MPS. A randomized study is needed to confirm our results before further recommendations.

A review of the management of post-cholecystectomy biliary leaks during the laparoscopic era: S.N. Mehta, E. Pavone, J.S. Barkun, et al. Am J Gastroenterol 92:1262–1267 (August), 1997

A review of the management of post-cholecystectomy biliary leaks during the laparoscopic era: S.N. Mehta, E. Pavone, J.S. Barkun, et al. Am J Gastroenterol 92:1262–1267 (August), 1997