Postcholecystectomy Bile Leak Research Articles

Usefulness of Intraductal Placement of a Dumbbell-Shaped Fully Covered Self-Expandable Metal Stent for Post-Cholecystectomy Bile Leaks.

Background and aims: In the treatment of post-cholecystectomy bile leaks, endoscopic naso-biliary drainage (ENBD) or biliary stenting using plastic stents is the standard of care. Fully covered self-expandable metal stent (FCSEMS) placement across the sphincter of Oddi is considered a salvage therapy for refractory cases, but pancreatitis and migration are the major concerns. Intraductal placement of a dumbbell-shaped FCSEMS (D-SEMS) could avoid these drawbacks of FCMSESs. In this retrospective study, we investigated the usefulness of intraductal placement of the D-SEMS for post-cholecystectomy bile leaks. Methods: Six patients who underwent intraductal placement of the D-SEMS for post-cholecystectomy bile leaks were enrolled. This method was performed as initial treatment in three patients and as salvage treatment in three ENBD refractory cases. Results: Technical and clinical successes were obtained in 6 (100%) patients and 5 (83%) patients, respectively. One clinically unsuccessful patient required laparoscopic peritoneal lavage. The early adverse event was one case of mild pancreatitis (17%). The median duration of the D-SEMS indwelling was 61 days (42-606 days) with no migration cases, all of which were successfully removed. The median follow-up after index ERCP was 761 (range: 161-1392) days with no cases of recurrent bile leaks. Conclusions: Intraductal placement of the D-SEMS for post-cholecystectomy bile leaks might be safe and effective even in refractory cases.

Laparoscopy in the management of post-cholecystectomy bile leaks

IntroductionOver 1% of cholecystectomies are complicated by a post-operative bile leak. Most bile leaks are managed with endoscopic retrograde cholangio-pancreatography (ERCP) with decompression of the biliary tree. This paper reports our outcomes of using early re-laparoscopy in the investigation and treatment of post-operative bile leak. Materials/patients and methodsWe analysed our prospectively compiled database to identify all patients suffering a bile leak after cholecystectomy. Demographic data, details of the index cholecystectomy, post-operative investigations and procedures, and readmissions to hospital were analysed. Results4870 cholecystectomies were performed between 2016 and 2020; 1793 (36.9%) were urgent cholecystectomies performed at the index admission. 41 patients were identified with unexpected post-operative bile leaks. 40 patients underwent urgent re-laparoscopy as initial management. 17 patients required ERCP subsequent to re-laparoscopy. Median post-operative stay was 5 days. No cases were converted to open surgery, and there were no mortalities. DiscussionUrgent repeat laparoscopy is an effective tool to manage an unexpected post-cholecystectomy bile leak. Re-laparoscopy allows thorough peritoneal washout and diagnosis of the cause of the leak, and provides definitive treatment for the majority of patients. It is associated with a short hospital stay with minimal morbidity and mortality.

Management of complex acute biliary disease for the general surgeon: A narrative review

Acute gallbladder diseases are a common surgical emergency faced by General Surgeons that can sometimes be quite challenging. These complex biliary diseases require multifaceted and expeditious care, optimized based on hospital facility and operating room (OR) resources and the expertise of the surgical team. Effective management of biliary emergencies requires two foundational principles: achieving source control while mitigating the risk of injury to the biliary tree and its blood supply. This review article highlights salient literature on seven complex biliary diseases: acute cholecystitis, cholangitis, Mirizzi syndrome, gallstone ileus with cholecystoenteric fistula, gallstone pancreatitis, gall bladder cancer, and post-cholecystectomy bile leak.

The mystery of post-cholecystectomy persistent bile leak: a case report.

Laparoscopic cholecystectomy (LC) is commonly performed for benign gallbladder diseases. Biliary leak is the most common complication of bile duct injury following this surgery. We report a case of persistent bile leak following the procedure despite endoscopic and radiological management. A female patient presented to the hepatopancreatobiliary unit of the Bahria International Hospital (Orchard), Lahore, with complaint of persistent bile leakage after laparoscopic cholecystectomy performed elsewhere. She had been investigated in various hospitals but the cause of the persistent bile leak remained a mystery and she was offered surgery. After real time fluoroscopic contrast enhanced imaging, further confirmed by a Computerised Tomography (CT) Scan of the abdomen, it was revealed that the persistent bile leak in the drain was due to iatrogenic injury of the duodenum secondary to percutaneous catheter insertion. The patient was managed non-surgically. She remained stable. This is a rare complication of one of the most common surgical procedures performed in the world.

The mystery of post-cholecystectomy persistent bile leak: a case report

Laparoscopic cholecystectomy (LC) is commonly performed for benign gallbladder diseases. Biliary leak is the most common complication of bile duct injury following this surgery. We report a case of persistent bile leak following the procedure despite endoscopic and radiological management. A female patient presented to the hepatopancreatobiliary unit of the Bahria International Hospital (Orchard), Lahore, with complaint of persistent bile leakage after laparoscopic cholecystectomy performed elsewhere. She had been investigated in various hospitals but the cause of the persistent bile leak remained a mystery and she was offered surgery. After real time fluoroscopic contrast enhanced imaging, further confirmed by a Computerised Tomography (CT) Scan of the abdomen, it was revealed that the persistent bile leak in the drain was due to iatrogenic injury of the duodenum secondary to percutaneous catheter insertion. The patient was managed non-surgically. ---Continue

S106 Management of Post-Cholecystectomy Bile Leaks: Predictors for Persistent Leak After Initial ERCP

Introduction: Endoscopic retrograde cholangiopancreatography (ERCP) is a 1st-line treatment for post-cholecystectomy bile leaks (PCBL). Despite appropriate initial ERCP interventions that optimize transpapillary bile flow, PCBL can persist. We aim to evaluate baseline clinical factors associated with persistent PCBL after initial ERCP. Methods: We created a retrospective database of patients with PCBL referred for ERCP at Indiana University Health (IUH) University Hospital. Data collected included endoscopic reports, fluoroscopic imaging, patient demographics, type of PCBL, ERCP timing and interventions, technical success, and treatment outcomes. A high-grade bile leak (HG-BL) was defined as visualization of contrast extravasation from the bile duct before filling of intrahepatic biliary branches with contrast. The PCBL was deemed to be persistent if > 1 interventional ERCP was required for the leak to resolve on cholangiogram. (Figure) Results: From 2011 to 2021, 369 cases of PCBL were referred for ERCP. After excluding cases with transected bile ducts (n=21) and patients lost to follow up (n=15), 333 cases were included in data analysis (Image 1). 21 patients received their initial ERCP at an outside hospital. All patients received biliary sphincterotomy with stenting unless there was coagulopathy or Roux-en-Y gastric bypass (n=12). Univariate logistic regression analysis identified male gender, steroids use at time of ERCP, presence of duodenal stricture, a HG-BL, Strasberg class D PCBL, presence of biloma, presence of abdominal drain, presence of biliary stricture, and initial ERCP performed at outside hospital to be significant variables for persistent PCBL (Table). On multivariate analysis, presence of a HG-BL (OR 7.08, CI 1.96 – 25.58, p = 0.003) and initial ERCP performed at an outside facility (OR 29.14, CI 3.35 – 253.63, p=0.002) remained significantly associated with persistent PCBL. Being a female gender (OR 0.30, CI 0.11 – 0.85, P = 0.022) remained significant for higher odds of PCBL resolution after initial ERCP. Conclusion: Our study suggests that a HG-BL in a male patient may justify more aggressive ERCP interventions or more prolonged stent indwell time. As a tertiary referral hospital, we had a significant referral bias in our cohort, which could have acted as a confounder causing statistical significance for lower initial ERCP success rates at outside medical facilities. The relatively high volume of ERCP cases at our center may also have contributed to better ERCP outcomes.Figure 1.: Flowchart of the Study Table 1. - Univariate analysis of clinical variables for persistent PCBL after initial ERCP treatment Variables Initial ERCP failure OR (95% CI) P value Patient Characteristics Female 25/204 (12.25%) 0.49 (0.27 – 0.86) 0.013 Age 55 years old or more 34/175 (19.43%) 1.60 (0.90-2.86) 0.112 Median BMI (IQR) 32.0 (26.0, 36.0) 1.00 (0.98 – 1.03) 0.874 On diabetic treatment 13/58 (22.41%) 1.81 (0.93 – 3.53) 0.083 On steroids 4/6 (66.67%) 10.18 (1.82 – 57.00) 0.008 Major papilla within duodenal diverticulum 11/57 (19.30%) 1.46 (0.73 – 2.93) 0.282 Duodenal stricture/stenosis 5/10 (50.00%) 5.17 (1.45 – 18.48) 0.011 Location and timing of ERCP Procedure ERCP performed > 3 days 48/273 (17.58%) 1.00 (0.47 – 2.12) 0.994 Initial ERCP performed at outside facility 17/21 (80.95%) 30.94 (9.96 -96.06) < 0.001 Bile leak characteristics Strasberg Class A bile leaks 44/302 (14.57%) 0.26 (0.12 – 0.54) < 0.001 Strasberg Class D bile leaks 10/31 (32.26%) 2.70 (1.19 – 6.12) 0.018 Bile leak from cystic duct* 34/192 (17.71%) 1.25 (0.70 – 2.24) 0.446 Bile leak from duct of Luschka 4/104 (3.85%) 0.21 (0.09 – 0.50) < 0.001 Bile leak from common bile duct/common hepatic duct 7/25 (28.00%) 2.66 (1.13 – 6.27) 0.025 High-grade bile leak 25/63 (39.68%) 4.80 (2.58 – 8.95) < 0.001 Concomitant biloma present 27/115 (23.48%) 2.06 (1.13 – 3.76) 0.018 Percutaneous abdominal drain present 42/204 (20.59%) 2.02 (1.07 – 3.82) 0.030 Presence of biliary stones 5/67 (7.46%) 0.34 (0.13 – 0.88) 0.026 Presence of biliary stricture 7/21 (33.33%) 2.63 (1.01 – 6.84) 0.048 ERCP interventions Biliary sphincterotomy performed 56/325 (17.23%) 1.04 (0.22 – 4.88) 0.960 Biliary sphincterotomy alone 2/6 (33.33%) 2.46 (0.44 – 13.73) 0.306 Biliary stenting alone 2/12 (16.67%) 0.96 (0.21 – 4.51) 0.960 Bridging biliary stents 20/134 (14.93%) 0.78 (0.43 – 1.43) 0.426 Multiple biliary plastic stents 6/55 (10.91%) 0.55 (0.22 – 1.36) 0.198 Self-expandable metal stent 2/11 (18.18%) 1.09 (0.23 – 5.21) 0.910 *Reference group. IQR, interquartile range; IUH, Indiana University Health.

S1923 Abutting Percutaneous Drains Can Jeopardize Healing of Post-Cholecystectomy Bile Leaks

S1923 Abutting Percutaneous Drains Can Jeopardize Healing of Post-Cholecystectomy Bile Leaks

English

RATIONALE Ectopic varix at the hepaticojejunostomy site is a rare finding. So symptomatic jejunal varices at this site are difficult to manage. PATIENT CONCERN A 37-year-old female presented with bleeding per rectum for 5 months with a history of hepaticojejunostomy done 6 years back for management of postcholecystectomy bile leak. DIAGNOSIS The endoscopic investigation could not identify the source of bleeding. When conservative management could not control her bleeding, she underwent DSA which showed haemorrhage from ectopic varices at the hepaticojejunostomy site. INTERVENTION The patient underwent embolization of ectopic varices to arrest bleeding OUTCOME After embolization, patient bleeding per rectum stopped and improvement in haemoglobin was noted within 3 days of the procedure. ABBREVIATIONS DSA: Digital subtraction angiography, SMA: Superior mesenteric artery, SMV: Superior mesenteric vein, HJ: Hepaticojejunostomy, AVSC: Adult variable stiffness colonoscope, SBE-Single balloon enteroscopy, DBE: Double balloon enteroscopy KEY WORDS Hepaticojejunostomy, Portal Biliopathy, Ectopic Varices, Variceal Embolization.

Biliary Sphincterotomy Alone versus Biliary Stent with or without Biliary Sphincterotomy for the Management of Post-Cholecystectomy Bile Leak: A Systematic Review and Meta-Analysis

Background: Endoscopic therapy with endoscopic retrograde cholangiopancreatography is considered the first-line treatment in the management of post-cholecystectomy bile leak (PCBL). Currently, there is no consensus on the most effective endoscopic intervention for PCBL. Hence, we performed a systematic review and meta-analysis to compare the effectiveness and safety of the two interventional groups (biliary sphincterotomy [BS] alone vs. biliary stent ± BS) in management of PCBL. Methods: We conducted a comprehensive search of multiple electronic databases and conference proceedings (from inception through January 2021). The primary outcome was to compare the pooled rate of clinical success between the 2 groups. The secondary outcome was to estimate the pooled rate of adverse events. Results: The pooled rate of clinical success with BS alone (5 studies, 299 patients) was 88% (95% confidence interval (CI): 84–92%, I²: 0%) and for biliary stent ± BS (5 studies, 864 patients) was 97% (CI: 93–100%, I²: 79%). The rate of clinical success in biliary stent ± BS group was significantly higher than BS alone group (OR: 3.91 95% CI: 2.29–6.69, p < 0.001, I²: 13%). The rate of adverse events was numerically lower in biliary stent ± BS group compared to BS alone (3 studies; OR: 0.65 95% CI: 0.41–1.03, p = 0.07) without statistical significance. Low heterogeneity was noted in the analysis. Conclusions: Biliary stent ± BS is more effective in endoscopic management of PCBL compared to BS alone. This may be related to inter-endoscopist variation in completeness of sphincterotomy and post-sphincterotomy edema, which can influence the preferential trans-papillary flow of bile.

Long-term outcomes of delayed biliary strictures following cholecystectomy.

Delayed biliary strictures (DBS) after cholecystectomy are uncommon and little is known of their aetiology or long-term consequences. The aims of this study were to investigate the clinical and economic impact of DBS after cholecystectomy. Patients who developed DBS after cholecystectomy were identified from a prospectively collected and maintained database. Risk factors for stricture development, quality of life (QoL) and long-term biliary complication rates were explored. Costs of treatment and follow up were determined. The same outcomes among patients with minor or major bile duct injury (BDI) were used as a comparison. Among 44 patients, a laparoscopic converted to open procedure or post cholecystectomy bile leak affected some 18 and 12 patients respectively. Most DBS required surgical treatment (40). Over a median follow-up of 8.9 years after DBS treatment, 16 (36%) patients developed biliary complications (similar to minor, 26%, and major BDI, 40%) and 1 patient died of causes related to the biliary stricture. Costs of treating DBS and its follow up (£14,309.26 per patient), were similar to previously reported costs for major BDI (£15,784). DBS typically occur after a technically and/or complicated cholecystectomy. Clinical, economic and QoL outcomes are similar to patients with major BDI.

Endoscopic plastic stent therapy for bile leaks following total vs subtotal cholecystectomy.

Background and study aims Plastic biliary stents are standard therapy for treatment of post-cholecystectomy bile leaks. An increasing proportion of patients now undergo subtotal cholecystectomy and are at perceived risk for high-grade bile leak. Data are limited regarding the optimal endoscopic therapy following subtotal cholecystectomy. The aim of this study was to compare outcomes of endoscopic plastic stent therapy for treatment of bile leak following total vs subtotal cholecystectomy. Patients and methods A retrospective cohort of patients with bile leak following cholecystectomy and treated with biliary stent was identified from an institutional database. Primary outcome was defined as cholangiographic resolution of leak at follow-up endoscopic retrograde cholangiopancreatography (ERCP). Results Sixty-one subjects met study inclusion criteria, 27 following total cholecystectomy and 34 following subtotal cholecystectomy. A single plastic biliary stent was placed in 87 % of subjects (53/61), while a fully covered self-expanding metal stent (FCSEMS) was placed in 13 % (8/61). Leak resolution was evident at first follow-up ERCP in 96 % of subjects (26/27) who had undergone total cholecystectomy and 91 % of subjects (31/34) who had undergone subtotal cholecystectomy ( P = 0.25). Among subjects who had received a plastic stent at index ERCP, leak resolution was evident at first follow-up ERCP in 96 % (23/24) of those who had undergone total cholecystectomy and 90 % (26/29) of those who had undergone subtotal cholecystectomy ( P = 0.62). Conclusions High rates of leak resolution can be achieved with placement of a single plastic biliary stent for treatment of post-cholecystectomy bile leaks, including after subtotal cholecystectomy.

Current Scenario of Postcholecystectomy Bile Leak and Bile Duct Injury at a Tertiary Care Referral Centre of Nepal.

Objective With the adoption of safe cholecystectomy principles at an academic institute, the risk of major bile duct injury has decreased. This study aims at evaluating the present status of bile duct injury, compared to the study published in 2013 by index centre. Methods This is a retrospective review of a prospectively maintained database of bile leak and bile duct injury from 2014 to 2019. Patients who completed postcholecystectomy bile leak or bile duct injury treatment and were on regular follow-up were included. Results Eighteen patients (0.78%) among 2,300 consecutive cholecystectomies presented with bile duct injury, including 8 (0.35%) major bile duct injuries and 10 (0.43%) bile leaks compared to major bile duct injury rate of 0.68% (92/11,345 cholecystectomies) between 2001 and 2010. Injuries were classified as Strasberg's type A (52.9%), type D (5.9%), and type E (41.1%). Eight patients (47%) of bile leak were managed conservatively with drains, while two required laparotomy and lavage. The mean time for spontaneous closure of bile leak was 11 days. Intraoperative repair was done in three cases: Roux en Y hepaticojejunostomy in 2 and end-to-end repair over T-tube in 1 for sharp transection of the duct. Delayed repair (Roux-en-Y hepaticojejunostomy) was done in five patients. The median postcholecystectomy hospital stay was 8 days, with no mortality. There was no restricture at a median follow-up of 13 months. Conclusion With the adoption of a safe culture of cholecystectomy, the major bile duct injury rate has decreased currently. Repair of bile duct injury by experienced hepatobiliary surgeon results in excellent outcome.

Endoscopic treatment of post-cholecystectomy bile leaks: a tertiary center experience.

Post-cholecystectomy bile leak is relatively a well-known surgical complication. Several potential treatment modalities for such leaks are used. The early use of ERCP to exclude significant bile duct injury and to treat the leak by various endoscopic means is supported by a large bulk of data. However, there is no consensus as to the optimal endoscopic intervention. A retrospective review of ERCP database was done to identify all cases of bile leak related to cholecystectomy. Patient records including surgical and endoscopic reports were reviewed, and telephone interviews were conducted to collect data. During the period 2004-2016, 100 patients (53 men, 47 women; mean age, 55years) with post-cholecystectomy bile leak were referred for ERCP. Cholecystectomy was done laparoscopically in 82 patients (with an open conversion rate of 13%). In the majority of cases (77%), the leak was diagnosed by ongoing bile flow from the drains. The most common symptoms were pain (17%) and fever (4%). The most common site of the leak was the cystic duct stump (79%) followed by subvesical ducts (7%). Low grade leaks were seen in 84% of cases. Treatment included stent insertion alone (9%), sphincterotomy alone (11%), combination stent/sphincterotomy (76%) and others (1%). Failed ERCP was encountered in 3%. Endoscopic therapy was successful in 90 patients (90%). In subgroup analysis, success rate of procedures with stent insertion (with or without sphincterotomy) is significantly higher compared to procedures without stent insertion (95.3% vs 72.7%, p < 0.05). The failure rate of sphincterotomy alone procedures (3/11, 27%) is much higher compared to procedures with stent insertion (4/85, 5%) with p < 0.05. Four patients (4%) developed post-ERCP pancreatitis (mild to moderate) and one patient (1%) suffered from retroperitoneal perforation. The optimal endoscopic intervention for post-cholecystectomy bile leak should include temporary insertion of a biliary stent.

1292 Combined Postcholecystectomy Bile Leak and Benign Biliary Stricture—Should a Temporary Placement of Fully Covered Self-Expanding Metal Stent Be the First Choice?

INTRODUCTION: Bile leaks are common complications seen after cholecystectomy. Endoscopic Retrograde Cholangiopancreatography (ERCP) with the establishment of an enhanced transpapillary flow – through biliary stent placement and/or sphincterotomy – is considered the standard of care and usually has high success rates. Failure of initial endoscopic therapy (complex bile leak) can be managed with the placement of a fully covered self-expanding metal stent (FCSEMS) or surgery. We present a patient in which large postcholecystectomy biloma developed despite the presence of biliary plastic stent in place. CASE DESCRIPTION/METHODS: 48-year-old female with history of chronic pancreatitis and benign distal biliary stricture was admitted with worsening abdominal pain for the last 2 days. One month prior to this episode, the patient was admitted with the diagnosis of acute on chronic pancreatitis. She underwent ERCP with balloon dilatation and placement of plastic biliary (10 Fr × 10 cm) and pancreatic duct (5 Fr × 7 cm) stents. She had cholecystectomy prior to her discharge. Her abdominal pain on readmission was associated with nausea, vomiting, loss of appetite. She has chronic loose stools, which remained unchanged. She denied fevers, chills, or hematemesis. Her vital signs were within normal range. Abdominal exam revealed sluggish bowel sounds and right upper quadrant abdominal tenderness. She had elevated white cell count at 13,900/µL. The rest of the labs including kidney and liver function tests were unremarkable. CT scan of the abdomen showed moderate to large subcapsular and intraperitoneal fluid. There was mild dilatation of the common bile duct with the biliary and pancreatic duct stents in place. Findings were consistent with post-cholecystectomy biliary leak. A right upper quadrant pigtail drain was placed followed by ERCP. Cystic duct stump bile leak was diagnosed and treated with placement of FCSEMS. The patient tolerated the procedure well with improvement of symptoms. Bile leak resolved and FCSEMS was removed after three months. DISCUSSION: Patients with postcholecystectomy bile leak superimposed on a benign biliary stricture are probably appropriate candidates for endoscopic therapy with FCSEMS. Despite their higher costs, initial temporary placement of FCSEMS may obviate additional ERCP sessions in cases of failure of plastic stents. FCSEMS improve drainage since they have larger lumens. They should be considered especially in the presence of biliary prestenotic duct dilatation and high-grade leaks.

3040 An Uncommon Presentation of Post-Cholecystectomy Bile Leak in the Setting of Existing CBD Stent Successfully Managed With Metallic Stent Placement

INTRODUCTION: About 1% of patients undergoing cholecystectomy develop bile leaks. Bile leaks from cystic duct stump or from a duct of Luschka are the most common sites. Endoscopic biliary sphincterotomy and stent placement remains cornerstone in management of most post-operative bile leaks. We present an unusual case of post cholecystectomy bile leak from cystic duct stump in the presence of existing common bile duct stent. CASE DESCRIPTION/METHODS: A 48-year-old lady presented with 4 days history of worsening abdominal pain after cholecystectomy. She was admitted one week ago for acute exacerbation of chronic pancreatitis and underwent repeat ERCP. A plastic biliary and pancreatic stent was placed. She complained of RUQ pain and underwent HIDA scan which showed delayed gall bladder emptying suspicious for chronic cholecystitis. Given history of recurrent acute pancreatitis and chronic cholecystitis, cholecystectomy was recommended. Patient underwent laparoscopic cholecystectomy one week before this presentation. Abdominal exam on admission showed severe diffuse abdominal tenderness. X ray abdomen in ER showed non obstructive bowel pattern and possible ileus but no perforation. Labs showed WBC 13,000, TB 1.0, AST 11, ALT 20, ALP 186 and lactate 1.0. Given significant abdominal tenderness a CT abdomen and pelvis was done which showed moderate to large subcapsular and intraperitoneal fluid and 2 cm caudal migration of CBD stent with slight prominence of the adjacent common bile duct. HIDA scan showed collection of radionuclide activity along the inferior margin of the liver, increasing overtime, consistent with bile leak. A CT guided percutaneous drain was placed. Patient underwent ERCP 2 days after presentation. Cystic duct stump bile leak was seen which was treated with placement of 8 mm × 60 mm self-expandable fully covered metallic biliary stent (FCSEMS). Distal common bile duct stricture was again seen, measured 2.5 cm in length. Patient underwent repeat ERCP one month later with showed healed site of cystic duct stump leak. DISCUSSION: Presence of CBD stent does not preclude diagnosis of post cholecystectomy bile leak. In our case, CBD stricture, multiple previous endoscopic interventions and stent migration were reasons for failure to eliminate the transpapillary pressure gradient, thereby permitting preferential extravasation at the site of the leak. Further research is needed to establish role of FCSEMS in management of complicated biliary leaks especially in setting of CBD stricture.

Selective Trans-Catheter Coil Embolization of Cystic Duct Stump in Post-Cholecystectomy Bile Leak.

Percutaneous drainage is a first-line treatment for bilomas developed post-cholecystectomy in the setting of bile leak from the cystic duct stump. Percutaneous drainage is usually followed by surgical or endoscopic treatment to address the leak. This study aimed to evaluate outcome of selective coil embolization of the cystic duct stump via the percutaneously placed drainage catheters in patients with post-cholecystectomy bile leak. Seven patients with persistent bile leak after laparoscopic cholecystectomy who underwent percutaneous catheter placement for biloma/abscess formation in the region of the gallbladder fossa were followed. These patients underwent selective trans-catheter cystic duct stump coil embolization from Feb 2013 to Feb 2019. Procedural management, complications, and success rates were analyzed. All patients underwent placement of a percutaneous catheter for drainage of biloma formation in the gallbladder fossa post-cholecystectomy. Selective coil embolization of the cystic duct was performed through the existing percutaneous tract on average 3.5weeks after percutaneous catheter placement, resulting in resolution of the biloma. All bile leaks were immediately closed. None of the patients showed recurrent bile leak or further clinical symptoms. Coil migration to the common bile duct was diagnosed in a single case, after 2.5years, with no bile leak reported. Selective trans-catheter coil embolization of the cystic stump is a feasible and safe procedure, which successfully seals leaking cystic duct stumps and can circumvent the need for repeat surgical or endoscopic intervention in selected patient populations.

Biodegradable biliary stents preferable to plastic stent therapy in post-cholecystectomy bile leak and avoid second endoscopy

Background: The treatment of post-cholecystectomy bile leak is endoscopic retrograde cholangiography (ERC) with plastic stent (PS) insertion combined with external drainage. Self-expanding biodegradable biliary stents (BDBS) have only recently become available.Aim: The aim was to compare success rate, adverse events and costs of BDBS with PS in the treatment of post-cholecystectomy cystic duct leakMaterials and methods: Patients recruited prospectively for treatment with BDBS during the period 2014–2017 were compared to a control group treated with PS in a non-randomized setting.Results: Altogether 32 patients (median age 68, range 33–88, 59% male) were treated for Strasberg A bile leak over a period of 3.5 years, accounting for 1.8% of all ERCs. Eight patients were treated with BDBS and 24 with PS. Treatment with BDBS was safe; rate of readmissions and 30-day adverse events were 13% in both groups. There was no statistical difference in the clinical success rate. All cases with laparoscopic lavation or re-ERC with stent exchange occurred in the PS group. Total drain output was lower in BDBS patients (330ml vs 83ml, p=.002). All PS patients required another endoscopy for stent removal, whereas all BDBS patients were spared repeated endoscopy.Conclusion: Treatment of cystic duct leak with BDBS is highly successful and as safe as traditional treatment with PS. The most obvious benefit of BDBS is that it avoids stent removal. The lower drain output after ERC with a trend for fewer unplanned interventions may indicate more efficient leak resolution with the large bore BDBS.

A systematic review of biodegradable biliary stents: promising biocompatibility without stent removal.

Biodegradable self-expanding stents are an emerging alternative to standard biliary stents as the development of endoscopic insertion devices advances. The aim was to systematically review the existing literature on biodegradable biliary stents. In-vivo studies on the use of biodegradable stents in the biliary duct were systematically reviewed from 1990 to 2017. Despite extensive research on the biocompatibility of stents, the experience so far on their clinical use is limited. A few favorable reports have recently been presented on endoscopically and percutaneously inserted self-expanding biodegradable polydioxanone stents in benign biliary strictures. Another potential indication appears to be postcholecystectomy leak of the cystic duct. The main benefit of biodegradable stents is that stent removal can be avoided. The biocompatibility of the current biodegradable stent materials, most prominently polydioxanone, is well documented. In the few studies currently available, biodegradable stents are reported to be feasible and safe, also in humans. The initial results of the endoscopic use of these stents in benign biliary stricture management and for treating postcholecystectomy bile leaks are promising. Further controlled studies on long-term clinical results and cost-effectiveness are needed.

Additional flap on plastic stents for improved antimigration effect in the treatment of post-cholecystectomy bile leak.

Background and study aims In plastic stent insertion for treatment of post-cholecystectomy bile leak, stent migration may be more common due to the absence of a shelf to anchor the stent. We evaluated how adding a flap to straight plastic stents for this indication might influence the rate of stent migration when compared to use of conventional plastic stents. Patients and methods This is a retrospective study including patients referred for ERCP for treatment of post-cholecystectomy bile leak. Patients with a customized anti-migration flap stent had the additional flap created on the distal end of straight plastic stents, intended to aid in anchoring in the distal supra-sphincteric biliary duct. The primary endpoint is stent migration events. The secondary endpoint is bile leak resolution after first ERCP session. Results Thirty-two patients were treated with the experimental additional flap stents and 225 patients were treated with standard straight biliary stents. The total failure rate of bile leak resolution after a single endoscopic treatment for all treated was 10.5 % (27/257) and the total stent migration rate for all enrolled was 15.2 % (39/257). Stent migration rate was lower in the additional flap stent group than in the conventional group (3.1 % vs. 16.9 %, respectively, P = 0.04). Furthermore, significantly more patients had resolution of their bile leak after the first ERCP session in the group with the additional flap (100 % vs. 88 %, respectively, P = 0.03). Conclusion A plastic biliary stent with an extra flap may have improved performance with regard to stent migration and resolution of bile leak over standard plastic biliary stents.

Post-Cholecystectomy cystic bile Leaks: Why Endoscopically Overtreat is so Diffuse?

Post-Cholecystectomy cystic bile Leaks: Why Endoscopically Overtreat is so Diffuse?