Post-cholecystectomy Biliary Leaks Research Articles

Post-Cholecystectomy Biliary Leak and its Management in a Tertiary Care Hospital of Lahore City: A Cross Sectional, Descriptive Study

Background and Objective: Leakage of bile after open or laparoscopic cholecystecmy is rare, but if occurred, is associated with higher risk of morbidity and mortality. The objective of this study was to describe the experience of managing post-cholecystectomy biliary leak in a tertiary care hospital of Lahore, Pakistan.Methods: In this descriptive, cross sectional study, twenty-two cases were included using purposive sampling technique. These cases presented with bile leakage after cholecystectomy (open and/or laparoscopic) over the period of 3.5 years in a surgical unit. The patients were managed on case-to-case basis using a standardized revised algorithm. All patients were managed by ultrasonography guided drainage, and laparoscopic wash with control of sepsis. Magnetic Resonance cholangiopancreatography (MRCP) was conducted to classify injury using Strasberg's classification and managed according to the injury type. Data were managed and analyzed using SPSS version 25 and described using frequency and percentages.Results: Cases were aged between 30-60 years and out of 22 patients, twelve presented with bile leaks through drain left in-situ (55%), six presented with peritonitis with drain in-situ (27%), four patients (18%) had abdominal distension and peritonitis. Firty-one percent patients were managed by ultrasound guided drainage and in 9/22 patients laparoscopic wash and drain placement was done. In six patients, ERCP with stent was used. In 5/22 patients, hepaticojejunostomies were performed.Conclusion: Post-cholecystectomy iatrogenic biliary leak can be managed by drain placement, abdominal wash and antibiotics. Presented algorithm will help surgeons to manage post-cholecystectomy biliary leak effectively with low risk of mortality and morbidity.Keywords: Bile duct disease, post-operative complications, Common bile duct injuries, Biliary fistula , fistula biliary, biliary leakage, Cholecystectomy

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

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

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.

Endoscopic management of postcholecystectomy biliary leak: When and how? A nationwide study

ERCP is considered the first-line therapy for biliary duct leaks (BDLs). However, the optimal ERCP timing and endotherapy methods remain controversial. Our aim was to evaluate these factors as predictors of poor clinical outcomes after BDLs. Adults who underwent ERCP for BDLs after cholecystectomy were identified from the Nationwide Inpatient Sample from 2000 to 2014. ERCP was classified as emergent, urgent, and expectant if it was done within 1 day, after 2 to 3 days, or >3 days after BDLs, respectively. Endotherapy was classified into sphincterotomy, stent, or combination. Post-ERCP adverse events (AEs) were defined as requiring pressor infusion, endotracheal intubation, invasive monitoring, or hemodialysis. Early endotherapy failure was defined as the need for salvage surgical or radiology-percutaneous biliary intervention after ERCP. A total of 1028 patients with a median age of 56 years were included. ERCP was done emergently (19%), urgently (30%), and expectantly (51%). Endotherapy procedures were sphincterotomy (24%), biliary stent (24%), and combination (52%). Post-ERCP AEs were 11%, 10%, and 9% for emergent, urgent, and expectant ERCP, respectively (P= .577). In-hospital mortality showed a U-shape trend of 5%, 0%, and 2% for emergent, urgent, and expectant ERCP, respectively (P< .001). Combination and stent monotherapy had lower failure rates of 3% and 4%, respectively as compared with sphincterotomy monotherapy with failure rate of 11% (P< .001). When multivariate analysis was used, both combination (odds ratio, .2; 95% confidence interval, .1-.5) and stent monotherapy (odds ratio, .4; 95% confidence interval, .2-.9) were less likely to fail as compared with sphincterotomy monotherapy. There were no statistically significant differences between combination therapy and stent monotherapy in the univariate and the multivariate analyses. Although limited by retrospective design and the possibility of selection bias, this analysis suggests that the timing of ERCP is not a significant predictor of post-ERCP AEs after BDLs. Furthermore, combination or stent monotherapy had lower failure rates as compared with sphincterotomy monotherapy.

Leak after Laparoscopic Cholecystectomy; Incidence and Management

Background: laparoscopic cholecystectomy is currently the procedure of choice for symptomatic gallstones. It has evolved from an innovative, but time-consuming, novelty to a routine day-case procedure over the last 20 years. Purpose: to estimate the incidence and management options of post laparoscopic cholecystectomy biliary leaks. Also, it is a trial to advocate a minimally invasive structured management protocol to treat patients with bile leak. Patients and Methods: this study was a case series of 100 patients who underwent laparoscopic cholecsystectomy. We didn’t include patients who had: Biliary leak post Laparoscopic converted to open cholecystectomy. Biliary leak due to other procedures. Biliary leaks managed by open surgery. Biliary injuries discovered and definitively managed intra-operatively. The included patients presented to the General Surgery Department at Manshyt El Bakry General Hospital. Patients’ age ranged from 12 to 65 years and patients’ sex was distributed as 78 females and 22 males. Results: in our cases there were two out of the 100 patients suffered from biliary leak ,one of the two cases that were presented with biliary leak after surgery was due to direct injury to accessory duct of Luschka and the other one was due to a slipped clips. Conclusion: cholecystectomy is the most frequently performed abdominal operation in the United States, with currently over 700,000 cases occurring per year. Bile leak as a result of cholecystectomy is uncommon. The frequency in large series is less than 2% and in our study it was exactly 2%. And the treatment of that leak varies from conservative treatment to ERCP and stent insertion like we did.

Leak after Laparoscopic Cholecystectomy; Incidence and Management

Background: laparoscopic cholecystectomy is currently the procedure of choice for symptomatic gallstones. It has evolved from an innovative, but time-consuming, novelty to a routine day-case procedure over the last 20 years. Purpose: to estimate the incidence and management options of post laparoscopic cholecystectomy biliary leaks. Also, it is a trial to advocate a minimally invasive structured management protocol to treat patients with bile leak. Patients and Methods: this study was a case series of 100 patients who underwent laparoscopic cholecsystectomy. We didn’t include patients who had: Biliary leak post Laparoscopic converted to open cholecystectomy. Biliary leak due to other procedures. Biliary leaks managed by open surgery. Biliary injuries discovered and definitively managed intra-operatively. The included patients presented to the General Surgery Department at Manshyt El Bakry General Hospital. Patients’ age ranged from 12 to 65 years and patients’ sex was distributed as 78 females and 22 males. Results: in our cases there were two out of the 100 patients suffered from biliary leak ,one of the two cases that were presented with biliary leak after surgery was due to direct injury to accessory duct of Luschka and the other one was due to a slipped clips. Conclusion: cholecystectomy is the most frequently performed abdominal operation in the United States, with currently over 700,000 cases occurring per year. Bile leak as a result of cholecystectomy is uncommon. The frequency in large series is less than 2% and in our study it was exactly 2%. And the treatment of that leak varies from conservative treatment to ERCP and stent insertion like we did.

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.

Placement of a New Fully Covered Self-expanding Metal Stent for Postoperative Biliary Strictures and Leaks Not Responding to Plastic Stenting

Fully covered self-expanding metal stents (FCSEMSs) are now being used to treat postoperative biliary strictures (BSs) and biliary leaks (BLs). The aim of this study was to assess the safety and effectiveness of a new FCSEMS (Wallflex) in patients with postoperative BSs and BLs after failure of traditional endoscopic treatment. Between January 2010 and December 2011, 16 patients (10 patients with postcholecystectomy BSs, 4 with postcholecystectomy BLs, and 2 with postorthotopic liver transplantation BSs) were enrolled. The technical and clinical success rate was 100%. All FCSEMSs were removed after a mean of 141 days. Complications occurred in 7 cases: 2 postprocedure pain, 2 mild pancreatitis, 1 early distal, and 2 late proximal FCSEMS migration. The overall long-term clinical success rate was 94% after a mean follow-up of 13 months. In our experience, the placement of FCSEMSs is an effective and secure method of treating refractory postoperative BSs or BLs.

PWE-191 The role of ERCP in the management of post cholecystectomy biliary leaks

IntroductionBile duct injury causing a biliary leak after cholecystectomy is an important and well recognised surgical complication. It has a significant impact on the post operative recovery and is often...

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...

Role of Symptoms, Trend of Liver Tests, and Endotherapy in Management of Post-Cholecystectomy Biliary Leak

Biliary leaks are widely reported complications of cholecystectomy, but standard management remains undecided. The objective of our study was to report the role of symptoms, biochemical tests, and ERCP in patients with a leak. Twenty-one patients (8 M, 26-77 years) with suspected post-cholecystectomy biliary leak were retrospectively studied. Symptoms and liver tests (LTs) after surgery were monitored. Trends of LTs were considered positive if increases at >48 h were seen. ERCP was performed in all patients. Findings at endoscopy and treatments were reported. Outcome results were obtained for all patients. Seventeen of 21 patients had persistent biliary leak at ERCP, because of direct injury (n = 10), accessory duct (n = 4), or cystic duct stump (n = 3). Eleven of 17 patients (six without symptoms), had distal obstruction because of surgical injury (n = 8), stone (n = 2), or cholangiocarcinoma (n = 1) and underwent stenting (n = 4), naso-biliary drainage, NBD (n = 3), or surgery (n = 4). Among the six patients without obstruction (four without symptoms), stenting was performed in two and NBD in four. The four patients without apparent leak underwent NBD. Impairment of LTs was present in ten out of eleven (91%) patients with obstruction versus six of ten (60%) without obstruction. No complications occurred after ERCP. During a median follow-up of 33 months (cholangiocarcinoma excluded) all but one remained asymptomatic. Symptoms and trend of LTs were not predictive of biliary obstruction in patients with a leak after cholecystectomy. Both endotherapy and surgery had favorable outcomes.

Endoscopic management of post-operative biliary tract injuries

Post-operative biliary tract injuries have traditionally been treated by surgery; since the 1990s, however, this was replaced by endoscopic methods. These complications occur most frequently after laparoscopic surgery. Whenever biliary leakage is suspected, a close cooperation between endoscopists and surgeons is essential. Immediate visualisation of the biliary tract by endoscopic retrograde cholangio-pancreatography (ERCP) is mandatory to confi rm the diagnosis and locate the exact site of the lesion. Various endoscopic techniques have proven to be effective in the treatment of post-cholecystectomy biliary leaks. The crucial point is to equalise duodenal and biliary tract pressures so that bile fl ow into the duodenum is ensured and healing of the lesion is facilitated. This can be achieved by endoscopic sphincterotomy either alone or in combination with subsequent implantation of a plastic stent. These methods seem to be equally suitable; for greater lesions, however, insertion of a stent is advisable. For biliary tract strictures, multiple stenting is recommended, the results of which are promising in the long run as well.

Endoscopic management of postoperative biliary injuries

The postoperative complications of the biliary tract, such as leakages and strictures, traditionally had been managed surgically, but from the 90s they are usually treated via endoscopic route. These complications occur most frequently after laparoscopic surgeries. Whenever biliary leakage is suspected, close collaboration between endoscopists and surgeons is needed. Immediate visualization of the biliary tract by ERCP is mandatory to confirm the diagnosis and to locate the exact site of the lesion. Various endoscopic techniques have been proved effective in treating post-cholecystectomy biliary leaks. The crucial point is to equalize the duodenal and the biliary pressures, allowing flow of the bile into the duodenum, advancing the healing of the lesion. This can be achieved with a simple endoscopic sphincterotomy or endoscopic sphincterotomy with subsequent insertion of a plastic stent. These methods seem to be equally suitable; however, for greater lesions stent placement is advisable. For strictures multiple stenting is the effective method, and the long standing effects also seem to be good.

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.

Biliary stenting alone versus biliary stenting plus sphincterotomy for the treatment of post-laparoscopic cholecystectomy biliary leaks: a prospective randomized study

Although various endoscopic techniques have been proved effective in treating post-cholecystectomy biliary leaks, the choice of the best method remains controversial. The aim of this prospective study was to compare the efficacy and safety of biliary stenting alone with biliary stenting plus sphincterotomy for the treatment of post-cholecystectomy biliary leaks. Patients with post-laparoscopic cholecystectomy leaks were randomized into two groups. The first group included 24 patients who were treated with a 7 Fr biliary stent alone, and the second group included 28 patients who underwent an endoscopic sphincterotomy followed by insertion of a 10 Fr biliary stent. Endoscopic therapy was successful in all patients (100%). Clinical improvement was observed after 2-6 days. Patients remained hospitalized for 4-12 days. Stents were removed after 6.7 (6-8) weeks. The overall complication rate was 4.16% for the first group and 10.71% for the second (P=0.615). No complications were recorded during the follow-up period. Endoscopic therapy of biliary leaks with a small-diameter biliary stent alone is as effective and safe as endoscopic sphincterotomy followed by insertion of a large-diameter stent.

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.

Failure of ERCP to identify biliary leak after laparoscopic cholecystectomy

Biliary leaks are a complication of laparoscopic cholecystectomy thought to occur in approximately 1.1% of cases. 1 Barkun AN Rezieg M Mehta SN Pavone E Landry S Barkun JS et al. Post-cholecystectomy biliary leaks in the laparoscopic era: risk factors, presentation, and management. Gastrointest Endosc. 1997; 45: 277-282 Abstract Full Text Full Text PDF PubMed Scopus (132) Google Scholar ERCP has become a standard component in the approach to management of such cases, for diagnosis as well as treatment. However, there are few data on the sensitivity of ERCP in the identification of biliary leaks, which has been assumed to approach 100%. This is a case of biliary peritonitis caused by a bile leak after laparoscopic cholecystectomy that was not apparent on ERCP despite excellent opacification of the biliary tree.

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