Treatment Of Bile Leaks Research Articles

Intraoperative Fluorescent Cholangiography Using Indocyanine Green Fluorescence for Identification and Treatment of Bile Leaks After Urgent Laparoscopic Cholecystectomy

Introduction: Laparoscopic cholecystectomy (LC) is one of the most common surgical procedures performed worldwide.1 Postoperative bile leaks caused by bile duct injuries (BDIs) are serious complications after LC, resulting in a prolonged length of hospital stay, increased costs, morbidity, and mortality rates.2 Incidence of BDIs during LC is ~0.4%–1.5%.1 Intraoperative fluorescent cholangiography using indocyanine green fluorescence (ICG-C) is a safe method to observe the biliary tree and may be useful to prevent postoperative bile leaks after LC and hepatic surgery.1,2 However, detection of bile leaks using the ICG-C during LC has limited evidence in international literature.3–8 This video illustrates how to use ICG-C to identify and treat a bile leak after an urgent LC. Materials and Methods: A 54-year-old man with a history of hypertension, diabetes mellitus, cholelithiasis, and hepatic abscesses was admitted with right upper quadrant pain and fever. An urgent CT scan of the abdomen showed acute cholecystitis associated with a large pericholecystic abscess. A percutaneous cholecystostomy (PC) was placed and nonoperative management with intravenous antibiotic was started. On the seventh postprocedural day, the PC was accidentally removed, and a second CT scan of the abdomen showed a reduction of the pericholecystic abscess size, and a subhepatic fluid collection. An urgent LC was performed, and two surgical drains were placed (one subhepatic and one suprahepatic). On the first postoperative day, a low-flow biliary output (250 mL/day) from the subhepatic drainage was associated with a gradual deterioration of the patient's clinical condition. Considering the low flow rate of the biliary fistula, nonoperative management was carried out; on the second post-operative day the patient presented hypotension, oliguria, fever (temperature 38.2°C), and worsening right upper abdominal pain with signs of diffuse peritonitis. The hematologic investigations showed a WBC 17,560/mL, Hb 10.7 g/dL, C-Reactive Protein 17.66 mg/dL, normal liver function tests, and normal bilirubin levels. Owing to signs of septic shock and diffuse signs of peritonitis, an urgent surgical exploration was performed. After the induction of anesthesia, 2.5 mg of Indocyanine Green was intravenously injected. Eight minutes later, the ICG-C demonstrated exactly and in real-time the biliary leak on the liver surface, coming from a subvesical bile duct. Two laparoscopic Roeder's knots were placed to repair the injury. Two surgical drains were placed. Results: The postoperative period was uneventful, with a progressive improvement of the patient's performance status, vital parameters, and laboratory tests. The surgical drains were serosanguinous with low output and both were removed on postoperative day 9. The patient was discharged on day 10 in good clinical condition. Conclusions: One of the most common causes of LC-associated biliary leaks are injuries to the subvesical bile ducts. ICG-C clearly identifies these bile spots on the liver surface during surgery, allowing them to be repaired immediately and prevent biliary fistulas. ICG-C is a safe, easy, repeatable, and noninvasive method to identify bile leaks during surgery. ICG-C may be useful to prevent and treat bile leaks after LC, especially in complicated cholecystitis.5,6 Authors have received and archived patient consent for video recording/publication in advance of video recording of procedure. No competing financial interests exist. Running time of video: 8 mins 27 secs

Stent Strategy in Bile Leakage after Liver Surgery

Introduction: Endoscopic retrograde cholangiopancreatography (ERCP) with stenting is considered the treatment of choice in bile leakage (BL) after liver surgery. Evidence is lacking on which strategy to choose, distal downstream decompression of the biliary tree or insertion of a longer stent for drainage closer to or bridging the the leakage point. Methods: All ERCPs performed in Sweden are registered in a national quality registry (GallRiks). Data on all ERCPs performed for the indication of BL between 2006-2017 were extracted. Patients who underwent endoscopic intervention for BL following liver resection were compared in two groups: sphincterotomy only or placement of a stent ≤ 7 cm (distal decompression) vs. placement of a stent >7cm (proximal drainage or bridging). The primary outcome was was cessation of BL within 30 days of endoscopic intervention. Results: A total of 2346 ERCPs were performed for BL, of which 259 procedures were in 201 persons following liver resection. Ten patients in whom ERCP could not demonstrate a leak were excluded from the analyses. In 87 patients distal decompression was performed and in 104 patients proximal drainage or bridging. The groups were comparable regarding age, sex and comorbidities. There were no differences in 30-day cessation of BL between the two groups (OR 0.71 (95% CI 0.26-1.98)) and complication rates were comparable (OR 1.30 (95% CI 0.73-2.31). Conclusion: Downstream control seems to be as efficient as the insertion of a proximal or bridging stent in treatment of BL after liver resection.

Argon plasma coagulation for successful treatment of bile leakage after subtotal cholecystectomy

BackgroundSubtotal cholecystectomy is an effective surgical method to decrease the risk of complications for gallbladders that are difficult to remove. However, there is a risk for postoperative refractory bile leakage through the gallbladder stump. Here, we report a new management technique involving the use of argon plasma coagulation (APC) to stop bile leakage after a subtotal cholecystectomy.Case presentationA 74-year-old man was referred to our hospital for abdominal pain and fever. Contrast-enhanced computed tomography of the abdomen showed fluid collection, such as an abscess, surrounding the gallbladder and hepatic flexure colon. The patient was diagnosed with colonic perforative peritonitis, and he underwent emergency surgery. On laparotomy, the abscess was observed outside of the hepatic flexure colon and gallbladder necrosis was detected. The neck of the gallbladder and the area close to the hepatoduodenal ligament was severely inflamed prohibiting dissection. The hepatic flexure colon was part of the abscess wall, and resection was needed. A subtotal cholecystectomy and right hemicolectomy confirmed peritonitis caused by cholecystic perforation. The mucous membrane of the gallbladder neck that remained was necrotic or detached. Therefore, the stump of the gallbladder was closed by primary sutures without cauterization of the mucosa. On postoperative day 6, bile leakage from the gallbladder stump was revealed. Percutaneous and endoscopic retrograde cholangiography drainage were performed. However, the liquid, which seemed to be secreted from the mucosa of the remnant gallbladder, was continuously obtained. We used APC to cauterize the gallbladder mucosa through the fistula of the abdominal drainage tube. Bile leakage and mucus discharge were improved after three rounds of APC cauterization.ConclusionsAPC effectively treated refractory bile leakage from a gallbladder stump after subtotal cholecystectomy for severe cholecystitis.

Sphincterotomy alone appears sufficient for the treatment of bile leaks.

Sphincterotomy alone appears sufficient for the treatment of bile leaks.

Comparison of Biliary Stent versus Biliary Sphincterotomy Alone in the Treatment of Bile Leak

Background and Aims: Bile leaks are uncommon but are a painful postoperative complication of hepatobiliary interventions. Many authors advocate treating them with biliary stenting. We compared the outcomes in patients treated with endoscopic biliary sphincterotomy (EBS) alone versus EBS with biliary stenting. Methods: We reviewed charts of patients treated endoscopically for bile leak from 2009 to 2015 at our tertiary care center. Based on endoscopists’ practice preference, patients underwent EBS alone or with a biliary stent. Clinical resolution of bile leak and total number of endoscopic and nonendoscopic interventions were compared between patients treated with EBS alone versus EBS with a biliary stent. Results: Fifty-eight patients were included; etiology was cholecystectomy (52), hepatic resection (5), and liver trauma (1). The leak was from the cystic duct (22), duct of Luschka (23), common bile, or hepatic duct (2), and intrahepatic duct (11). Thirty-seven patients had EBS alone (EBS group), and 21 had stents (stent group). Single intervention resolved the bile leak in 34 (92%) patients in EBS group and 19 (90%) in the stent group (p = 0.85). Resolution was slower (p = 0.02) and more patients required second intervention (p < 0.01) in the stent group. Conclusion: EBS with or without a biliary stent is highly effective in the management of bile leak. Clinical resolution of the bile leak is quicker with EBS alone, requires fewer interventions, and may cost less.

Endoscopic surgical treatment for bile leakage

胆漏是肝胆外科常见的手术并发症，内镜逆行胰胆管造影术(ERCP)因微创、安全、有效，是医源性胆漏推荐的一线治疗方案。针对不同类型的胆漏，如何选择ERCP治疗并将其规范化有重要临床意义，现对其应用进行评价，以供临床参考。

Causes and Treatment of Bile Leaks at the Puncture Site After Percutaneous Transhepatic Biliary Decompression

Introduction: Bile leaks at the puncture site after percutaneous transhepatic biliary decompression (PTBD) are not uncommon and cause a lot of problems for patients with non-resectable biliary malignant obstruction. However, to the best of the authors’ knowledge, no study is conducted to establish the causes and to find an appropriate treatment. The current study was conducted on 264 patients who underwent PTBD for a malignant biliary obstruction. Material and Methods: This retrospective study reviewed 264 patients with non-resectable malignant biliary obstruction requiring PTBD. A two-stage biliary decompression is done. An 8Fr pigtail catheter is placed for PTBD, the patients would return after two days for stent placement. After stent placement, an 8 Fr pigtail catheter (internal – external) would be placed for flushing, and also for cholangiography. The patients are then observed for another two days. Patients who have persistent puncture site bile leakage after 24 hours are considered to have a bile leak. In these patients, cholangiography is performed. If cholangiography reveals stent occlusion, stent reopening by irrigation/ballooning is done. For those with patent stents and bile leakage, an internal-external biliary drain is placed which does not solve the problem, and a cholangiography is done into the drain tract via a syringe. Results: Sixteen of 264 patients who underwent percutaneous biliary decompression developed bile leakage at the puncture site. Twelve of these patients demonstrated an occluded biliary stent and their bile leak resolved after irrigation/ballooning. Four patients with bile leak demonstrated patent biliary stents and persistent leakage despite internal-external biliary drain placement. Cholangiograms in these patients demonstrated connections from the stented biliary system (the ipsilateral system), branches of a different occluded biliary system (the contralateral biliary tract), and the drain tract. All four patients underwent PTBD of the contralateral biliary system with subsequent resolution of their bile leak. Discussion: One of the complications of PTBD is bile leakage at the puncture site which could have two reasons. The most common is stent occlusion by clot and debris which can be managed by irrigation/ stenting. The second mechanism of bile leakage, not reported previously, was a fistulous connection between the drained biliary system (the ipsilateral system) and a separate obstructed biliary system (the contralateral system). We would like to refer to this mechanism of bile leak “Yo-Yo reflux” for its specific pattern of cholangiography. The Yo-Yo reflux mechanism of bile leaks occurs when a small branch from the adjacent separated contralateral system is transgressed inadvertently during ipsilateral biliary drainage. High-pressure bile fluid from the obstructed system flows through the lower pressure ipsilateral system and through the cannulation tract and onto the skin surface. In the Yo-Yo mechanism, stenting of the contralateral side is the only treatment. Conclusion: Bile leakage at the puncture site after PTBD has two major causes. The most common is stent occlusion by clot/debris which is diagnosed by cholangiography and treated by irrigation/ballooning. The second cause is Yo-Yo reflux which is diagnosed by cholangiography injecting directly into the orifice of skin fistula and treated by contralateral stenting.

Sa1490 USE OF FULLY COVERED SELF-EXPANDING METAL STENTS IN MANAGEMENT OF BILE LEAKS

Management of bile leaks can present a complicated problem for surgeons and endoscopists. Bile leaks are primarily managed endoscopically, however, interventional radiology and surgical approaches may be necessary for complex persistent bile leaks or for the treatment of associated fluid collections. Little data exists to support the use of fully covered self-expanding metal stents (FCSEMS) in management of bile leaks. In this study we aimed to evaluate FCSEMS in the treatment of bile leaks.

Endoscopic treatment of bile duct post-traumatic and post-operative lesions in children

Background and study aims: The aim of this study was to assess the significance and safety of endoscopic retrograde cholangiopancreatography (ERCP) in diagnosing and treating bile duct injuries in children.Patients and methods: Fourteen pediatric patients, with traumatic or postoperative bile duct injury, in which ERCP was performed, were retrospectively evaluated.Results: We performed 46 ERCP and 12 endoscopic papillotomies in children with suspected bile duct injuries. A bile stent was primarily inserted in 13 patients and there were 20 replacements. Endoscopic treatment of bile leakage without need for bile duct sutures or reconstruction was successful in 85.7%. Post ERCP complications included cholangitis and recurrent bleeding, which occurred only in two patients each.Conclusions: ERCP and endoscopic bile stent insertion is a highly effective, minimally-invasive treatment for bile duct injury and should be included as part of the therapeutic procedures in pediatric patients with suspected bile duct injury.

Treatment of bile leaks after hepatopancreatobiliary surgery

Treatment of bile leaks after hepatopancreatobiliary surgery

A retrospective analysis of endoscopic treatment outcomes in patients with postoperative bile leakage.

OBJECTIVE:Bile leakage, while rare, can be a complication seen after cholecystectomy. It may also occur after hepatic or biliary surgical procedures. Etiology may be underlying pathology or surgical complication. Endoscopic retrograde cholangiopancreatography (ERCP) can play major role in diagnosis and treatment of bile leakage. Present study was a retrospective analysis of outcomes of ERCP procedure in patients with bile leakage.METHODS:Patients who underwent ERCP for bile leakage after surgery between 2008 and 2012 were included in the study. Etiology, clinical and radiological characteristics, and endoscopic treatment outcomes were recorded and analyzed.RESULTS:Total of 31 patients (10 male, 21 female) were included in the study. ERCP was performed for bile leakage after cholecystectomy in 20 patients, after hydatid cyst operation in 10 patients, and after hepatic resection in 1 patient. Clinical signs and symptoms of bile leakage included abdominal pain, bile drainage from percutaneous drain, peritonitis, jaundice, and bilioma. Twelve (60%) patients were treated with endoscopic sphincterotomy (ES) and nasobiliary drainage (NBD) catheter, 7 patients (35%) were treated with ES and biliary stent (BS), and 1 patient (5%) was treated with ES alone. Treatment efficiency was 100% in bile leakage cases after cholecystectomy. Ten (32%) cases of hydatid cyst surgery had subsequent cystobiliary fistula. Of these patients, 7 were treated with ES and NBD, 2 were treated with ES and BS, and 1 patient (8%) with ES alone. Treatment was successful in 90% of these cases.CONCLUSION:ERCP is an effective method to diagnose and treat bile leakage. Endoscopic treatment of postoperative bile leakage should be individualized based on etiological and other factors, such as accompanying fistula.

Bile duct injury repair —— earlier is not better.

Bile duct injury is a common complication of cholecystectomy. The timing of bile duct injury repair remains controversial. A recent review conducted in France reported 39% complications and 64% failure after immediate repair in 194 patients compared with 14% complications and 8%failure after late repair in 133 patients. A national review of 139 consecutive early repairs conducted at five hepatopancreaticobiliary centers in Denmark reported 4% mortality, 36% morbidity, and 42 restrictures (30%) at a median follow-up of 102 months, and only 64 patients (46%) demonstrated uneventful short-term and long-term outcomes. Most patients with bile duct injury present with bile leak and sepsis; thus, early repair is not recommended. Percutaneous drainage of bile and endoscopic stenting are the mainstays of treatment of bile leak because they convert acute bile duct injury into a controlled external biliary fistula. The ensuing benign biliary stricture should be repaired by a biliary surgeon after a delay of 4–6 weeks once the external biliary fistula has closed.

Endoscopic management is the treatment of choice for bile leaks after liver resection

Despite improvements in surgical techniques and postoperative patient care, bile leaks still occur postoperatively in as many as 15% of liver resections (LRs) and are associated with high mortality. There is a paucity of outcome data on endoscopic treatment of complex bile leaks. The aim of this retrospective study was to evaluate the efficacy of interventional endoscopy in the treatment of bile leaks after LR. Retrospective interventional study. Sixty patients with bile leaks after LR were treated endoscopically with or without implantation of endoprostheses by using ERCP. The characteristics of LR, effects of surgical and other nonendoscopic treatment measures, clinical and endoscopic presentation of bile leaks, and outcomes after stent placement were recorded. Main outcome measure was resolution of leakage or termination of unsuccessful endoscopic leakage therapy. The median age of the observed cohort was 58 years. Sixty-five percent of patients had central and 35% peripheral bile leaks; 55% had resection of an entire hepatic lobe, and 45% underwent segmental resection. The overall success rate of endoscopic therapy was 77%. Although endoscopic therapy was performed in all patients with a mean of 2.6 interventions, 28% underwent additional percutaneous drainage. Success of endoscopic treatment was related to stent implantation. Thirteen patients with unsuccessful endoscopic treatment underwent surgical reintervention, and 1 patient died before surgical intervention. No standardized protocol for stent placement due to retrospective nature of the study. Small sample number with uneven distribution of outcome. Endoscopic therapy with sphincterotomy and insertion of endoprostheses is effective, even in large postoperative bile leaks and particularly for leaks proximal to the common hepatic duct. Complete resolution of the leakage often necessitates multiple treatment sessions.

Endoscopic management of bile leakage after cholecystectomy: a single-center experience for 12 years.

Background/AimsBile leakage is an uncommon but serious complication of cholecystectomy. The aim of this study is to evaluate the efficacy of the endoscopic management of bile leakage after cholecystectomy.MethodsA total of 32 patients who underwent endoscopic retrograde cholangiopancreatography (ERCP), because of bile leakage after cholecystectomy, from January 2000 to December 2012 were reviewed retrospectively. The clinical parameters, types of management, and procedure-related complications were documented.ResultsMost bile leakages presented as percutaneous bile drainage through a Hemovac (68.8%), followed by abdominal pain (18.8%). The sites of bile leaks were the cystic duct stump in 25 patients, intrahepatic ducts in four, liver beds in two, and the common bile duct in one. Biliary stenting with or without sphincterotomy was performed in 22 and eight patients, respectively. Of the four cases of bile leak combined with bile duct stricture, one patient had severe bile duct obstruction and the others had mild stricture. Concerning endoscopic modalities, endoscopic therapy for bile leak was successful in 30 patients (93.8%). Two patients developed transient post-ERCP pancreatitis, which was mild, and both recovered without clinical sequelae.ConclusionsThe endoscopic approach of ERCP should be considered a primary modality for the diagnosis and treatment of bile leakage after cholecystectomy.

Enclosed Passive Infraversion Lavage–Drainage System (EPILDS): A Novel Safe Technique for Local Management of Early Stage Bile Leakage and Pancreatic Fistula Post Pancreatoduodenectomy

This study's objective was to test the new drainage apparatus called enclosed passive infraversion lavage-drainage system (EPILDS) in the treatment of bile leakage and pancreatic fistula Post Pancreatoduodenectomys. The EPILDS device has a design of a siphon. The inlet bag that contains the rinse liquid is put lower than the abdominal lacuna to be washed but higher than the outlet bag. The hydrostatic pressure difference between the inlet and outlet bags constitutes the driving force of the flow. The three-way cock valves are installed in the inlet and outlet tubes to facilitate the washing of occluded tubes. Two side by side Penrose drainage tubes were placed during the operation. One tube passed through the posterior side of pancreatico-jejunal and biliary-jejunal anastomoses, right paracolic gutter, and exited through an opening made in the right lower abdomen. Second tube came from the smaller sac, went through the anterior side of pancreatico-jejunal and biliary-jejunal anastomoses, and exited through an opening made in the left upper abdomen. Using this system, we successfully treated two patients. Both inlet and outlet volumes were observed to verify that the outlet exceeds the inlet volume. In conclusion, EPILDS has a simple and practical design. It changes the active washing process into a passive one, in which the input is controlled by the exiting fluid. This is the effective and safe system for treatment of severe bile leakage and pancreatic fistula at the early postoperative stage.

Intraoperative Placement of External Biliary Drains for Prevention and Treatment of Bile Leaks After Extended Liver Resection Without Bilioenteric Anastomosis

Improved surgical techniques, substantial preoperative diagnostics, and advanced perioperative management permit extensive and complex liver resection. Thus, hepatic malignancies that would have been considered inoperable some years ago may be curatively resected today. Despite all this progress, biliary leakage remains a clinically relevant issue, especially after extended liver resection. Intraoperative decompression of bile ducts by means of distinct biliary drains is controversial. Although drainage is rarely used as a routine procedure, it might be useful in selected patients at high risk for biliary leakage. We describe surgical management of long-segment exposed or injured bile ducts after extended parenchymal resection with concomitant lymphadenectomy. Because blood supply to the bile duct may be impaired, the risk of biliary necrosis and/or leakage is significant. Internal splinting of the bile duct to ensure optimum decompression plus guidance might be helpful. Thus, in selected cases after trisectionectomy we inserted an external-internal or internal-external drain into long-segment exposed bile ducts. For internal-external drains the tube was diverted via the major duodenal papilla into the duodenum and then transfixed after the duodenojejunal flexure through the jejunal wall by means of a Witzel's channel. Because the entire bile duct is splinted, this technique is superior to bile duct decompression with a T-tube. This is supported by the course of a patient suffering biliary leakage after extended right-sided hepatectomy for colorectal metastasis. Initially, a T-tube was inserted for decompression, but biliary leakage persisted. After inserting transhepatic external-internal drainage, bile leakage stopped immediately. The patient's course was then uneventful. Five other patients (mostly with locally advanced hepatocellular or cholangiocellular carcinoma) treated similarly were discharged without complications. Drain removal 6 weeks postoperatively was uncomplicated in five of the 6 patients. In the sixth patient, external-internal drainage was replaced by a Yamakawa-type prosthesis for a biliary stricture. None of the patients suffered severe complications during long-term follow-up. The bile duct drainage technique presented in this study was useful for preventing and treating bile leakage after long-segment exposure of extrahepatic bile ducts during major hepatectomy. Transhepatic or internal-external drains are often used for bilioenteric anastomoses, but similar drainage techniques have not been reported for the native bile duct. T-tubes are generally used in this situation. In particular cases, however, inner splinting of the bile duct and appropriate movement of the bile via a tube can be helpful.

Location of bile leak predicts the success of ERCP performed for postoperative bile leaks

ERCP is effective for treating a bile leak (BL) after cholecystectomy (CCY), but few data exist on its effectiveness after hepatobiliary surgery (HBS). To determine the effectiveness of ERCP for treating BLs after HBS compared with BLs after cholecystectomy and to identify factors associated with treatment success. Retrospective cohort. Academic tertiary-care referral center. Patients referred from 2001 to 2009 for ERCP treatment of BL after cholecystectomy or HBS. ERCP. Resolution of BL after a single ERCP. A total of 223 patients were identified and 46 were excluded. Fifty underwent ERCP for treatment of BL after HBS and 127 after CCY. A single ERCP was successful at resolving BL in 89% of patients. Failure occurred in 7 HBS patients (14%) and 12 CCY patients (9%) (P = .379). After multiple ERCPs, success improved to 95% of the CCY group and 86% of the HBS group (P = .033). HBS patients underwent 30% more ERCPs (P = .049). ERCP was 3.3 times more likely to be successful in patients with cystic duct or duct of Luschka BLs (P = .028). Patients undergoing biliary stent placement were significantly more likely to have successful outcomes (odds ratio 71.0, P < .001). Surgical history or biliary sphincterotomy did not affect outcome. Odds of treatment failure were 3.5 times higher for each additional ERCP performed (P < .001). Single-center, retrospective study. ERCP is effective for treating postoperative BLs. Location of a BL and placement of a biliary stent are the best predictors of endoscopic treatment success.

Urgent endoscopic retrograde cholangio-pancreatography: to whom, when and how to perform?

Although the effectivity of an urgent endoscopic retrograde cholangio-pancreatography was documented, some aspects relating to this method are still debated. Timing of this procedure has not been established yet. Indications for urgent endoscopic retrograde cholangio-pancreatography with stone extraction from the common bile duct in patients with biliary pancreatitis remains controversial. Biliary decompression and drainage is the cornerstone of acute cholangitis treatment. The timing of endoscopic retrograde cholangio-pancreatography should be based on the grade of the severity of the disease. Using endoscopic retrograde cholangio-pancreatography, the accurate diagnosis and treatment of bile leaks in a timely manner is imperative to limit associated morbidity and mortality. Difficulty in cannulating the common bile duct is one of the main risk factors for pancreatitis occurring after the procedure. Alternative techniques to facilitate difficult cannulation are discussed. Organized training and introduction of objective measures of the investigator's competence are emphasized to improve the performance of the procedure in Hungary.

Comparisoil between ERCP and conventional treatment for bile leakage after cholecystectomy

Objective To compare the therapeutic result between ERCP and conventional treatment for bile leakage after cholecystectomy. Methods Data of 35 cases with bile leakage after cholecystectomy were retrospectively studied, in which 18 patients underwent conventional therapy and surgery （conventional group）, and 17 others underwent ERCP （endoscopy group）. The time of bile leakage closure, complication rate, and re-operation rate of the 2 groups were compared. Results In conventional group, leakage location was identified in 7 cases and mean bile leakage closure time was 23 days. A second operation was performed in 8 cases and complications occurred in 7. In endoscopy group, leakage location was identified in 13 cases and mean bile leakage closure time was 13 days. A second operation was performed in 2 cases and complications occurred in 3. Significant differences were found between 2 groups in regarding of the above references. Conclusion ERCP is accurate and valuable for diagnosis and treatment for bile leakage after cholecystectomy. Key words: Cholecystectomy; Biliary fistula; Endoscopes ; Comparative study

Prophylaxis and treatment of bile leakage from anormous hepatic ducts after liver transplantation

Objective To investigate prophylaxis and treatment of bile leakage from hepatic duct anomalies after liver transplantation.Methods We retrospectively analyzed 3 patients with bile leakage from hepatic duct anomalies after liver transplantation in our institute.The graft procurements were combined liver-kidney harvesting.The reconstruction of the bile ducts was end-to-end anastomoses.Results In the first patient with a right accessory duct joining the cystic duct,leakage of bile came from the stump of the cystic duct after anastomosis of the bile ducts.The original anastomosis was taken down,and reanastomosis was performed after plasty of the bile ducts.The patient recovered uneventfully.In the second patient with a Luschka bile duct,the biliary fistula closed spontaneously after percutaneous drainage.However,re-transplantation was performed for severe infection 7 month after the primary transplantation.In the third patient with an accessory hepatic duct from the right posterior sector joining the common bile duct,the bile duct stump which we missed leaked bile.Re-transplantation was performed because of severe complications.Conclusion Understanding the anatomy of intra- and extra-hepatic bile ducts and their common anomalies identifying the structures in the porta hepatis during preparation of the liver grafts,and looking for possible accessory hepatic ducts and aberrant bile ducts are important steps to prevent bile leakage in liver transplantation. Key words: Liver transplantation; Bile-duct variation; Biliary fistula