Most "simple" biliary leaks are successfully managed by transpapillary stenting [TPS] and/or endoscopic sphincterotomy [ES]. Biliary leaks with concomitant obstruction to flow by stricture or stone have been termed "complex"; and typically require adjunctive therapies. We have identified a subgroup of bile leaks distinguished by being "complicated" by a local organized fluid collection and their poor response to "simple" management. We define these complicated bile leaks in the context of all leaks and describe specific management strategies. Methods: We reviewed all bile duct leaks identified and managed endoscopically over a 40 month period. We reviewed the etiology, site of ductal injury, presence of focal fluid collection, type of endoscopic intervention and clinical outcome. Results: Among 36 patients, the etiologies were: laparoscopic cholecystectomy(12), open cholecystectomy(3). T-tube removal after orthotopic liver transplantation [OLT](12), biliary anastomosis after OLT(3), abdominal trauma(3), partial hepatectomy for malignancy(2), and other abdominal surgery(l). Endoscopic management included TPS (21), ES(1), combined TPS and ES(12), and 7Fr nasobiliary [NB] tube(2) (both for OLT T-tube tract leaks). Of those with TPS, 3 of the stents were preferentially placed to bridge the leak. Transpapillary stent diameters were 10 Fr(12) and 7 Fr(20). Follow up ERCP was performed to confirm leak healing (mean interval = 4.5 wk) except after NB tube placement. At follow up ERCP 28 patients(78%) had resolution of the leak. Eight patients had persistant leaks: i)Two post-laparoscopic cholecystectomy cystic duct leaks initially treated with 7 Fr TPS had persistant catheter drainage at I week, prompting repeat TPS with 12Fr stent fascillitating resolution at 4 weeks follow up. ii) Three patients with focal flud collections at the leak site (biloma=2, hemutoma=1) failed to respond to 7F TPS's at 2,4, and 6 wks respectively. In these three cases two large diameter (≥ 10Fr) TPS's were placed in parallel bridging the leak site, and follow up ERCP at 5 to 9 wk confirmed resolution, iii) One post-OLT T-tube tract leak was repaired surgically 3 days after ERCP.iv) Two patients had non-biliary sepsis and died of septic complications. Among patients who responded to initial therapy, local fluid collection at the leak site was only documented in 6 patients. Conclusions: (1) "Simple" bile leaks are effectivly managed by TPS, ES, TPS + ES, or NB tube in the majority of cases. (2) TPS with large diameter (≥ 10 Fr) stent alone achieves high success and avoids the risks of ES. (3) "Complicated" bile leaks may be effectivly managed by placing two stents in parallel, bridging the leak.
ASJC Scopus subject areas
- Radiology Nuclear Medicine and imaging