Endoscopic therapies for post-cholecystectomy biliary leaks

Endoscopic strategies for treating postoperative biliary leaks have not been assessed in controlled trials. Comparison of current therapies may provide a guide for design of future studies. AIM: To determine the patient outcomes following several different endoscopic therapies for post-cholecystectomy bile leaks. METHODS: Medical records were retrospectively reviewed from 1/1/91 to 6/30/95 for patients who had undergone endoscopic therapy for post-cholecystectomy biliary leaks. Biliary strictures and stones were treated using accepted techniques. Stents were removed 4-6 weeks after insertion when indicated. RESULTS: Twenty patients had received endoscopic therapy for bile leaks occurring after cholecystectomy. This included 12 women and 8 men with a mean age 62 years (range 24-80 yrs). 11 patients had undergone laparoscopic cholecystectomy, 2 others were converted to open procedures, and 7 had open cholecystectomies. Leaks were found to originate from the cystic duct (6 pts), common bile duct/common hepatic duct (6), accessory ducts of Lushka (5), and right hepatic duct (3). Treatment modalities included sphincterotomy alone (ES) (12), nasobiliary tube drainage (NBT) (6=2 with ES, 4 without ES), and biliary stenting (stent) (2). The mean time from operative injury to endoscopic diagnosis for all patients was 10 days (range 356 days). Initial endoscopic therapy was successful in the permanent closure of all biliary leaks in 15/19 patients (79%). (ES success = 83%, NBT = 45%, stent = 50%). 4 patients failed initial therapies but ultimately closed their leaks following one or more stent placements. One patient died of hepatic failure within days of injury and NBT therapy. Complications from ES alone included perforation of the common bile duct (1) and bleeding requiring surgical intervention (1). No complications occurred from NBT or stent therapy. Bilomas or subhepatic bile collections required percutaneous drainage at initial presentation in 9 patients (45%). Post-treatment hospital stay did not vary significantly between biloma drainage and non-drainage patients. Post-treatment stay was longer for initial NBT therapy than for ES (ES=7.6d,NBT=12.3d, stent=9.0d) CONCLUSIONS: 1) Biliary leaks resolved with initial endoscopic management in 79% of patients and ultimately with further endoscopic therapy in 100% of cases. 2) Sphincterotomy alone appears to be effective for most patients, however, it has a greater risk of serious complications. 3) Sphincterotomy, and possibly stent therapy, allowed for shorter post-treatment hospital duration than nasobiliary drainage.