The role of endoscopic treatment in postoperative bile leaks

Bile leak is among the most common and serious complications of biliary tract surgery. The aim of this non-randomized study was to evaluate the role of endoscopic intervention as an accepted treatment for this complication.

An endoscopic retrograde cholangiopancreatography (ERCP) database was reviewed retrospectively to identify all cases of bile leak related to cholecystectomy (laparoscopic or open). Patients' records and endoscopy reports were reviewed. Moreover, structured telephone interviews were conducted to collect data.

Twenty-four patients, 4 males and 20 females, with a median age of 54 (range 28-76 years) with suspected postcholecystectomy bile leaks were referred for ERCP performed 3-73 days after operation (mean 9.5 days). All but one case had high-grade bile-like liquid outflowing from the original drainage tubes or the fistulous tract of T-tube. One patient presented with bilious ascites, 17 patients had sudden or gradual abdominal pain, 3 jaundice, 2 abdominal pain with fever, and 1 nausea and vomiting. ERCP was successful in all cases, and revealed leakage from the cystic stump in 10 cases, from a common bile duct (CBD) defect in 6, from a common hepatic duct defect in 3, from the gallbladder bed in 2, from a T-tube track in 1, and complete CBD transection in 2 patients. Seventeen patients were successfully treated by endoscopic sphincterotomy (ES) plus endoprosthesis, 3 by stent placement without sphincterotomy, 2 with complete transection by proximal hepaticojejunostomy, and 2 patients with leakage from the cystic stump and a CBD defect were operated after unsuccessful endoscopic intervention.

ERCP is recommended as a safe and efficacious intervention to detect and treat postoperative bile leaks. ES plus endoprosthesis is effective for the treatment of bile leakage. Endoscopic stenting without sphincterotomy may be offered as a primary option in young patients with postoperative bile leaks.