Bile Leak: Is There Optimal Timing for Endoscopy?

Background and Objectives: Bile leak is a common complication after hepatopancreatobiliary surgery, requiring timely management to prevent life-threatening outcomes. Endoscopic retrograde cholangiopancreatography (ERCP) is essential in treatment, but large data concerning optimal timing and technique selection are unavailable. This study evaluates whether the timing of ERCP influences healing and if different bile duct injuries affect outcomes. Materials and Methods: Data from a prospectively maintained database over 25 years (2001-2025) included 176 patients (M/F: 91/85, mean age 62) undergoing ERCP for bile leaks. Results: Most leaks followed cholecystectomy (n = 143, 81.5%). The median time from leak to ERCP was 7 days. Ten patients (5.7%) had complete common bile duct (CBD) transection-considered major leaks-requiring surgery. Among the 166 minor leaks, the cystic duct stump (40.1%) was the most common injury site, followed by the CBD (24.1%) and the gallbladder bed (15.4%). Healing occurred in 90.6%. Stent placement improved healing rates (93.9% vs. 75.9%, p = 0.007), with no difference between pig-tail and (Amsterdam) straight plastic stents (90% vs. 96%, p = 0.267). Retained CBD stones or CBD strictures did not affect outcomes. Leaks from the cystic duct stump had a 96.9% resolution rate, whereas gallbladder bed leaks healed in 88%. The median healing time was 2 days, unaffected by stent placement or ES alone (p = 0.842), but later ERCP correlated with longer healing (RR: 0.362, p < 0.001). Following a right aberrant bile leak, the time for healing was longer than in leaks from other sites. Conclusions: ERCP with stenting remains the first-line approach for minor bile leaks. Early ERCP accelerates healing, emphasizing the importance of prompt intervention.