Endoscopic management of bile leaks after subtotal vs total laparoscopic cholecystectomy: A single center comparative...

Laparoscopic subtotal cholecystectomy (STC) is an established approach for difficult cholecystectomy (CCY) and a well-recognized strategy to mitigate complications such as bile duct injury. The incidence of post-CCY bile leak is higher after STC than after total CCY (TC). Endoscopic retrograde cholangiopancreatography (ERCP) with biliary sphincterotomy and bile duct stent placement is the standard, effective therapy for bile leaks after CCY. With the increasing adoption of STC as a strategy for complex CCY, a comprehensive understanding of ERCP's effectiveness for a bile leak after STC is imperative. We performed a comparative analysis of patient characteristics, periprocedure details, and clinical outcomes in patients who underwent ERCP for bile leak after STC vs TC.

Data from patients referred for ERCP at Indiana University Health Hospital between 2011 and 2021 were collected within a retrospective database. Patients with Strasberg Type A bile leaks and/or leak from the gallbladder remnant were included in the analysis. Patients with bile leaks with etiologies other than CCY (eg, hepatectomy or trauma) or additional CCY-related complications (eg, common bile duct injury) were excluded. Operative reports, ERCP cholangiogram findings, and post-CCY cross-sectional imaging were reviewed to verify TC or STC status. High-grade bile leaks were defined as evidence of contrast extravasation before opacification of the intrahepatic ducts on retrograde cholangiogram. Outcomes evaluated included resolution of the bile leak at the first postintervention follow-up ERCP (via biliary sphincterotomy or stent insertion), the total number of ERCP procedures required for resolution, and the overall success of ERCP for leak resolution.

Among patients with bile leak, 301 met study criteria. Patients who underwent STC were older, had a higher body mass index, and were more often male. Patients who underwent STC more frequently had a drain in place at the time of the first ERCP (P <.001) and less often had a biloma (P =.009). Patients who underwent STC were more frequently treated with the placement of self-expanding metal biliary stents (SEMS) (P =.001) and had a longer stent dwell time after the index ERCP (41 vs 35 days; P =.02). The overall success rate for leak resolution was high with ERCP (98%). Although there was a trend toward a higher rate of leak resolution at the first follow-up ERCP among TC patients (P =.07), the total number of ERCP procedures and the overall success of ERCP in managing post-CCY bile leak did not differ between the 2 groups.

ERCP remains an effective strategy for the management of bile leak after CCY, including in patients experiencing bile leak as a complication of STC. In our cohort, strategies such as SEMS placement and extended stent dwell time were more frequently employed in patients who underwent STC at the discretion of the endoscopist. Despite this, no differences in ERCP procedure burden or rates of bile leak resolution were observed between TC and STC patients.