The Crucial Role of Biliary Endoscopists in the Management of Bile Leak after Cholecystectomy

1 published an original article on the efficacy of the endoscopic management of bile leak after cholecystectomy. Endoscopic management , which involved biliary stent placement with or without biliary sphincterotomy, was successful in 30 of 32 cases (93.8%). Complications of endoscopic management occurred in four of 32 cases (1.3%), but were managed conservatively without se-quelae. 1 Results from this study reconfirm the crucial role of biliary endoscopists in the management of bile leak after cho-lecystectomy. 1 Bile leak is a well-known complication of cholecystectomy. It occurs in approximately 1.1% of patients who undergo lapa-roscopic cholecystectomy. 2 Intraoperative complications, which include bile duct injuries such as lacerations and transection, gallbladder spillage or perforation, bleeding, hepatic lacera-tion, and leakage from the duct of Luschka, were reported in 36% of patients. 2 The presence of an intraoperative complication increases the likelihood of a bile leak after cholecystec-tomy. 2 Fortunately, the incidence of biliary complication after cholecystectomy seems to have reached a plateau. A retrospective study from a high-volume tertiary referral center that evaluated the frequency of both bile leak and other biliary complications after laparoscopic cholecystectomy detected by endoscopic retrograde cholangiopancreatography (ERCP) revealed that the incidence static over a 10-year period. 3 Patients with bile leak after cholecystectomy commonly present with abdominal pain, tenderness, fever, and persistent bile drainage from a surgically placed drain or T tube tract. Bile leak after cholecystectomy is usually detected within the first postoperative week, but could be delayed for up to 6 weeks. Transabdominal ultrasonography, computed tomography, cholescintigraphy, and/or ERCP can be used for diagnosis. ER-CP can demonstrate the site of the bile leak in nearly 98% of patients. 2 Also, it enables detection of concomitant bile duct stones and strictures. The most common site of bile leak is the cystic duct remnant, followed by the duct of Luschka or peripheral intrahepatic duct, and the common bile duct. Endo-scopic management of the bile leak is highly successful, with a success rate of 88% to 93%. Two main goals of endoscopic management are 1) to eliminate the pressure gradient across the sphincter of Oddi and 2) to bridge and close the leak site. 2 These goals can be accomplished by endoscopic bile duct stent placement with or without sphincterotomy. In some patients, sphincterotomy with temporary nasobiliary drainage will result in successful resolution of the bile leak. Most studies on the endoscopic management of the bile leak placed the …