Endoscopic treatment for post-cholecystectomy bile leaks: update and recent advances

The introduction of laparoscopic cholecystectomy (LC) was associated with an increased incidence of biliary injuries. One of the initial series reported an incidence of bile duct or hepatic duct injuries of roughly 0.5%, likely an underestimate [1]. A substantial decline in such complications was noted with acquisition of experience in LC. Subsequent studies reported an incidence of 0.8% to 1.1% [2,3]. The incidence of biliary injuries has since remained unchanged as shown by a recent study from a large tertiary care center [4]. From the endoscopist’s stand point, biliary injuries during LC can result in bile leaks, biliary stricture formation, or both. Bile leaks are divided into: 1) low grade (LG), where the leak can only be identified after complete opacification of the intrahepatic biliary system and 2) high grade (HG), where the leak can be observed before intrahepatic opacification [5]. The most common sites of post-cholecystectomy bile leak (PCBL) are the cystic duct stump and the duct of Luschka, which tend to be LG and often resolve spontaneously [3, 6, 7]. The duct of Luschka refers to an accessory bile duct that is in close proximity to the gallbladder body and can be injured during LC. Other types of PCBLs range from direct hepatic duct injury and leak to complete bile duct transection and are usually HG. Patients with HG leaks present within the first post-operative week with persistent biliary discharge from an abdominal drain left during surgery or varying degrees of abdominal pain and distension, consistent with intrabdominal bile collections or bile peritonitis, jaundice, or even sepsis. Ultrasound is the initial diagnostic test although in many LG cases diagnosis can be confirmed by a hepatobiliary iminodiacetic acid (HIDA) scan, also called cholescintigraphy, or an endocopic retrograde cholangiopancreatography (ERCP) [8]. Endotherapy is the standard of care in the management of LG and HG bile leaks [9, 10]. The main goal of endoscopic therapy is to reduce the transpapillary pressure gradient to facilitate preferential bile flow through the papilla as opposed to the site of the leak, providing time to the biliary tree injury to heal. This is most commonly achieved by placing a transpapillary stent with or without sphincterotomy [11]. Another approach includes placement of a nasobiliary drain to decompress the biliary system without a sphincterotomy. This approach offers the advantage of repeat cholangiography without the need of another ERCP [12-14]. Its use, however, has been limited due to poor patient tolerance, tube displacement and need for hospitalization until the tube is removed [5]. A variety of endoscopic approaches have been proposed for the management of PCBL. Sandha et al [5] proposed an algorithm for their management based on the grade of leak in a non-randomized setting. They concluded that endoscopic biliary sphincterotomy (EBS) alone without stent placement is a viable treatment option for most patients with LG leaks, unless there is a compelling indication for stent insertion such as retained stone, biliary injury with stricture formation, coagulopathy precluding EBS, or sepsis necessitating immediate closure of the leak. All HG lesions were successfully treated with EBS and stent placement. The study did not address whether EBS alone had an equally favorable outcome as biliary stent placement in patients with LG leaks. Mavrogiannis et al compared biliary stenting alone vs. EBS plus biliary stenting in a prospective randomized study limited to patients with endoscopically-proven PCBL [10]. They concluded that both methods were equally efficacious in resolving LG leaks and did not differ significantly in their adverse effect profile. However, it is known that EBS is associated with both shortand long-term adverse consequences. Mild pancreatitis is perhaps the most common early complication followed by hemorrhage, perforation and sepsis [15, 16]. Long-term effects include papillary stenosis and cholangitis [17]. The authors therefore recommended against routine EBS in the management of patients with LG bile leaks. In the same study, 7Fr plastic biliary stents were placed due to ease of insertion in the group without EBS. In the group with EBS, however, wider 10Fr stents were used to minimize risk of migration. It is worth mentioning that 10Fr stents could have been used in both groups, since there is no evidence that insertion of wider 10Fr stents is associated with any increased risk of complications. In fact, it may pose a lower risk of stent clogging in the setting of bile leak with associated choledocholithiasis [10]. There is also debate regarding the optimal proximal extent of the biliary stent. Some investigators believe that the endoprosthesis should extend beyond the site of leakage [3,18]. Others propose that placement of a transpapillary stent in an effort to equilibrate pressure across the biliary tree and duodenum is sufficient to stop the leak [12]. Actually, based Correspondence to: Dr. Georgios I. Papachristou, Assistant Professor of Medicine, Division of Gastroenterology, Hepatology & Nutrition, Presbyterian University Hospital, M2, C Wing, 200 Lothrop St. Pittsburgh, PA 15213, USA. tel: ++1-412-648-7893, fax: ++1-412-383-7580, e-mail: [email protected]