Endoscopic management of postoperative biliary fistula

Nasobiliary tube management of postcholecystectomy bile leaks

BACKGROUND

Endobiliary stenting is the traditional form of endoprosthetic drainage for biliary leaks. Nasobiliary tubes offer the advantage of easy removal and interval tube cholangiograms to assess leak resolution.

AIM

To determine the efficacy of nasobiliary tube drainage in patients with postcholecystectomy biliary leaks and provide our experience with management of biliary leak using nasobiliary drains.

MATERIALS AND METHODS

Retrospective study of 24 patients who were treated for postcholecystectomy biliary leaks in a tertiary referral center from 1998 to 2002. These patients were managed with either nasobiliary tube (NBT) alone or NBT + endoscopic sphincterotomy (ES).

RESULTS

Twenty-four patients (mean age, 57.5 years; 50% women) had postcholecystectomy leak noted on ERCP. Twenty patients were managed by NBT+ES and 4 patients had NBT placement alone. In the NBT+ES group, 2 patients pulled their NBT out, but 18 patients had complete leak resolution in 3 to 9 days. In the NBT group, all patients had complete leak resolution in 4 to 12 days. Using an intention-to-treat analysis, 22 of 24 (92%) patients were successfully treated with NBT treatment over 3 to 12 days.

CONCLUSIONS

ERCP with NBT placement is an effective and safe treatment modality in the management of postcholecystectomy biliary leaks.

Effectiveness of endoscopic sphincterotomy in complicated hepatic hydatid disease

BACKGROUND

The aim of this study was to evaluate the results of endoscopic sphincterotomy in patients with hepatic hydatid cysts that have ruptured into the biliary tract.

METHODS

Over a 10-year period, 25 patients (11 men, 14 women, mean age 60 years) underwent treatment; 13 with no prior surgery were treated for biliary obstruction. Postoperative treatment was undertaken in 12 cases because of persistent drainage (8), duct obstruction (3), and postoperative pancreatitis (1).

RESULTS

In patients who had not undergone previous surgery, cholangiographic findings were hydatid vesicles in the biliary tract (6), dilation of the biliary tract (3), biliary fistula (2), distal stenosis (1), and purulent bile content after sphincterotomy (1). In all of these cases, sphincterotomy resolved duct obstruction with no complications. All patients with persistent postoperative drainage had a fistula tract between the biliary duct and the cavity, which was resolved by endoscopic treatment in all 8. The 3 patients with postoperative biliary obstruction had hydatid vesicles in the biliary tract, one with a long stenosis resembling sclerosing cholangitis, whereas the patient with postoperative pancreatitis had a distal stenosis. Satisfactory results were obtained with endoscopic sphincterotomy, although 1 patient required a biliary prosthesis.

CONCLUSION

Endoscopic sphincterotomy resolves biliary obstruction and postoperative fistulae in most patients with hepatic hydatid cysts that have ruptured into the biliary tract. In some cases, a biliary prosthesis may be required.

Postcholecystectomy biliary leaks in the laparoscopic era: risk factors, presentation, and management. McGill Gallstone Treatment Group

BACKGROUND

The management of bile leaks has evolved in the laparoscopic era. This study characterizes risk factors for their developmental and their clinical course and management.

METHODS

Data on a cohort of patients who developed bile leaks after cholecystectomy in the laparoscopic era were gathered prospectively and retrospectively from an ongoing surgical database and following a review of hospital charts.

RESULTS

Sixty-four patients (mean age 56 +/- 17.1 years, 72% women) were included over a 5-year study period. The incidence of leaks was 1.1% among patients entered in a laparoscopic cholecystectomy database. Intraoperative complications were encountered in 36%. Rates of intraoperative complication and conversion to open surgery were greater among patients who developed leaks (5.2% vs 0.6% and 33% vs 6.3%, respectively, p < 0.00001). Patients presented 5.3 +/- 4.2 days following surgery with abdominal pain (89%), fever (74%), and tenderness (81%). Ultrasound diagnosed a suspected leak in 73%, which ERCP showed as originating from the cystic duct stump in 77%. Biliary obstruction was noted in 20 (31%) patients (14 with stones). Treatments included percutaneous (13%), endoscopic (28%), primary or secondary operative procedures (14%), or a combination thereof (45%).

CONCLUSION

A complication at laparoscopic cholecystectomy increases the likelihood of a subsequent bile leak. Most patients present early with a patent cystic duct stump in the absence of biliary obstruction. Endoscopic therapy is successful in the majority of cases, but otherwise percutaneous or operative procedures may be needed.

Endoscopic management of postoperative bile leak

Significant bile leak is an uncommon but serious complication of biliary tract surgery. Of twenty-five patients presenting with postoperative bile leak, 11 had complete tie-off of common bile duct and required surgery, while the remaining 14 had injury without complete obstruction and could be managed by endoscopic methods. Of these 14 cases, bile leak occurred from the cystic duct in 11 patients and from the common hepatic duct, right hepatic duct and left hepatic duct in one patient each. Endoscopic procedures performed included sphincterotomy alone (four patients), sphincterotomy and stent placement (seven patients) and sphincterotomy followed by nasobiliary catheter drainage (three patients). There was no technical failure and bile leak was stopped in all patients. One patient died of haemobilia 5 days after stent placement. When technically feasible, postoperative bile leak can be managed safely and effectively by endoscopic methods, obviating the need for surgical reexploration.

Bile duct injury and bile leakage in laparoscopic cholecystectomy

Between January 1991 and July 1992, 350 laparoscopic cholecystectomies were performed. There were six biliary complications (1.7 per cent): common bile duct (CBD) injury (one patient), delayed CBD necrosis (one), immediate postoperative bile leakage (one) and delayed bile leakage (three). All six patients required laparotomy. Primary repair with long-arm T tube splinting for 3 months was performed for the CBD injury. Religation of the cystic duct was carried out after immediate postoperative bile leakage. Laparotomy with T tube choledochostomy only was performed in the three patients with delayed bile leakage, and hepatojejunostomy Roux-en-Y was undertaken for CBD necrosis. The patient with primary repair of the CBD injury required choledochojejunostomy Roux-en-Y 18 months later for stenosis. Episodes of intermittent cholangitis occurred in the patient with CBD necrosis. The outcome for the four patients with bile leakage was good. There were no deaths.

Endoscopic therapy for patients with a post-operative biliary leak

Twenty-three patients with a post-operative biliary leak were treated by various endoscopic methods and results were analyzed. Leaks occurred at the cystic duct in 13 patients, at the common duct in 6 patients, and at an anomalous branch of the right hepatic duct in 4 patients. Treatments included sphincterotomy alone (4 patients), stent alone (6 patients), sphincterotomy and stent (12 patients), and sphincterotomy and nasobiliary drainage catheter (1 patient). Five patients also had supplemental percutaneous catheter drainage of a biloma. All treatments were completed successfully in the absence of major morbidity, and permanent closure of the leak occurred in 100% of cases. Endoscopic therapy for patients with a post-operative biliary leak is safe and effective and should be recommended before surgical re-exploration.