A comparative study of 10-Fr vs. 7-Fr straight plastic stents in the treatment of postcholecystectomy bile leak

Is there a place for endoscopic management in post-cholecystectomy iatrogenic bile duct injuries?

In this editorial we comment on the article by Emara et al published in the recent issue of the World Journal of Gastrointestinal Surgery. Previously, surgery was the primary treatment for bile duct injuries (BDI). The treatment of BDI has advanced due to technological breakthroughs and minimally invasive procedures. Endoscopic and percutaneous treatments have largely supplanted surgery as the primary treatment for most instances in recent years. Patient management, including the specific technique, is typically impacted by local knowledge and the kind and severity of the injury. Endoscopic therapy is a highly successful treatment for postoperative benign bile duct stenosis and offers superior long-term outcomes compared to surgical correction. Based on the damage features of BDI, therapeutic options include endoscopic duodenal papillary sphincterotomy, endoscopic nasobiliary drainage, and endoscopic biliary stent implantation.

Efficacy and associated factors of endoscopic transpapillary drainage for postoperative biliary leakage

Objective

Adequate biliary decompression is important in treating bile leaks, and endoscopic transpapillary drainage is widely used for this purpose. As an indicator to evaluate the usefulness of endoscopic drainage for postoperative biliary leakage, we focused on external drain removability, which affects quality of life, after endoscopic treatment. Our aim was to clarify the success rate of external tube removal after endoscopic drainage for postoperative biliary leakage and to examine associated factors.

Methods

This was a multicenter retrospective study; 99 patients with biliary leakage at 13 institutions were enrolled between April 2014 and March 2019. Among these patients, 66 who were initially treated with endoscopic interventions for biliary leakage after cholecystectomy (n = 17) or hepatectomy (n = 49) were reviewed.

Results

In post-cholecystectomy biliary leakage, the external-drain-free rate at first endoscopic intervention was 100%, and the drains, including transpapillary stents, were successfully removed in almost all cases (16/17). In contrast, in post-hepatectomy biliary leakage, the external-drain-free rate was 44.9% (22/49), with all 22 of those patients eventually becoming entirely drain-free. A lower body mass index was the only significant factor associated with freedom from external drainage in post-hepatectomy biliary leakage (odds ratio 0.18, 95% confidence interval 0.05-0.65).

Conclusions

Initial endoscopic treatment was effective for post-cholecystectomy biliary leakage, while approximately half of the patients with post-hepatectomy biliary leakage required multidisciplinary management. Achieving freedom from external drainage contributes to patients' quality of life and may be a predictor of treatment response after endoscopic therapy for postoperative biliary leakage.

Usefulness of Intraductal Placement of a Dumbbell-Shaped Fully Covered Self-Expandable Metal Stent for Post-Cholecystectomy Bile Leaks

Background and aims: In the treatment of post-cholecystectomy bile leaks, endoscopic naso-biliary drainage (ENBD) or biliary stenting using plastic stents is the standard of care. Fully covered self-expandable metal stent (FCSEMS) placement across the sphincter of Oddi is considered a salvage therapy for refractory cases, but pancreatitis and migration are the major concerns. Intraductal placement of a dumbbell-shaped FCSEMS (D-SEMS) could avoid these drawbacks of FCMSESs. In this retrospective study, we investigated the usefulness of intraductal placement of the D-SEMS for post-cholecystectomy bile leaks. Methods: Six patients who underwent intraductal placement of the D-SEMS for post-cholecystectomy bile leaks were enrolled. This method was performed as initial treatment in three patients and as salvage treatment in three ENBD refractory cases. Results: Technical and clinical successes were obtained in 6 (100%) patients and 5 (83%) patients, respectively. One clinically unsuccessful patient required laparoscopic peritoneal lavage. The early adverse event was one case of mild pancreatitis (17%). The median duration of the D-SEMS indwelling was 61 days (42-606 days) with no migration cases, all of which were successfully removed. The median follow-up after index ERCP was 761 (range: 161-1392) days with no cases of recurrent bile leaks. Conclusions: Intraductal placement of the D-SEMS for post-cholecystectomy bile leaks might be safe and effective even in refractory cases.

Clinical presentation, management and outcomes of bile duct injuries after laparoscopic cholecystectomy: a 15-year single-center experience in Vietnam

Objectives

To evaluate the clinical presentation, management, and outcomes of bile duct injuries (BDIs) after laparoscopic cholecystectomy (LC).

Methods

This is a case series of 28 patients with BDIs after LC treated at a tertiary hospital in Vietnam during the 2006-2021 period. The BDI's clinical presentations, Strasberg classification types, management methods, and outcomes were reported.

Results

BDIs were diagnosed intraoperatively in 3 (10.7%) patients and postoperatively in 25 (89.3%). The BDI types included Strasberg A (13, 46.4%), D (1, 3.6%), E1 (1, 3.6%), E2 (4, 14.3%), E3 (5, 17.9%), D + E2 (2, 7.1%), and nonclassified (2, 7.1%). Of the postoperative BDIs, the injury manifested as biliary obstruction (18, 72.0%), bile leak (5, 20.0%), and mixed scenarios (2, 8.0%). Regarding diagnostic methods, endoscopic retrograde cholangiopancreatography (ERCP) was more useful in bile leak scenarios, while multislice computed tomography, magnetic resonance cholangiopancreatography, and percutaneous transhepatic cholangiography were more useful in biliary obstruction scenarios. All 28 BDIs were successfully treated. ERCP with stenting was very effective in the majority of Strasberg A BDIs. For more complex BDI types, hepaticocutaneous jejunostomy was a safe and effective approach. The in-hospital morbidities included postoperative pneumonia (2, 10.7%) and biliary-enteric anastomosis leakage (1, 5.4%). There was no cholangitis or anastomotic stenosis during the follow-up after discharge (median 18 months).

Conclusions

The majority of BDIs are type A and diagnosed postoperatively. ERCP is effective for the majority of Strasberg A BDIs. For major and complex BDIs, hepaticocutaneous jejunostomy is a safe and effective approach.

Best Practices in Pancreatico-biliary Stenting and EUS-guided Drainage

Indications for endoscopic placement of endoluminal and transluminal stents have greatly expanded over time. Endoscopic stent placement is now a well-established approach for the treatment of benign and malignant biliary and pancreatic diseases (ie, obstructive jaundice, intra-abdominal fluid collections, chronic pancreatitis etc.). Ongoing refinement of technical approaches and development of novel stents is increasing the applicability and success of pancreatico-biliary stenting. In this review, we discuss the important developments in the field of pancreatico-biliary stenting, with a specific focus on endoscopic retrograde cholangiopancreatography and endoscopic ultrasound-associated developments.

Endoskopisches Management von Gallengangskomplikationen nach Leberchirurgie

Biliäre Komplikationen stellen häufige Komplikationen nach Leberchirurgie dar und tragen wesentlich zur postoperativen Morbidität und Mortalität bei. Den größten Anteil dieser machen Gallengangsleckagen und -strikturen aus, wobei die Leckagen nach Cholezystektomie und Leberresektion dominieren und die Strikturen ein wesentliches Problem nach Lebertransplantationen darstellen. Patienten nach orthotoper Lebertransplantation stellen besonders vulnerable Patienten dar, deren biliäre Komplikationen von denen nach Cholezystektomie und Leberresektion differieren und niederschwellig sowie mit größter Vorsicht behandelt werden müssen. Mit der endoskopischen retrograden Cholangiografie steht ein exzellentes Verfahren zur Behandlung dieser Komplikationen zur Verfügung. Die therapeutischen Möglichkeiten beinhalten die endoskopische Sphinkterotomie, die Anlage von Prothesen und Dilatationen. Mittels dieser Verfahren können Erfolgsraten in bis zu 90% der Fälle erreicht werden. Bei Hepatikojejunostomien bestehen alternative Interventionsmöglichkeiten wie die ballon- oder motorunterstützte antegrade Enteroskopie, die perkutan-transhepatische Cholangiodrainage oder mit zunehmendem Einsatz die endosonografisch gestützten Verfahren.

The Role of Endoscopic Retrograde Cholangiopancreatography in the Management of Biliary Complication Post-Laparoscopic Cholecystectomy

BACKGROUND: Laparoscopic cholecystectomy considers a golden surgery for gallbladder removal nowadays, and it carries some complications like biliary injuries, which can manage successfully by endoscopic retrograde cholangiopancreatography. AIM: To estimate the role of endoscopic management of bile duct injury (BDI) following laparoscopic cholecystectomy. PATIENT AND METHODS: A prospective study conducted at Al-Sader Medical City, Najaf City, Iraq, during the period between September 2018 and December 2020, included 44 patients complicated by the biliary injury resulting in a persistent biliary leak and/or jaundice after laparoscopic cholecystectomy and evaluated by endoscopic retrograde cholangiopancreatography (ERCP). RESULTS: Findings revealed that 25% of cases had complete BDI, only one managed by plastic stent placement, the other 10 referred for open surgical constructions, 61% had partial injury associated with the biliary leak, all managed by sphincterotomy and plastic stent placement through ERCP, almost 7% had a partial clipping of bile duct all managed with sphincterotomy, balloon dilatation/stone extraction, and plastic stent placement, 5% had slipped clips of cystic duct stump, are managed with sphincterotomy and plastic stent placement. Moreover, only one patient, 2%, had distal common bile duct stone with bile leak, managed by sphincterotomy and stone extraction. CONCLUSIONS: Laparoscopic cholecystectomy, a gold standard therapeutic option for symptomatic cholecystolithiasis, is associated with an increased risk of biliary injury due to many factors. ERCP is a safe means of diagnosing the cause of bile leakage after laparoscopic cholecystectomy. It also offers definitive treatment in most cases by endoscopic sphincterotomy and plastic stent placement.

Postcholecystectomy biliary injuries: frequency, and role of early versus late endoscopic retrograde cholangiopancreatography

BACKGROUND AND STUDY AIM

Bile duct injuries are not infrequently seen during hepatobiliary surgery, particularly after liver transplantation and cholecystectomy. The current study aims to figure out the frequency of postcholecystectomy biliary injuries (PCBI) and the role of early versus late endoscopic retrograde cholangiopancreatography (ERCP) in their management.

PATIENTS AND METHODS

Totally 960 cases operated by both laparoscopic and open cholecystectomy were evaluated in the current study. In total, 942 cases were operated in our institutes, by both laparoscopic (n = 925) and open (n = 17) cholecystectomy, and the frequency of PCBI among patients operated in our institutes was (9/942) 0.95%. Additional 18 cases of PCBI referred to our centers were included in the study. One patient was treated by repair during the surgery, in the remaining 26 patients, ERCP management was attempted. The full details of the 26 patients regarding ERCP management were discussed.

RESULTS

The overall success rate of ERCP management was 88.46% (23/26), whereas 11.54% of cases were treated surgically by choledochal-jejunal anastomosis due to complete common bile duct ligation. There were no differences between patients treated by early (first week) versus late (after the first week) ERCP regarding the needed interventions, type of PCBI, type and diameter of the inserted stents, and the overall success. There were no adverse events associated with ERCP management.

CONCLUSIONS

ERCP was valuable in the treatment of 88.46% of injured cases. There were no differences between early and late ERCP in the treatment of PCBI. Furthermore, ERCP management was not associated with adverse events.

Endoscopic Diagnosis and Management of Gastrointestinal Trauma

Trauma affects all sociodemographic profiles and is a major cause of morbidity and mortality particularly in patients less than forty years of age. A variety of endoscopic tools and techniques initially used for iatrogenic etiologies (post-operative bile or pancreatic duct leaks, intra-procedural perforation) have been adopted for use in the gastrointestinal trauma victim. The purpose of this review is to highlight a variety of gastrointestinal traumatic complications where endoscopy can serve a complement and/or definitive management strategy.

Endoscopic Treatment of Post-Cholecystectomy Biliary Leaks

Postcholecystectomy leaks may occur in 0.3-2.7% of patients. Bile leaks associated with laparoscopy are often more complex and difficult to treat than those occurring after open cholecystectomy. Furthermore, their incidence has remained unchanged despite improvements in laparoscopic training and technological developments. The management of biliary leaks has evolved from surgery into a minimally invasive endoscopic procedural approach, namely, endoscopic retrograde cholangiopancreatography (ERCP), which decreases or eliminates the pressure gradient between the bile duct and the duodenum, thus creating a preferential transpapillary bile flow and allowing the leak to seal. For simple leaks, the success rate of endotherapy is remarkably high. However, there are more severe and complex leaks that require multiple endoscopic interventions, and clear strategies for endoscopic treatment have not emerged. Therefore, there is still some debate regarding the optimal time point at which to intervene, which technique to use (sphincterotomy alone or in association with the placement of stents, whether metallic or plastic stents should be used, and, if plastic stents are used, whether they should be single or multiple), how long the stents should remain in place, and when to consider treatment failure. Here, we review the types and classification of postoperative biliary injuries, particularly leaks, as well as the evidence for endoscopic treatment of the latter.

Biodegradable biliary stents preferable to plastic stent therapy in post-cholecystectomy bile leak and avoid second endoscopy

BACKGROUND

The treatment of post-cholecystectomy bile leak is endoscopic retrograde cholangiography (ERC) with plastic stent (PS) insertion combined with external drainage. Self-expanding biodegradable biliary stents (BDBS) have only recently become available.

AIM

The aim was to compare success rate, adverse events and costs of BDBS with PS in the treatment of post-cholecystectomy cystic duct leak Materials and methods: Patients recruited prospectively for treatment with BDBS during the period 2014-2017 were compared to a control group treated with PS in a non-randomized setting.

RESULTS

Altogether 32 patients (median age 68, range 33-88, 59% male) were treated for Strasberg A bile leak over a period of 3.5 years, accounting for 1.8% of all ERCs. Eight patients were treated with BDBS and 24 with PS. Treatment with BDBS was safe; rate of readmissions and 30-day adverse events were 13% in both groups. There was no statistical difference in the clinical success rate. All cases with laparoscopic lavation or re-ERC with stent exchange occurred in the PS group. Total drain output was lower in BDBS patients (330ml vs 83ml, p=.002). All PS patients required another endoscopy for stent removal, whereas all BDBS patients were spared repeated endoscopy.

CONCLUSION

Treatment of cystic duct leak with BDBS is highly successful and as safe as traditional treatment with PS. The most obvious benefit of BDBS is that it avoids stent removal. The lower drain output after ERC with a trend for fewer unplanned interventions may indicate more efficient leak resolution with the large bore BDBS.

Additional flap on plastic stents for improved antimigration effect in the treatment of post-cholecystectomy bile leak

BACKGROUND AND STUDY AIMS

In plastic stent insertion for treatment of post-cholecystectomy bile leak, stent migration may be more common due to the absence of a shelf to anchor the stent. We evaluated how adding a flap to straight plastic stents for this indication might influence the rate of stent migration when compared to use of conventional plastic stents.

PATIENTS AND METHODS

This is a retrospective study including patients referred for ERCP for treatment of post-cholecystectomy bile leak. Patients with a customized anti-migration flap stent had the additional flap created on the distal end of straight plastic stents, intended to aid in anchoring in the distal supra-sphincteric biliary duct. The primary endpoint is stent migration events. The secondary endpoint is bile leak resolution after first ERCP session.

RESULTS

Thirty-two patients were treated with the experimental additional flap stents and 225 patients were treated with standard straight biliary stents. The total failure rate of bile leak resolution after a single endoscopic treatment for all treated was 10.5 % (27/257) and the total stent migration rate for all enrolled was 15.2 % (39/257). Stent migration rate was lower in the additional flap stent group than in the conventional group (3.1 % vs. 16.9 %, respectively, P  = 0.04). Furthermore, significantly more patients had resolution of their bile leak after the first ERCP session in the group with the additional flap (100 % vs. 88 %, respectively, P  = 0.03).

CONCLUSION

A plastic biliary stent with an extra flap may have improved performance with regard to stent migration and resolution of bile leak over standard plastic biliary stents.

Use of 4-Fr versus 6-Fr Nasobiliary Catheter for Biliary Drainage: A Prospective, Multicenter, Randomized, Controlled Study

Background and Aim. Endoscopic nasobiliary drainage (NBD) effects according to diameter remain unclear. We aimed to assess the drainage effects of the 4-Fr and 6-Fr NBD catheters. Methods. This prospective, multicenter, randomized, controlled study was conducted at Hiroshima University Hospital and related facilities within Hiroshima Prefecture. Endoscopic retrograde cholangiopancreatography (ERCP) in 246 patients revealed acute cholangitis, obstructive jaundice, and/or extrahepatic cholestasis; 4-Fr or 6-Fr NBD catheters were randomly allocated and placed in these patients. The primary endpoint was the efficacy of NBD based on the technical success rate and clinical success (rates of change in blood test and amount of bile output). Secondary endpoints included the spontaneous catheter displacement rate and nasal discomfort. Results. The technical success rate and clinical success did not differ significantly between groups. No spontaneous catheter displacement was noted in either group. Nasal discomfort due to catheter placement was significantly lower in the 4-Fr group versus the 6-Fr group (24 h after ERCP: 2.4 versus 3.5 cm, P = 0.005; 48 h after ERCP: 2.2 versus 3.1 cm, P = 0.01). Conclusion. The 4-Fr NBD catheter was not inferior to 6-Fr NBD catheter in terms of clinical success; the 4-Fr NBD catheter was useful to reduce nasal discomfort.

Clinical outcomes in patients with bile leaks treated via ERCP with regard to the timing of ERCP: a large multicenter study

BACKGROUND AND AIMS

Postsurgical or traumatic bile duct leaks (BDLs) can be safely and effectively managed by endoscopic therapy via ERCP. The early diagnosis of BDL is important because unrecognized leaks can lead to serious adverse events (AEs). Our aim was to evaluate the relationship between timing of endotherapy after BDL and the clinical outcomes, AEs, and long-term results of endoscopic therapy.

METHODS

We conducted a multicenter, retrospective study on patients with BDLs who underwent ERCP between 2006 and 2014. Data were assembled on patient demographics, etiology of BDL, and procedural details. Endotherapy for BDLs were classified a priori into 3 groups based on timing of ERCP from time of biliary injury: within 1 day of BDL, on day 2 or 3 after BDL, and greater than 3 days after BDL. The relationship among timing of ERCP after BDL injury and outcomes, procedure-related AEs, and patient AEs and mortality were evaluated.

RESULTS

From February 2006 to June 2014, 518 patients (50% male; mean age, 51.7 years) underwent ERCP for therapy of BDLs. The etiology of the BDL was laparoscopic cholecystectomy (70.7%), post-liver transplantation (11.2%), liver resection (14.1%), trauma (2.5%), and other causes (1.5%). Endotherapy was performed by placing a transpapillary stent alone (73.5%) or with a sphincterotomy (26.5%). The timing of ERCPs was as follows: ≤1 day = 57 patients, day 2 or 3 = 140 patients, and >3 days = 321 patients. There was no statistical difference in patient demographics, etiology/site of BDL, or type of endotherapy performed among the 3 groups. On multivariate analysis there was no statistically significant difference in BDL success rate for ERCPs performed within 1 day compared with those performed on day 2 or 3 or after 3 days of bile duct injury (91.2%, 90%, and 88.5%, respectively; P = .77). Similarly, there was no significant difference in the overall patient AE rate among the 3 groups (21.1%, 22.9%, and 24.6%, respectively; P = .81). AEs in men occurred significantly more frequently when compared with women, even after adjusting for age, BDL etiology, and location of leak (27.6% vs 19.9%; OR, 1.53; P = .04). Patients whose BDL was due to a cholecystectomy had a lower AE and mortality rate compared with those who had biliary injury from other etiologies (OR, .42; P < .001).

CONCLUSIONS

The overall success rates and AEs after ERCP were not dependent on the timing of the procedure relative to the discovery of the bile leak. This suggests that ERCP in these patients can usually be performed in an elective, rather than an urgent, manner.

A retrospective analysis of endoscopic treatment outcomes in patients with postoperative bile leakage

OBJECTIVE:

Bile leakage, while rare, can be a complication seen after cholecystectomy. It may also occur after hepatic or biliary surgical procedures. Etiology may be underlying pathology or surgical complication. Endoscopic retrograde cholangiopancreatography (ERCP) can play major role in diagnosis and treatment of bile leakage. Present study was a retrospective analysis of outcomes of ERCP procedure in patients with bile leakage.

METHODS:

Patients who underwent ERCP for bile leakage after surgery between 2008 and 2012 were included in the study. Etiology, clinical and radiological characteristics, and endoscopic treatment outcomes were recorded and analyzed.

RESULTS:

Total of 31 patients (10 male, 21 female) were included in the study. ERCP was performed for bile leakage after cholecystectomy in 20 patients, after hydatid cyst operation in 10 patients, and after hepatic resection in 1 patient. Clinical signs and symptoms of bile leakage included abdominal pain, bile drainage from percutaneous drain, peritonitis, jaundice, and bilioma. Twelve (60%) patients were treated with endoscopic sphincterotomy (ES) and nasobiliary drainage (NBD) catheter, 7 patients (35%) were treated with ES and biliary stent (BS), and 1 patient (5%) was treated with ES alone. Treatment efficiency was 100% in bile leakage cases after cholecystectomy. Ten (32%) cases of hydatid cyst surgery had subsequent cystobiliary fistula. Of these patients, 7 were treated with ES and NBD, 2 were treated with ES and BS, and 1 patient (8%) with ES alone. Treatment was successful in 90% of these cases.

CONCLUSION:

ERCP is an effective method to diagnose and treat bile leakage. Endoscopic treatment of postoperative bile leakage should be individualized based on etiological and other factors, such as accompanying fistula.

Initial study of sediment antagonism and characteristics of silver nanoparticle-coated biliary stents in an experimental animal model

Objective

Plastic biliary stents used to relieve obstructive jaundice are frequently blocked by sediment, resulting in loss of drainage. We prepared stents coated with silver nanoparticles (AgNPs) and compared their ability to resist sedimentation with Teflon stents in a beagle model of obstructive jaundice.

Methods

AgNP-coated Teflon biliary stents were prepared by chemical oxidation–reduction and evaluated in an obstructive jaundice model that was produced by ligation of common bile duct (CBD); animals were randomized to two equal groups for placement of AgNP-coated or Teflon control stents. Liver function and inflammatory index were found to be similar in the two groups, and the obstruction was relieved. Stents were removed 21 days after insertion and observed by scanning and transmission electron microscopy. The AgNP coating was analyzed by energy dispersive X-ray analysis (EDXA), and the composition of sediment was assayed by Fourier-transform infrared (FTIR) spectroscopy.

Results

Electron microscopy revealed a black, closely adherent AgNP stent coating, with thicknesses of 1.5–6 µm. Sediment thickness and density were greater on Teflon than on AgNP-coated stents. EDXA confirmed the stability and integrity of the AgNP coating before and after in vivo animal experimentation. FTIR spectroscopy identified stent sediment components including bilirubin, cholesterol, bile acid, protein, calcium, and other substances.

Conclusion

AgNP-coated biliary stents resisted sediment accumulation in this canine model of obstructive jaundice caused by ligation of the CBD.

Guidewire-assisted transpancreatic sphincterotomy for difficult biliary cannulation: a prospective randomized controlled trial

PURPOSE

Precut techniques have been used to facilitate biliary cannulation during difficult endoscopic retrograde cholangiopancreatography. Presently, needle-knife sphincterotomy (NKS) is a commonly used precut technique. Since its first description, transpancreatic sphincterotomy, as an alternative method for bile duct entry when conventional biliary cannulation failed, has been debated on its success rate of cannulation and its complications, such as increased incidence of pancreatitis. Guidewire techniques are another effective method to improve the success rate of selective bile duct cannulation. This is a single-center prospective randomized controlled trial aimed to compare success rate, cannulation time, and complications of guidewire-assisted transpancreatic sphincterotomy (GATS) and NKS for difficult biliary cannulation.

METHODS

Between July 2010 and October 2013, consecutive patients who failed in the standard biliary cannulation were randomly assigned to the GATS and NKS groups. The outcome measures included success rate, cannulation time, and complications.

RESULTS

A total of 149 patients were enrolled and analyzed: 73 in the GATS group and 79 in the NKS group. The characteristics of the 2 groups were similar. Bile duct cannulation was successful in 70 patients (95.9%) in the GATS group and 64 (84.2%) in the NKS group (P=0.018). The median cannulation time spent in precut was 193 seconds in the GATS group and 485 seconds in the NKS group (P<0.001). There was no difference between the groups for the incidence of complications, pancreatitis, and hemorrhage (9.6% vs. 10.5%, 6.8% vs. 6.6%, 1.4% vs. 3.9%, respectively). No perforation occurred.

CONCLUSIONS

GATS compared with NKS increases biliary cannulation rate and requires less cannulation time during difficult biliary access. This technique is not associated with an increased risk for complications. It seems to be an effective and safe alternative for biliary access during difficult endoscopic retrograde cholangiopancreatography.

Outcomes of endoscopic management of primary and refractory postcholecystectomy biliary leaks in a multicentre review of 178 patients

BACKGROUND

Biliary leaks have been treated with endoscopic management using different techniques with conflicting results. Furthermore the appropriate rescue therapy for refractory leaks has not been established. We evaluated the clinical effectiveness of initial endotherapy for postcholecystectomy biliary leaks using an homogenous approach (sphincterotomy + placement of a 10-French plastic stent) in a large series of patients as well as the optimal and efficacy of rescue endotherapy for refractory biliary leaks.

METHODS

This was a multicenter, retrospective study of 178 patients who underwent endoscopic management of postcholecystectomy biliary leaks with a combination of biliary sphincterotomy and the placement of a large-bore (10-French) plastic stent. Data were collected to analyze the clinical outcomes and technical success, efficacy of the rescue endotherapy and the need for surgery, adverse events and prognostic factors for clinical success of endotherapy.

RESULTS

Following endotherapy, closure of the leak was accomplished in 162/178 patients (91.0%). The multivariate logistic model showed that the type of leak, namely a high-grade biliary leak, was the only independent prognostic factor associated with treatment failure (OR = 26.78; 95% CI = 6.59-108.83; P < 0.01). The remaining 16 patients were treated with multiple plastic stents (MPSs) with a success rate of 62.5% (10 patients). The use of fewer than 3 plastic stents (P = 0.023) and a high-grade biliary leak (P = 0.034) were shown to be significant predictors of treatment failure with MPSs in refractory bile leaks. The 6 patients in whom the placement of MPSs failed were retreated with a fully cover self-expandable metallic stent (FCSEMS), resulting in closure of the leak in all cases.

CONCLUSIONS

Endotherapy of biliary leaks with a combination of biliary sphincterotomy and the placement of a large-bore plastic stent is associated with a high rate of success (90%). However in our series there were several failures using MPSs as a strategy for rescue endotherapy suggesting that refractory biliary leaks should be treated with FCSEMS especially in patients with high-grade leaks.

Outcome of stenting in biliary and pancreatic benign and malignant diseases: A comprehensive review

Endoscopic stenting has become a widely method for the management of various malignant and benign pancreatico-biliary disorders. Biliary and pancreatic stents are devices made of plastic or metal used primarily to establish patency of an obstructed bile or pancreatic duct and may also be used to treat biliary or pancreatic leaks, pancreatic fluid collections and to prevent post-endoscopic retrograde cholangiopancreatography pancreatitis. In this review, relevant literature search and expert opinions have been used to evaluate the outcome of stenting in biliary and pancreatic benign and malignant diseases.

A non-randomized study in consecutive patients with postcholecystectomy refractory biliary leaks who were managed endoscopically with the use of multiple plastic stents or fully covered self-expandable metal stents (with videos)

BACKGROUND

Endoscopic management of postcholecystectomy biliary leaks is widely accepted as the treatment of choice. However, refractory biliary leaks after a combination of biliary sphincterotomy and the placement of a large-bore (10F) plastic stent can occur, and the optimal rescue endotherapy for this situation is unclear.

OBJECTIVE

To compare the clinical effectiveness of the use of a fully covered self-expandable metal stent (FCSEMS) with the placement of multiple plastic stents (MPS) for the treatment of postcholecystectomy refractory biliary leaks.

DESIGN

Prospective study.

SETTING

Two tertiary-care referral academic centers and one general district hospital.

PATIENTS

Forty consecutive patients with refractory biliary leaks who underwent endoscopic management.

INTERVENTIONS

Temporary placement of MPS (n = 20) or FCSEMSs (n = 20).

MAIN OUTCOME MEASUREMENTS

Clinical outcomes of endotherapy as well as the technical success, adverse events, need for reinterventions, and prognostic factors for clinical success.

RESULTS

Endotherapy was possible in all patients. After endotherapy, closure of the leak was accomplished in 13 patients (65%) who received MPS and in 20 patients (100%) who received FCSEMSs (P = .004). The Kaplan-Meier (log-rank) leak-free survival analysis showed a statistically significant difference between the 2 patient populations (χ(2) [1] = 8.30; P < .01) in favor of the FCSEMS group. Use of <3 plastic stents (P = .024), a plastic stent diameter <20F (P = .006), and a high-grade biliary leak (P = .015) were shown to be significant predictors of treatment failure with MPS. The 7 patients in whom placement of MPS failed were retreated with FCSEMSs, resulting in closure of the leaks in all cases.

LIMITATIONS

Non-randomized design.

CONCLUSION

In our series, the results of the temporary placement of FCSEMSs for postcholecystectomy refractory biliary leaks were superior to those from the use of MPS. A randomized study is needed to confirm our results before further recommendations.

Endoscopic management of biliary leaks after laparoscopic cholecystectomy

Laparoscopic cholecystectomy has become the procedure of choice for management of symptomatic cholelithiasis. Although it has distinct advantages over open cholecystectomy, bile leak is more common. Endoscopic retrograde cholangiopancreatography is the diagnostic and therapeutic modality of choice for management of postcholecystectomy bile leaks and has a high success rate with the placement of plastic biliary stents. Repeat endoscopic retrograde cholangiopancreatography with placement of multiple plastic stents, a covered metal stent, or possibly cyanoacrylate therapy may be effective in refractory cases. This review will discuss the indications, efficacy, and complications of endoscopic therapy.

Comparative study of 4 Fr versus 6 Fr nasobiliary drainage catheters: a randomized, controlled trial

BACKGROUND AND AIM

Despite the benefits of endoscopic nasobiliary drainage (NBD) in endoscopic retrograde cholangiopancreatography (ERCP), post-ERCP pancreatitis (PEP) and nose/throat discomfort can result. We aimed to determine whether the use of a smaller catheter alleviates these complications.

METHOD

A randomized, controlled trial at a tertiary care center compared 4 Fr and 6 Fr NBD catheters; 165 ERCP patients with naïve papillae were randomly assigned to a catheter-size group.

RESULTS

The prevalence of PEP was significantly lower in the 4 Fr group (3.7%; 3/82) than in the 6 Fr group (15.7%; 13/83; P = 0.019). No spontaneous catheter displacement occurred within 24 h. Discomfort visual analog scores were 2.6 and 4.3 in the 4 Fr and 6 Fr groups, respectively (P = 0.0048) on procedure day; on the following day, the scores were 2.3 and 3.6 (P = 0.028). Bile output was 16.3 mL/h and 21.4 mL/h in the 4 Fr and 6 Fr groups (P = 0.051). On obstructive jaundice subgroup analysis, bile drainage was 19.2 mL/h and 22.1 mL/h in the 4 Fr and 6 Fr groups (P = 0.40). The 4 Fr group required 5.6 days to reduce bilirubin levels versus 6.1 days in the 6 Fr group (P = 0.51).

CONCLUSIONS

In patients with naïve papillae, lower rates of PEP and less nose/throat discomfort are associated with the use of 4 Fr NBD catheters. In patients with obstructive jaundice, 4 Fr and 6 Fr catheters are comparable with regard to bile output and bilirubin level reduction.

Placement of a new fully covered self-expanding metal stent for postoperative biliary strictures and leaks not responding to plastic stenting

Fully covered self-expanding metal stents (FCSEMSs) are now being used to treat postoperative biliary strictures (BSs) and biliary leaks (BLs). The aim of this study was to assess the safety and effectiveness of a new FCSEMS (Wallflex) in patients with postoperative BSs and BLs after failure of traditional endoscopic treatment. Between January 2010 and December 2011, 16 patients (10 patients with postcholecystectomy BSs, 4 with postcholecystectomy BLs, and 2 with postorthotopic liver transplantation BSs) were enrolled. The technical and clinical success rate was 100%. All FCSEMSs were removed after a mean of 141 days. Complications occurred in 7 cases: 2 postprocedure pain, 2 mild pancreatitis, 1 early distal, and 2 late proximal FCSEMS migration. The overall long-term clinical success rate was 94% after a mean follow-up of 13 months. In our experience, the placement of FCSEMSs is an effective and secure method of treating refractory postoperative BSs or BLs.

Management of bile duct leaks

The cause of bile duct leaks can be either iatrogenic or more rarely, traumatic. The most common cause is related to laparoscopic cholecystectomy. While surgical repair has been the standard for many years, management in these often morbid and complex situations must currently be multidisciplinary incorporating the talents of interventional radiologists and endoscopists. Based on the literature and in particular the recent recommendations of the European Society of Gastrointestinal Endoscopy (ESGE), this review aims to update the management strategy. The incidence of these complications decreases with surgeon experience attesting to the value of training to prevent these injuries. Bile duct injuries must be categorized and their mapping detailed by magnetic resonance cholangiography MRCP or endoscopic cholangiography (ERCP) when endoscopic therapy is considered. Endoscopic management should be preferred in the absence of complete circumferential interruption of the common bile duct. The ESGE recommends insertion of a plastic stent for 4 to 8 weeks without routine sphincterotomy. For complete circumferential injuries, hepaticojejunostomy is usually necessary. In conclusion, adequate training of surgeons is essential for prevention since the incidence of bile duct injury decreases with experience. Faced with a bile duct injury, a multidisciplinary team approach, involving radiologists, endoscopists and surgeons improves patient outcome.

MRCP is not a cost-effective strategy in the management of silent common bile duct stones

BACKGROUND

Few formal cost-effectiveness analyses simultaneously evaluate radiographic, endoscopic, and surgical approaches to the management of choledocholithiasis.

STUDY DESIGN

Using the decision analytic software TreeAge, we modeled the initial clinical management of a patient presenting with symptomatic cholelithiasis without overt signs of choledocholithiasis. In this base case, we assumed a 10 % probability of concurrent asymptomatic choledocholithiasis. Our model evaluated four diagnostic/therapeutic strategies: universal magnetic resonance cholangiopancreatography (MRCP), universal endoscopic retrograde cholangiopancreatography (ERCP), laparoscopic cholecystectomy (LC), or laparoscopic cholecystectomy with universal intraoperative cholangiogram (LCIOC). All probabilities were estimated from a review of published literature. Procedure and intervention costs were equated with Medicare reimbursements. Costs of hospitalizations were derived from median hospitalization reimbursement for New York State using diagnosis-related groups (DRG). Sensitivity analyses were performed on all cost and probability variables.

RESULTS

The most cost-effective strategy in the diagnosis and management of symptomatic cholelithiasis with a 10 % risk of asymptomatic choledocholithiasis was LCIOC. This was followed by LC alone, MRCP, and ERCP. LC was preferred only when the probability that a retained CBD stone would eventually become symptomatic fell below 15 % or if the probability of technical success of an intraoperative cholangiogram (IOC) was less than 35 %. Universal MRCP and ERCP were both more costly and less effective than surgical strategies, even at a high probability of asymptomatic choledocholithiasis. Within the tested range for both procedural and hospitalization-related costs for any of the surgical or endoscopic interventions, LCIOC and LC were always more cost-effective than universal MRCP or ERCP, irrespective of the presence or absence of complications. Varying the cost, sensitivity, and specificity of MRCP had no effect on this outcome.

CONCLUSIONS

LC with routine IOC is the preferred strategy in a cost-effectiveness analysis of the management of symptomatic cholelithiasis with asymptomatic choledocholithiasis. MRCP was both more costly and less effective under all tested scenarios.

Fully covered, self-expandable metal stents for first-step endoscopic treatment of biliary leaks secondary to hepato-biliary surgery: a retrospective study

BACKGROUND

Fully covered self-expanding metal stents are now being used to treat benign biliary diseases.

AIMS

To assess the outcomes of these stents as first-step therapy in patients with biliary leaks secondary to hepato-biliary surgery.

METHODS

Thirty patients (56.7% males; mean age: 60.2 ± 13 years) were retrospectively evaluated. The data collected included technical and clinical success, adverse events and follow-up findings (1, 3 and 6 months).

RESULTS

Technical and clinical success rates were 100%. One early mild post-procedure pancreatitis occurred and resolved spontaneously. Three late stent distal migrations occurred, however cholangiography showed correct leak sealing in all patients. Stents were removed after a mean of 55.9 days. During follow-up no other complications occurred.

CONCLUSION

In our experience fully covered self-expanding metal stent placement was safe and efficacious as first-step therapy for post-operative biliary leaks. However, prospective comparative studies with plastic stents are required to validate these findings.

Endoscopic therapy for postoperative leaks and fistulae

Endoscopic techniques for the treatment of postoperative fistulae and leaks are rapidly developing. Conventional surgical therapy for postsurgical leaks and fistulae is associated with significant morbidity and mortality. Novel endoscopic therapies have demonstrated safety, despite the inherent challenges of intervention in this patient population, and are steadily building evidence for efficacy relative to surgical management. The article examines endoscopic therapy for leaks and fistulae after esophageal, gastric, bariatric, colonic, and pancreaticobiliary surgery.

Prevention and treatment of bile duct injuries during laparoscopic cholecystectomy: the clinical practice guidelines of the European Association for Endoscopic Surgery (EAES)

BACKGROUND

Laparoscopic cholecystectomy is one of the most common surgical procedures in Europe (and the world) and has become the standard procedure for the management of symptomatic cholelithiasis or acute cholecystitis in patients without specific contraindications. Bile duct injuries (BDI) are rare but serious complications that can occur during a laparoscopic cholecystectomy. Prevention and management of BDI has given rise to a host of publications but very few recommendations, especially in Europe.

METHODS

A systematic research of the literature was performed. An international expert panel was invited to appraise the current literature and to develop evidence-based recommendations. Statements and recommendations were drafted after a consensus development conference in May 2011, followed by presentation and discussion at the annual congress of the EAES held in Torino in June 2011. Finally, full guidelines were consented and adopted by the expert panel via e-mail and web conference.

RESULTS

A total of 1,765 publications were identified through the systematic literature search and additional submission by panellists; 671 publications were selected as potentially relevant. Only 46 publications fulfilled minimal methodological criteria to support Clinical Practice Guidelines recommendations. Because the level of evidence was low for most of the studies, most statements or recommendations had to be based on consensus of opinion among the panel members. A total of 15 statements and recommendations were developed covering the following topics: classification of injuries, epidemiology, prevention, diagnosis, and management of BDI.

CONCLUSIONS

Because BDI is a rare event, it is difficult to generate evidence for prevention, diagnosis, or the management of BDI from clinical studies. Nevertheless, the panel has formulated recommendations. Due to the currently limited evidence, a European registry should be considered to collect and analyze more valid data on BDI upon which recommendations can be based.

Safety and efficacy of therapeutic endoscopic interventions in the management of biliary leak

Endoscopic procedures which reduce the trans-papillary pressure gradient are the treatment of choice for management of biliary leaks. We analyzed the data of 102 patients with biliary leak managed by various endoscopic procedures like endoscopic sphincterotomy (ES), ES with stenting, stenting alone or nasobiliary drainage (NBD) alone; 90 of these patients had developed a leak after cholecystectomy. In the post-cholecystectomy group, cannulation was successful in 79 patients; therapeutic intervention was not possible in 14 of them due to complete transection of common bile duct in 6, and leak proximal to ligature in 8. In the remaining 65 patients, ES with stenting was done in 52, stent alone in 6, ES alone in 5 and NBD alone in 2. All 12 patients in other etiology group were treated with ES plus stenting. The leak closed in a mean of 3 (1-10) days in all patients. Stents were removed after 6-8 weeks. Endoscopic procedures are effective in managing biliary leaks.

Use of fully covered self-expanding metal stents in benign biliary diseases

Biliary fully covered self-expanding metal stents (FCSEMS) are now being used to treat several benign biliary conditions. Advantages include small predeployment and large postexpansion diameters in addition to an easy insertion technique. Lack of imbedding of the metal into the bile duct wall enables removability. In benign biliary strictures that usually require multiple procedures, despite the substantially higher cost of FCSEMS compared with plastic stents, the use of FCSEMS is offset by the reduced number of endoscopic retrograde cholangiopancreatography interventions required to achieve stricture resolution. In the same way, FCSEMS have also been employed to treat complex bile leaks, perforation and bleeding after endoscopic biliary sphincterotomy and as an aid to maintain permanent drainage tracts obtained by means of Endoscopic Ultrasound-guided biliary drainage. Good success rates have been achieved in all these conditions with an acceptable number of complications. FCSEMS were successfully removed in all patients. Comparative studies of FCSEMS and plastic stents are needed to demonstrate efficacy and cost-effectiveness

Endoscopic management of postcholecystectomy biliary leaks

OBJECTIVE

To evaluate the nature of bile duct injuries following cholecystectomy and the success of endoscopic retrograde cholangiopancreatography (ERCP) in their identification and management.

DESIGN

All patients referred for ERCP with a diagnosis of a postcholecystectomy bile leak were identified prospectively from October 1994 to August 2008.

SETTING

The study was carried out in a district general hospital with the endoscopies performed by a single operator.

PATIENTS

All patients had undergone imaging with at least two of abdominal ultrasound scanning, CT scanning or MR cholangiopancreatography.

INTERVENTIONS

ERCP with treatment of a biliary leak by sphincterotomy and insertion of a temporary 7 Fr plastic biliary stent.

MAIN OUTCOME MEASUREMENTS

Clinical healing of the injury was assessed as resolution of symptoms with normalisation of liver function tests, cessation of external drain output and a repeat ERCP with removal of the indwelling stent within 2-8 weeks and no further complications.

RESULTS

46 patients were identified, of whom 42 responded well to endoscopic treatment. Four patients ultimately needed surgery, of whom three had recurrent strictures. One patient had complete transection of the biliary duct and endoscopic treatment was not attempted.

CONCLUSION

ERCP, with sphincterotomy and temporary plastic stent placement, is successful in the early management of patients with postcholecystectomy biliary leaks, which most commonly involve the cystic duct stump. ERCP carried out in a district general hospital identifies those patients requiring further specialised hepatobiliary care in a tertiary centre.

Endoscopic management of post-cholecystectomy biliary fistula

OBJECTIVE

Bile duct injury is an uncommon but potentially serious complication in cholecystectomy. A recognized treatment for minor biliary injury is internal biliary decompression by endoscopic retrograde cholangiopancreatography (ERCP) and stent insertion. The aim of this study was to assess the effectiveness of ERCP in the management of minor biliary injuries.

METHODS

A retrospective review of medical records at a tertiary referral centre identified 36 patients treated for postoperative minor biliary injuries between 2006 and 2010. Management involved establishing a controlled biliary fistula followed by ERCP to confirm the nature of the injury and decompress the bile duct with stent insertion.

RESULTS

Controlled biliary fistulae were established in all 36 patients. Resolution of the bile leak was achieved prior to ERCP in seven patients, and ERCP with stent insertion was successful in 27 of the remaining 29 patients. Resolution of the bile leak was achieved in all patients without further intervention. The median time to resolution after successful ERCP was 4 days. Two patients underwent ERCP complicated by mild pancreatitis. No other complications were seen.

CONCLUSIONS

This review confirms that postoperative minor biliary injuries can be managed by sepsis control and semi-urgent endoscopic biliary decompression.

Plastic biliary stents for benign biliary diseases

Biliary plastic stenting plays a key role in the endoscopic management of benign biliary diseases. Complications following surgery of the biliary tract and liver transplantation are amenable to endoscopic treatment by plastic stenting. Insertion of an increasing number of plastic stents is currently the method of choice to treat postoperative biliary strictures. Benign biliary strictures secondary to chronic pancreatitis or primary sclerosing cholangitis may benefit from plastic stenting in select cases. There is a role for plastic stent placement in nonoperative candidates with acute cholecystitis and in patients with irretrievable bile duct stones.

Endoscopic treatment of biliary fistulas after complex liver resection

OBJECTIVE

The aim of this study was to evaluate the safety and efficacy of endoscopic treatment for biliary fistulas after complex liver resection.

BACKGROUND

The role of endoscopy in the treatment of fistulas of the common bile duct is well documented. On the contrary, results of endoscopic procedures for fistulas arising from peripheral bile ducts after liver resections are poorly studied, although more complex hepatectomies are increasingly performed. We analyzed retrospectively the results of these procedures in our experience.

PATIENTS

Twenty-six patients aged 10 to 74 years were included. Fistulas arose after extended right hepatectomy, n = 14; extended left hepatectomy, n = 2; segmentectomy, n = 7; and split-liver transplantation, n = 3. All patients underwent radiologic or surgical external drainage before endoscopic retrograde cholangiopancreatography (ERCP). Mean bile outflow before endoscopy was 493.1 ± 386.1 mL/24 h (median, 400; range, 100-2000 mL). The mean time from surgery to diagnosis was 29.4 ± 45.5 days.

RESULTS

The ERCP was performed after a median of 13 days after the diagnosis of biliary fistula. A sphincterotomy was required in 96.1% of patients. A 5F to 10F polyethylene stent bypassing the leaking bile duct was implanted in 21 (80.7%) of 26 patients. Fistulas were dried up completely in 25 (96.1%) of 26 patients. The mean time from initial ERCP to running dry of the leaks was 17.5 ± 12.4 days. Procedure-related morbidity was 0%. There was no mortality.

CONCLUSION

Biliary fistulas arising from intrahepatic ducts after complex liver resections are more difficult to treat than distal fistulas arising from the common bile duct. However, despite a longer time for cure and the need for repeated ERCP, endoscopic therapy appears efficient and does not induce additional morbidity.

Minimally invasive management of biliary complications after laparoscopic cholecystectomy

BACKGROUND

We conducted this prospective study to evaluate the efficacy of percutaneous catheter drainage as a minimally invasive treatment in the management of symptomatic bile leak following biliary injuries associated with laparoscopic cholecystectomy.

METHODS

Twenty two patients with symptomatic bile leak following laparoscopic cholecystectomy underwent percutaneous drainage of the bile collection under ultrasound control. In patients with jaundice and in those with persistent drainage, endoscopic retrograde cholecysto-pancreatography (ERCP) was performed immediately for diagnostic and for therapeutic intervention when appropriate. In other patients, ERCP was performed 4-6 weeks after the discharge from the hospital to document the healing of the leaking site.

RESULTS

Five patients with jaundice were initially treated by a combination of endoscopic plus percutaneous drainage. One of them required surgical treatment following diagnosis of a major duct injury. The other 17 were treated by percutaneous drainage initially and for 14 of them it was definitive treatment. Three patients required sphincterotomy as additional treatment for stopping the leak. There were no complications related to the percutaneous drainage procedure.

CONCLUSIONS

Most patients with bile leakage can be managed successfully by percutaneous drainage. If biliary output does not decrease, endoscopy is needed. In patients with jaundice endoscopic diagnostic and therapeutic procedures should be performed immediately.

Migration of plastic biliary stents and endoscopic retrieval: an experience of three referral centers

BACKGROUND

Proximal or distal migration of a plastic biliary stent is uncommon, but its management can be a technical challenge to the pancreatobiliary endoscopist.

PATIENTS AND METHODS

All cases (n=51) of proximally and distally migrated plastic biliary stents over an 8-year period at 3 referral pancreaticobiliary centers were included in this retrospective study. Indications for stenting, risk factors for migration, presentation of migration, and various techniques used for stent's retrieval are herein analyzed.

RESULTS

Twenty-one proximal and 30 distal bile duct-migrated stents were identified. All patients with proximally and 17 (56.7%) with distally migrated stents were symptomatic. Choledocholithiasis, dilated common bile duct, short and large size stent were the main risk factors. The retrieval of proximally migrated stents was successful in 15 patients (71.4%) and in all symptomatic patients with distal migration. The retrieval techniques included forceps, Dormia basket, snare, Soehendra stent retriever, and balloon. One patient died of sepsis due to peritonitis from duodenal perforation from a distally migrated stent.

CONCLUSIONS

Retrieval of a proximally migrated stent requires experience with different endoscopic devices. Moreover, distal migration needs attention because it can cause severe complications.

ERCP in the management of biliary complications after cholecystectomy

Open cholecystectomy has been associated historically with 0.2% to 0.5% risk of postoperative biliary injury. Laparoscopic cholecystectomy, which has become the first-line surgical treatment of calculous gallbladder disease, has been associated with a 2.5-fold to fourfold increase in the incidence of postoperative bile duct injury. The biliary endoscopist can expect to see a varied spectrum of complications after cholecystectomy by either technique, including postoperative biliary strictures, bile leaks, and retained calculi in the biliary tree. Proper diagnosis and treatment are paramount in ensuring a satisfactory outcome after bile duct injury. Endoscopic retrograde cholangiopancreatography (ERCP) has become the primary modality for treatment and effectively manages most bile duct injuries.