The role of ERCP in the management of bile leakage: endoscopic sphincterotomy versus biliary stenting

Management of anastomotic biliary stricture through utilizing percutaneous transhepatic cholangioscopy

AIM

Occurrence of anastomotic biliary stricture (AS) remains an essential issue following hepatobiliary surgeries, and percutaneous transhepatic cholangioscopy (PTCS) has great therapeutic significance in handling refractory AS for patients with altered gastrointestinal anatomy after cholangio-jejunostomy. This present study aimed to investigate feasibility of PTCS procedures in AS patients for therapeutic indications.

MATERIALS AND METHODS

This study was a single-center, retrospective cohort study with a total number of 124 consecutive patients who received therapeutic PTCS due to AS. Clinical success rate, required number, and adverse events of therapeutic PTCS procedures as well as patients survival state were reviewed.

RESULTS

These 124 patients previously underwent choledochojejunostomy or hepatico-jejunostomy, and there was post-surgical altered gastrointestinal anatomy. Overall, 366 therapeutic PTCS procedures were performed for these patients through applying rigid choledochoscope, and the median time of PTCS procedures was 3 (1-11). Among these patients, there were 34 cases (27.32%) accompanied by biliary strictures and 100 cases (80.65%) were also combined with biliary calculi. After therapeutic PTCS, most patients presented with relieved clinical manifestations and improved liver functions. The median time of follow-up was 26 months (2-86 months), and AS was successfully managed through PTCS procedures in 104 patients (83.87%). During the follow-up period, adverse events occurred in 81 cases (65.32%), most of which were tackled through supportive treatment.

CONCLUSION

PTCS was a feasible, safe and effective therapeutic modality for refractory AS, which may be a promising alternative approach in clinical cases where the gastrointestinal anatomy was changed after cholangio-jejunostomy.

A Rare Case of Small Bowel Obstruction due to Migration of a Percutaneous Biliary Stent

Biliary endoprostheses are widely used in the treatment of biliary lithiasis, malignant and benign strictures, and occasionally in long-lasting biliary fistulas. They can be placed endoscopically during endoscopic retrograde cholangiopancreatography and radiologically (percutaneous) when the endoscopic route is not feasible. Complications associated with the endoscopic placement of biliary endoprostheses are well described in the literature, with migration being the most common. Intestinal obstruction is a rare complication associated with the migration of these devices. There are no reports in the literature of this complication occurring after percutaneous placement. We present a case of a patient who arrived at the emergency department with ileal obstruction secondary to the migration and concurrent embedding of a covered stent placed radiologically to treat a biliary leak after surgery. The patient underwent diagnostic laparoscopic and ileal resection, revealing a lithiasic concretion at the tip of the stent, causing the small bowel obstruction.

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.

The reasonable therapeutic modality for biliary duct-to-duct anastomotic stricture after liver transplantation: ERCP or PTC?

Objective

To compare the initial success rate, feasibility, and effectiveness of endoscopic retrograde cholangiopancreatography (ERCP) versus percutaneous transhepatic cholangiography (PTC) for anastomotic biliary stricture after liver transplantation (LT).

Methods

We retrospectively analyzed the data collected during January 2015 to December 2021 from liver transplantation recipients who developed anastomotic biliary stricture after liver transplantation and treated by ERCP and/or PTC. The success rate, complications and patients’ survival rate of ERCP and PTC procedures was evaluated.

Results

Forty-eight patients who underwent LT and were confirmed to have the anastomotic biliary stricture were enrolled. Overall, 48/48 patients underwent single or multiple ERCP procedures as the first line therapy; 121 therapeutic ERCPs (3.36 ± 2.53 ERCPs per patient) were performed in 36/48 patients successfully. All the 12 patients who failed ERCP tend to have special bile duct conditions such as overlong, angle shaped, and/or extremely narrowed bile duct and underwent PTC as an alternative treatment. The initial success rate of ERCP was 75% (36/48) while the success rate of ERCP for the 12 patients with special bile duct was 0% (0/12). PTC was an effective second-line treatment for those 12 patients who failed ERCP, and 58.33% (7 of 12 cases) were treated successfully. The average procedure time in PTC group was significantly lower than ERCP group (t=2.292, P=0.027). The feasibility of ERCP was associated with the anatomical shape of bile duct and the severity of the stricture site. Finally, the cumulative survival rate was 100% (12/12) in PTC group compared to 86.11% (31/36) in ERCP group (χ^{2 =}0.670, P=0.413).

Conclusion

ERCP is the gold standard method for the diagnosis and effective intervention for the management of biliary complications after LT. However, its use in certain types of biliary complications (e.g., patients with severe anastomotic biliary stricture and those with overlong and angle shaped bile ducts) is not promising and associated with significant risk of complications. PTC and other interventions should be studied along with ERCP for patients for whom ERCP may not work. The feasibility and efficacy of primary management can be predicted by the noninvasive imaging examinations like Magnetic Resonance Cholangiopancreatography (MRCP) before the procedure, which may help with the choice of the most reasonable therapeutic modality and avoiding unnecessary financial burden and complications.

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.

ERCP licence in the context of medical practices, legal regulations, medical ethics and patient’s rights in our country

Endoscopic Retrograde Cholangiopancreatography (ERCP) is an invasive endoscopic procedure mainly used for hepatobiliary and pancreatic disorders. Although it was first developed by a surgeon, McCune, there is still debate on who can perform this procedure. This problem, which actually needs to be solved within medical ethics, has been brought to the courts, and lawsuits have been filed against general surgeons to prevent them from performing ERCP. The current situation in our country demonstrates that 50-70% of ERCP procedures are performed by general surgeons. In regions where there are not enough gastroenterology specialists, only general surgeons perform this procedure. Today, general surgeons have hundreds of articles on ERCP procedures and studies accepted as international guideline. ERCP procedure -which is in fact a surgical procedure- is included in hepatobiliary surgical procedures in the general surgery core training schedule. General surgeons receive ERCP education in a 6-month challenging program at centers accredited by the Turkish Surgical Society. The problem of ERCP license cannot be solved by legal authorities but by medical, ethical and deontological discussions. Our recommendation here is that the Ministry of Health should associate this procedure with a specific legislation, just like in endoscopy, and establish a specific ERCP training program accepted for license. In this article, the problem of who should perform ERCP was discussed within the framework of legal legislation, medical doctrine and realities of our country.

Biliary Sphincterotomy Alone versus Biliary Stent with or without Biliary Sphincterotomy for the Management of Post-Cholecystectomy Bile Leak: A Systematic Review and Meta-Analysis

BACKGROUND

Endoscopic therapy with endoscopic retrograde cholangiopancreatography is considered the first-line treatment in the management of post-cholecystectomy bile leak (PCBL). Currently, there is no consensus on the most effective endoscopic intervention for PCBL. Hence, we performed a systematic review and meta-analysis to compare the effectiveness and safety of the two interventional groups (biliary sphincterotomy [BS] alone vs. biliary stent ± BS) in management of PCBL.

METHODS

We conducted a comprehensive search of multiple electronic databases and conference proceedings (from inception through January 2021). The primary outcome was to compare the pooled rate of clinical success between the 2 groups. The secondary outcome was to estimate the pooled rate of adverse events.

RESULTS

The pooled rate of clinical success with BS alone (5 studies, 299 patients) was 88% (95% confidence interval (CI): 84-92%, I2: 0%) and for biliary stent ± BS (5 studies, 864 patients) was 97% (CI: 93-100%, I2: 79%). The rate of clinical success in biliary stent ± BS group was significantly higher than BS alone group (OR: 3.91 95% CI: 2.29-6.69, p < 0.001, I2: 13%). The rate of adverse events was numerically lower in biliary stent ± BS group compared to BS alone (3 studies; OR: 0.65 95% CI: 0.41-1.03, p = 0.07) without statistical significance. Low heterogeneity was noted in the analysis.

CONCLUSIONS

Biliary stent ± BS is more effective in endoscopic management of PCBL compared to BS alone. This may be related to inter-endoscopist variation in completeness of sphincterotomy and post-sphincterotomy edema, which can influence the preferential trans-papillary flow of bile.

2020 WSES guidelines for the detection and management of bile duct injury during cholecystectomy

Bile duct injury (BDI) is a dangerous complication of cholecystectomy, with significant postoperative sequelae for the patient in terms of morbidity, mortality, and long-term quality of life. BDIs have an estimated incidence of 0.4-1.5%, but considering the number of cholecystectomies performed worldwide, mostly by laparoscopy, surgeons must be prepared to manage this surgical challenge. Most BDIs are recognized either during the procedure or in the immediate postoperative period. However, some BDIs may be discovered later during the postoperative period, and this may translate to delayed or inappropriate treatments. Providing a specific diagnosis and a precise description of the BDI will expedite the decision-making process and increase the chance of treatment success. Subsequently, the choice and timing of the appropriate reconstructive strategy have a critical role in long-term prognosis. Currently, a wide spectrum of multidisciplinary interventions with different degrees of invasiveness is indicated for BDI management. These World Society of Emergency Surgery (WSES) guidelines have been produced following an exhaustive review of the current literature and an international expert panel discussion with the aim of providing evidence-based recommendations to facilitate and standardize the detection and management of BDIs during cholecystectomy. In particular, the 2020 WSES guidelines cover the following key aspects: (1) strategies to minimize the risk of BDI during cholecystectomy; (2) BDI rates in general surgery units and review of surgical practice; (3) how to classify, stage, and report BDI once detected; (4) how to manage an intraoperatively detected BDI; (5) indications for antibiotic treatment; (6) indications for clinical, biochemical, and imaging investigations for suspected BDI; and (7) how to manage a postoperatively detected BDI.

SPHINCTEROTOMY ALONE VERSUS SPHINCTEROTOMY AND BILIARY STENT PLACEMENT IN THE TREATMENT OF BILE LEAKS: 10 YEAR EXPERIENCE AT A QUATERNARY HOSPITAL

BACKGROUND

Hepatobiliary surgery and hepatic trauma are frequent causes of bile leaks and this feared complication can be safely managed by endoscopic retrograde cholangiopancreatography (ERCP). The approach consists of sphincterotomy alone, biliary stenting or a combination of the two but the optimal form remains unclear.

OBJECTIVE

The aim of this study is to compare sphincterotomy alone versus sphincterotomy plus biliary stent placement in the treatment of post-surgical and traumatic bile leaks.

METHODS

We retrospectively analyzed 31 patients with the final ERCP diagnosis of "bile leak". Data collected included patient demographics, etiology of the leak and the procedure details. The treatment techniques were divided into two groups: sphincterotomy alone vs. sphincterotomy plus biliary stenting. We evaluated the volume of the abdominal surgical drain before and after each procedure and the number of days needed until cessation of drainage post ERCP.

RESULTS

A total of 31 patients (18 men and 3 women; mean age, 51 years) with bile leaks were evaluated. Laparoscopic cholecystectomy was the etiology of the leak in 14 (45%) cases, followed by conventional cholecystectomy in 9 (29%) patients, hepatic trauma in 5 (16%) patients, and hepatectomy secondary to neoplasia in 3 (9.7%) patients. The most frequent location of the leaks was the cystic duct stump with 12 (38.6%) cases, followed by hepatic common duct in 10 (32%) cases, common bile duct in 7 (22%) cases and the liver bed in 2 (6.5%) cases. 71% of the patients were treated with sphincterotomy plus biliary stenting, and 29% with sphincterotomy alone. There was significant difference between the volume drained before and after both procedures (P<0.05). However, when comparing sphincterotomy alone and sphincterotomy plus biliary stenting, regarding the volume drained and the days needed to cessation of drainage, there was no statistical difference in both cases (P>0.005).

CONCLUSION

ERCP remains the first line treatment for bile leaks with no difference between sphincterotomy alone vs sphincterotomy plus stent placement.

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.

Hepatobiliary Scintigraphy-Role in Preliminary Diagnosis and Management of Biliary Tract Injuries

PURPOSE

This study was conducted to identify the role of hepatobiliary scintigraphy (HBS) in the management of biliary tract injuries.

METHODS

We retrospectively studied 54 patients (28 male and 26 female patients) aged 3 to 78 years with evidence of bile leak on HBS performed between January 2015 and October 2017. Following intravenous injection of Tc-mebrofenin, dynamic images were acquired for 30 minutes followed by static images until 24 hours. SPECT/CT was performed in patients with suspicion of bile leak on the planar images. Patients were classified as those with free intraperitoneal or localized bile leak. Any abdominal drain output was documented, and its statistical significance was assessed using Mann-Whitney U test. Subsequent management was also documented.

RESULTS

Of the 54 patients, 28 demonstrated free intraperitoneal bile leak and 26 localized leak on HBS. Thirty-four patients (24 with free intraperitoneal leak and 10 with localized leak) had an abdominal drain. Drain output was significantly higher in patients with free intraperitoneal leak compared with patients with localized leak (370 vs 78 mL/d per patient, P < 0.01). All patients with free intraperitoneal bile leak underwent interventional procedures such as endoscopic retrograde cholangiopancreatography and stenting or Roux-en-Y hepaticojejunostomy later on. Patients with localized bile leak were managed conservatively and were free of symptoms at 1-year follow-up.

CONCLUSIONS

Our findings indicate that, in addition to detecting biliary leak, HBS may be used to identify patients with localized bile leak (48% of patients in our study) who do not require active intervention.

Endoscopic Management of Biliary Issues in the Liver Transplant Patient

Biliary complications remain a common problem after liver transplantation (LT). The therapeutic endoscopist encounters a variety of situations in LT including strictures at the duct-to-duct biliary anastomosis, strictures elsewhere in the biliary tree caused by an ischemic injury, and bile leaks at the anastomosis or from the cut surface and stone disease. Biliary complications lead to significant morbidity and occasionally reduced graft and patient survival. Several factors increase the risk of strictures and leaks. Endoscopic intervention in experienced hands is successful in the management of biliary complications following LT and percutaneous or surgical correction should seldom be required.

Endoscopic Therapy of Biliary Injury After Cholecystectomy

BACKGROUND

Iatrogenic bile duct injury (BDI) is a common complication after cholecystectomy. Patients are mainly treated endoscopically, but the optimal treatment method has remained unclear.

AIMS

The aim was to analyze endoscopic treatment in BDI after cholecystectomy and to explore endoscopic sphincterotomy (ES), with or without stenting, as the primary treatment for an Amsterdam type A bile leak.

METHODS

All patients referred to Helsinki University Hospital endoscopy unit due to a suspected BDI between the years 2004 and 2014 were included in this retrospective study. To collect the data, all ERC reports were reviewed.

RESULTS

Of the 99 BDI patients, 94 (95%) had bile leak of whom 11 had concomitant stricture. Ninety-three percent of all patients were treated endoscopically. Seventy-one patients had native papillae and a leak in the cystic duct or peripheral radicals. They were treated with ES (ES group, n = 50) or with sphincterotomy and stenting (EST group, n = 21). There was no difference between the closure time of the fistula (p = 0.179), in the time of discharge from hospital (p = 0.298), or in the primary healing rate between the ES group and the EST group (45/50 vs 19/21 patients, p = 0.951).

CONCLUSION

After the right patient selection, the success rate of endoscopic treatment can approach 100% for Amsterdam type A bile leak. ES is an effective and cost-effective single procedure with success rate similar to EST. It may be considered as a first-line therapy for the management of Amsterdam type A leaks.

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.

Diagnostic value of Gd-EOB-DTPA-enhanced MR cholangiography in non-invasive detection of postoperative bile leakage

OBJECTIVE

To assess the diagnostic value of dynamic T₁ weighted (T1w) gadolinium ethoxybenzyl diethylenetriamine penta-acetic acid (Gd-EOB-DTPA)-enhanced MR cholangiography (MRC) for the detection of active bile leaks.

METHODS

A total of 28 patients with suspected biliary leakage who underwent routine T₂ weighted (T2w) MRC and T1w GD-EOB-DTPA-enhanced MRC at our institution from February 2013 to June 2016 were included in this study. The image sets were retrospectively analyzed in consensus by three radiologists. T1w Gd-EOB-DTPA-enhanced MRC findings were correlated with clinical data, follow-up examinations and findings of invasive/surgical procedures. Patients with positive bile leak findings in Gd-EOB-DTPA-enhanced MRC were divided into hepatobiliary phase (HBP) (20-30 min) and delayed phase (DP) (60-390 min) group according to elapsed time between Gd-EOB-DTPA injection and initial bile leak findings in MRC images. These groups were compared in terms of laboratory test results (total bilirubin, liver enzymes) and the presence of bile duct dilatation in T2w MRC images.

RESULTS

In each patient, visualization of bile ducts was sufficient in the HBP. The accuracy, sensitivity and specificity of dynamic Gd-EOB-DTPA-enhanced T1w MRC in the detection of biliary leaks were 92.9%, 90.5% and 100%, respectively (p < 0.001). 19 of 28 patients had bile leak findings in T1w Gd-EOB-DTPA-enhanced MRC [HBP group: N = 7 (36.8%), DP group: N = 12 (63.2%)]. There was no statistically significant difference in terms of laboratory test results and the presence of bile duct dilatation between HBP and DP group (p > 0.05). Three patients, each of them in DP group, showed normal laboratory test results and bile duct diameters.

CONCLUSION

Dynamic T1w Gd-EOB-DTPA-enhanced MRC is a useful non-invasive diagnostic tool to detect bile leak. Advances in knowledge: Prolonged DP imaging may be required for bile leak detection even if visualization of biliary tree is sufficient in HBP and liver function tests, total bilirubin levels and bile duct diameters are normal.

Biliary sphincterotomy is not required for bile duct stent placement

BACKGROUND

The aim of the present study was to assess the success and outcome of bile duct stent placement without the use of endoscopic biliary sphincterotomy (EBS).

PATIENTS AND METHODS

Over a period of 10 years and 9 months, all patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) were prospectively identified. Bile duct stent placement was routinely done without EBS unless additional therapy (stone removal, multiple stenting) was anticipated.

RESULTS

Of 5020 patients who underwent ERCP, bile duct stents were placed in 1668 patients. After excluding those requiring additional endoscopic therapy, 1112 patients (89.5%) had ERCP and stent placement without a sphincterotomy and 130 patients (10.5%) had ERCP and stent placement with asphincterotomy. Deployed endoprostheses were self-expandable metallic stents in 15.7% and plastic in 77.5%. Caliber of plastic stents was 10 Fr in 78.9% and <10 Fr in 21.1%. All stents were successfully placed in these 1112 patients without the need for EBS. Comparing patients undergoing bile duct stenting with and without sphincterotomy, no difference was seen in rates of pancreatitis (1.54% vs 2.07%, P > 0.9999).

CONCLUSION

Single bile duct stents, both plastic and metal, can be deployed without EBS.

The Effects of Repeat Laparoscopic Surgery on the Treatment of Complications Resulting from Laparoscopic Surgery

Laparoscopic surgery is frequently applied in the operative management of appendicitis and symptomatic cholelithiasis because it is a minimally invasive procedure. There are, however, some complications of laparoscopic cholecystectomy (LC) and laparoscopic appendectomy (LA) that result in the need for reoperation. In the current study, we examine the effects of repeat laparoscopic surgery on the treatment of complications arising from LC/LA. From April 2005 to March 2011, we examined a cohort of patients who had received LC or LA and experienced complications that required reoperations. We focused on patients with postoperative hemorrhages, postoperative peritonitis, early postoperative small bowel obstructions (EPSBO), and biliary complications (after LC) who were treated through a repeat laparoscopic approach. The general demographics of the patients, their postoperative complications, procedures for selecting the appropriate reoperation method, and repeat laparoscopic findings are described in detail. During the 6-year period examined, 1608 patients received LC and 1486 patients received LA at the hospitals participating in this study. In patients with complications requiring reoperation, the repeat laparoscopic approach was performed successfully (without the need for further laparotomy) in 50 per cent of the patients with postoperative hemorrhage (2 of 4), 50 per cent of the patients with postoperative peritonitis (2 of 4), 75 per cent of the EPSBO patients (3 of 5), and 50 per cent the of patients with biliary complications (1 of 2). The repeat laparoscopic approach is an appropriate method for the management of complications arising from laparoscopic surgery. In patients with postoperative hemorrhage, laparoscopic hemostasis and hematoma evacuations can be performed while maintaining stable hemodynamics. In addition, laparoscopic approaches are also feasible for selective post-LC ductal injuries, EPSBO, and unconfirmed diagnoses of peritonitis after laparoscopic surgery.

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.

Duodenoscopic diagnosis and treatment of bile leakage after laparoscopic cholecystectomy

AIM: To investigate the value of duodenoscopy in the diagnosis and treatment of bile leakage after laparoscopic cholecystectomy (LC).

METHODS: The clinical data for 32 patients who had bile leakage after LC and were treated at Tianjin Nankai Hospital from June 2004 to January 2010 were retrospectively analyzed.

RESULTS: All 32 patients received endoscopic retrograde cholangiopancreatography (ERCP), and the nature of bile leakage in all of them was elucidated. Of all patients, 20 had cystic duct stump leakage, 7 had common bile duct leakage, 3 had hepatic duct leakage, 2 had aberrant bile duct leakage; 28 were cured by endoscopic nasobiliary drainage (ENBD), and 4 by plastic biliary stent implantation.The overall cure rate was 100%. The length of hospitalization stay ranged from 1 to 6 wk, with an average length of 24 d. No recurrence occurred in all patients during 3 to 72 months of follow-up.

CONCLUSION: Duodenoscopy is a feasible and effective approach for the diagnosis and treatment of bile leakage after LC.