Endoscopic Treatment of Post-Cholecystectomy Biliary Leaks

Abstract

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.

Keywords: Biliary leak; Biliary stent; Cholecystectomy; ERCP; Endoscopic retrograde cholangiopancreatography; Sphincterotomy.

Conflict of interest statement

The authors have no personal conflicts of interest or financial relationships relevant to this publication.

Copyright © 2020 by S. Karger AG, Basel.

Figures

Fig. 1

Strasberg classification of biliary injuries. Type A: bile leak from a cystic duct stump or Luschka's duct leaks. Type B: occluded right posterior sectorial duct. Type C: bile leak from divided right posterior sectorial duct. Type D: bile leak from the main bile duct involving 2 cm from the hilum. Type E2: stricture located

Fig. 2

Fluoroscopic images of endoscopic management of a refractory biliary leak using a fully covered self-expandable metallic stent (FCSEMS). a A high-grade (HG) biliary leak from cystic stump. b After endoscopic placement of a single plastic stent. c Persistence of a HG biliary leak after 5 days of plastic stenting. d Immediately after endoscopic placement of a FCSEMS with immediate reduction in the contrast flow through the leak. e Follow-up cholangiography immediately after FCSEMS removal at week 4. No contrast media extravasation is seen.

Fig. 3

Treatment of biliary leaks, a step-up approach. ES, endoscopic sphincterotomy; PS, plastic stent; MPS, multiple plastic stent; FCSEMS, fully covered self-expandable metallic stent.