Leaks from laparoscopic cholecystectomy

BACKGROUND/AIMS: Significant postoperative bile leaks occur in approximately 1% of patients. The goal of endoscopic therapy is to eliminate the transpapillary pressure gradient, thereby permitting preferential transpapillary bile flow rather than extravasation at the site of leak. METHODOLOGY: Sixty-four patients were retrospectively evaluated. Endoscopic treatment comprised endoscopic sphincterotomy followed by insertion of a naso-biliary drainage or a stent. Retained stones were extracted by standard procedures. RESULTS: The site of bile extravasation was the cystic duct in 50 cases, ducts of Luschka in 4 cases, common bile duct in 6 cases and common hepatic duct in 4 cases. Retained bile duct stones were detected in 21 cases and papillary stenosis in 4 cases. Endoscopic sphincterotomy was performed in 25 cases, with stones extraction and nasobiliary drainage in 21 cases, and placement of stent in the remainder. Bile leaks resolved in 96.9% of patients, after endoscopic procedure. Two cases of mild pancreatitis were evidenced from endoscopic treatment. CONCLUSIONS: Endoscopic management is the treatment of choice of postcholecystectomy bile leaks.     

Temporary placement of a newly designed, fully covered, self-expandable metal stent for refractory bile leaks

Bile leaks remain a significant cause of morbidity for patients undergoing laparoscopic cholecystectomy. Leakage from an injured duct of Luschka (subvesical duct) follows the cystic duct as the most common cause of postcholecystectomy bile leaks. Although endoscopic sphincterotomy, plastic-stent placement, or nasobiliary-drain placement are effective in healing biliary leaks, in patients in whom leakage persists and the symptoms worsen despite conventional endoscopic treatment, re-exploration with laparoscopy and ligation of the injured subvesical duct should be considered. We present herein the case of a 31-year-old woman with refractory bile leakage from a disrupted subvesical duct after cholecystectomy that could not be managed with endoscopic sphincterotomy and plastic-stent placement. A newly designed, fully covered, self-expandable metal stent (FC-SEMS) was successfully placed for the treatment of refractory bile leaks in this patient. It appears that temporary placement of an FC-SEMS is technically feasible and provides an effective alternative to surgical therapy for refractory bile leaks after cholecystectomy.     

Endoscopic biliary stenting for treatment of bile leakage after hepatic resection

BACKGROUND/AIMS: Persistent bile leakage after hepatic resection may cause intraperitoneal sepsis and hepatic failure. Surgical treatment for bile leakage carries a high risk. Endoscopic treatment has only infrequently been documented. METHODOLOGY: Ten patients underwent endoscopic biliary stenting without sphincterotomy for persistent (9-138 days; median, 19 days) bile leakage after hepatic resection. Bile leakage was complicated by intraperitoneal sepsis in seven patients. RESULTS: ERCP showed bile leakage from the bile duct stump in nine patients. Stent placement was successful without complications in all 10 patients. Bile leakage disappeared within 1-17 days (mean, 5 days) in all patients. After 55-91 days, the stent was removed and ERCP confirmed disappearance of the leak. No patients have developed recurrent bile leakage for a mean of 4.1 years of follow-up after stent removal. CONCLUSIONS: Endoscopic biliary stenting is a safe and effective treatment for persistent bile leakage after hepatic resection. Endoscopic treatment may eliminate the need for difficult operations in high risk postoperative cases.     

Endoscopic management of postoperative bile leaks

BACKGROUND: Significant bile leak as an uncommon complication after biliary tract surgery may constitute a serious and difficult management problem. Surgical management of biliary fistulae is associated with high morbidity and mortality. Biliary endoscopic procedures have become the treatment of choice for management of biliary Gstulae. METHODS: Ninety patients presented with bile leaks after cholecystectomy ( open cholecystectomy in 45 patients, cholecystectomy with common bile duct exploration in 20 and laparoscopic cholecystectomy in 25). The presence of bile leaks was confirmed by ERCP and the appearance of bile in percutaneous drainage of abdominal collections. Of the 90 patients with postoperative bile leaks, 18 patients had complete transaction of the common bile duct by ERCP and were subjected to bilioenteric anastomosis. In the remaining patients after cholangiography and localization of the site of bile leaks. therapeutic procedures like sphinctero-tomy, biliary stenting and nasobiliary drainage ( NBD ) were performed. If residual stones were seen in the common bile duct, sphincterotomy was followed by stone extraction using dormia basket. Nasobiliary drain or stents of 7F size were placed according to the standard techniques. The NBD was removed when bile leak stopped and closure of the fistula confirmed cholangiographically. The stents were removed after an interval of 6-8 weeks. RESULTS: Bile leaks in 72 patients occurred in the cystic duct (38 patients), the common bile duct (30 ), and the right hepatic duct (4). Of the 72 patients with post-operative bile leak, 24 had associated retained common bile duct stones and 1 had ascaris in common bile duct. All the 72 patients were subjected to therapeutic procedures including sphincterotomy with stone extraction followed by biliary stenting (24 patients), removal of ascaris and biliary stenting (1), sphincterotomy with biliary stenting (18), sphincterotomy with NBD (12), biliary stenting alone (12), and NBD alone (5). Bile leaks stopped in all patients at a median interval of 3 days (range 3-16 days) after endoscopic in- terventions. No difference was observed in efficacy and in time for the treatment of bile leak by sphincterotomy with endoprosthesis or endoprosthesis alone in patients with bile leak after surgery. CONCLUSIONS: Post-cholecystectomy bile leaks occur most commonly in the cystic duct and associated common bile duct stones are found in one-third of cases. Endoscopic therapy is safe and effective in the management of bile leaks and fistulae after surgery. Sphincterotomy with endoprosthesis or endoprosthesis alone is equally effective in the management of postoperative bile leak.     

The role of endoscopic treatment in postoperative bile leaks

BACKGROUND/AIMS: Bile leak is among the most common and serious complications of biliary tract surgery. The aim of this non-randomized study was to evaluate the role of endoscopic intervention as an accepted treatment for this complication. METHODOLOGY: An endoscopic retrograde cholangiopancreatography (ERCP) database was reviewed retrospectively to identify all cases of bile leak related to cholecystectomy (laparoscopic or open). Patients' records and endoscopy reports were reviewed. Moreover, structured telephone interviews were conducted to collect data. RESULTS: Twenty-four patients, 4 males and 20 females, with a median age of 54 (range 28-76 years) with suspected postcholecystectomy bile leaks were referred for ERCP performed 3-73 days after operation (mean 9.5 days). All but one case had high-grade bile-like liquid outflowing from the original drainage tubes or the fistulous tract of T-tube. One patient presented with bilious ascites, 17 patients had sudden or gradual abdominal pain, 3 jaundice, 2 abdominal pain with fever, and 1 nausea and vomiting. ERCP was successful in all cases, and revealed leakage from the cystic stump in 10 cases, from a common bile duct (CBD) defect in 6, from a common hepatic duct defect in 3, from the gallbladder bed in 2, from a T-tube track in 1, and complete CBD transection in 2 patients. Seventeen patients were successfully treated by endoscopic sphincterotomy (ES) plus endoprosthesis, 3 by stent placement without sphincterotomy, 2 with complete transection by proximal hepaticojejunostomy, and 2 patients with leakage from the cystic stump and a CBD defect were operated after unsuccessful endoscopic intervention. CONCLUSIONS: ERCP is recommended as a safe and efficacious intervention to detect and treat postoperative bile leaks. ES plus endoprosthesis is effective for the treatment of bile leakage. Endoscopic stenting without sphincterotomy may be offered as a primary option in young patients with postoperative bile leaks.     

Endoscopic management of biliary leaks. The answer for the future

Bile duct diseases and biliary leaks are not uncommon complications and their management is challenging. Majority of bile leaks occur secondary to trauma, major liver, gallbladder and biliary tract surgeries. Early recognition of bile leaks by imaging combined with a high clinical suspicion is required. Bile leaks can be managed either conservatively, or through percutaneous drainage, or endoscopically or by surgical intervention. The innovations in endoscopic techniques have expanded the horizons for managing patients with bile leaks irrespective of their etiology. Endoscopic interventions through biliary sphincterotomy alone, biliary stenting with or without sphincterotomy, and nasobiliary drainage with or without sphincterotomy, use of self expanding covered metal stents and the recent use of biodegradable stents have been very effective in the management of all kinds of biliary leaks. All endoscopic techniques are based on the principle that eliminating the rise in pressure inside the bile duct by promoting decompression in the form of stent placement/sphincterotomy promotes healing of bile leaks. Further future developments in endoscopic techniques are expected to improve their effectiveness in managing patients with bile leaks.     

Treatment of biliary leakages after cholecystectomy and importance of stricture development in the main bile duct injury.

BACKGROUND/AIMS: Endoscopic treatment of biliary leakages after cholecystectomy, though widely accepted, has some restrictions. The efficacy and safety of endoscopic treatments in this patient group are evaluated in this study, and the problem of biliary stricture development in time after biliary ductal injuries is also emphasized. METHODS: Seventy-four patients (20 male, 54 female, mean age 50.9+/-21 years) referred for ERCP between 1992-2002 were included in the study. Minor leakages (cystic duct leaks, accessory bile duct leaks) were managed by nasobiliary drainage +/- endoscopic sphincterotomy; major leakages were managed by nasobiliary drainage +/- endoscopic sphincterotomy +/- stenting. RESULTS: Twenty-seven patients with cystic duct leaks and 6 patients with accessory bile duct leaks were successfully treated with nasobiliary drainage. Endoscopic treatment could not be performed on patients with total bile duct obstruction (7 patients) and aberrant bile duct injury (7 patients). All leakages from main bile ducts were closed (27 patients). Six of 27 patients had strictures at the beginning and they were treated by stenting. Twenty-one patients had no strictures at the beginning. Eight of 21 were treated by stenting and only 1 of them developed biliary stricture. Seven of 13 patients who had been treated by nasobiliary drainage developed biliary strictures. There were no mortalities due to procedure. CONCLUSIONS: ERCP is an effective and safe method for diagnosis and management of bile leakages after cholecystectomy. Stricture development in the main bile duct leakages was an important complication.     

A Case of Post-Laparoscopic Cholecystectomy Bile Leakage from the Cystic Duct Treated by Endoscopic Nasobiliary Drainage without EST

Abstract: The patient was a 45 year old female with cholelithiasis who had undergone laparoscopic cholecystectomy. Bile leakage was detected from the site of Penrose drain insertion immediately after the operation. As no improvement of bile leakage was subsequently observed, ERCP (endoscopic retrograde cholangiopancreatography) was performed on the third postoperative day. Neither choledocholithiasis nor choledochal stricture was found and the diagnosis of bile leakage from the cystic duct stump was made. A 5Fr ENBD (endoscopic nasobiliary drainage)-tube without EST (endoscopic sphincterotomy) was inserted into the common bile duct, and bile leakage disappeared completely on the third day after insertion of the ENBD tube. Additional laparotomy, EST or biliary stenting was thereby avoided. Choledo-chography, via the ENBD-tube, showed no leakage of contrast material, the ENBD-tube was removed and the patient was discharged. ENBD should be considered as a method of treatment for management of bile leaks from the cystic duct stump.     

Endoscopic therapy for bile leak based on a new classification: results in 207 patients

BACKGROUND: Bile leak is among the most common complications of cholecystectomy. Endoscopic therapy is empiric; a systematic approach to management of bile leak has not been established. METHODS: The severity of bile leak was classified by endoscopic retrograde cholangiography into low grade (leak identified only after intrahepatic opacification) or high grade (leak observed before intrahepatic opacification). Therapy was based on this distinction: biliary sphincterotomy alone for low-grade leaks and stent placement for high-grade leaks. The success of this strategy in consecutive patients treated between 1989 and 1999 was reviewed. RESULTS: A total of 207 patients (127 women, 80 men; median age 57 years) with bile leak were referred for endoscopic management; 134 had undergone laparoscopic, and 72 had open cholecystectomy. Patients presented at a median of 9 days (range 1-50 days) after surgery. Symptoms included pain (56%), jaundice (16%), fever (11%), and abdominal distension (7%). Persistent percutaneous drainage was present in 48%. Endoscopic retrograde cholangiography identified the leak site in 204 patients: cystic duct stump, 159 patients (78%); duct of Luschka, 26 (13%); other, 19 (9%). Of 104 patients with low-grade leaks, 75 had sphincterotomy alone; improvement occurred in 68 patients (91%). Subsequent treatment was required in 7 patients (6 stent, 1 surgery). Stents were placed in the remaining 29/104 patients for the following reasons: biliary stricture (11/29); coagulopathy, precluding sphincterotomy (8/29); severe sepsis (3/29); inadequate drainage after prior sphincterotomy (2/29); and unclear reasons (5/29). Of 100 patients with high-grade leaks, 97 had stent placement. Persistent leakage necessitated another stent insertion in 4 patients. Closure of the leak was documented by endoscopic retrograde cholangiography in all 97 patients. Three patients with leaks not amenable to endoscopic treatment were referred for surgery. Bile-duct stones were identified in 41 patients (28, low-grade group; 13, high-grade group) and were extracted in all cases. Overall, complications occurred in 3 patients (2 pancreatitis, 1 perforation) and were managed conservatively with no mortality. CONCLUSIONS: A simple, practical endoscopic classification system for bile leak after cholecystectomy is proposed. This classification has clinical relevance for selection of optimal endoscopic management.     

Endoscopic nasobiliary drainage for treating bile leak after laparoscopic cholecystectomy.

BACKGROUND/AIMS: Bile leaks are common complications of laparoscopic cholecystectomy. We evaluated the diagnosis and endoscopic treatment of bile leaks. METHODOLOGY: A total of 436 patients underwent laparoscopic cholecystectomy with infrahepatic drainage. We performed immediate endoscopic retrograde cholangiopancreatography (ERCP) on all patients with bile discharge from an infrahepatic drain, and treated bile leaks which were not due to a major ductal injury by endoscopic nasobiliary drainage (ENBD) without endoscopic sphincterotomy (ES). RESULTS: Ten patients developed bile leaks which were recognized within 18 hours of operation. ERCP, on post-operative day 1 or 2, showed a bile leak from the cystic duct (9 patients) or the liver bed (1 patient). All patients underwent ENBD. Only 1 patient, who had a retained stone, had ES. In all patients, the bile leak resolved promptly and both the infrahepatic and nasobiliary drains were removed within 6 days of cholecystectomy. All patients were asymptomatic at a mean follow-up of 30 months. CONCLUSIONS: Routine placement of an infrahepatic drain is recommended for the early detection of bile leaks. Bile leaks can be successfully treated by prompt ENBD without ES.     

Postsurgical Bile Leaks: Endoscopic Obliteration of the Transpapillary Pressure Gradient is Enough

Objectives: Bile leaks are a well documented complication of biliary surgery, occurring more frequently with laparoscopic procedures. Endoscopic therapy with a long biliary endoprosthesis traversing the site of the leak is effective. We have evaluated the hypothesis that equalizing biliary and duodenal pressures with a short trans-papillary stent in is an equally effective therapy for bile leaks.
Methods: Thirty one consecutive patients presenting over a 52-month period with postsurgical bile leaks were evaluated. Patients had been treated with long endoprostheses (stents or nasobiliary tubes), sphincterotomy, or short transpapillary stents. The success, complication rate, need for additional therapy, and hospitalization time of each therapeutic approach werc determined.
Results: Endoscopic therapy was successful in all 25 patients in whom a bile leak could be documented. The clinical success, need for radiological drainage, length of hospitalization, and incidence of pancreatitis were similar for all methods of treatment.
Conclusions: These results confirm that endoscopic therapy is highly successful in the treatment of postoperative bile leaks and suggest that the mechanism of healing is the equalization of bile duct and duodenal pressures, allowing flow of bile into the duodenum. The endoscopic placement of short transpapillary stents without sphincterolomy is a temporary, effective, and technically simple method of pressure equalization. This should be considered as the primary therapy for most postoperative bile leaks.     

Endoscopic management of bile leaks after blunt abdominal trauma

Background and Study Aims:  Endoscopic retrograde cholangiopancreaticography (ERCP) has been found to be useful for the diagnosis and treatment of post-traumatic bile leaks, but data on outcome after therapeutic ERCP is limited. We performed a prospective study on evaluation of ERCP for diagnosis and treatment of bile leaks following blunt abdominal trauma.
Patients and Methods:  Ten patients of bile leaks following blunt abdominal trauma were evaluated for modes of injury, clinical presentations, investigations, ERCP findings, modes of therapy and outcome. The time interval between trauma and ERCP, ERCP and healing of bile leak and complications of ERCP were also recorded.
Results:  Ten patients (age 21.9 ± 14.5 years, 6 males) presented 24.6 ± 17.1 days following trauma. The modes of injury were motor vehicle accident ( n  = 6), and fall from height ( n  = 4). The ERCP revealed bile leak from the right hepatic duct ( n  = 7), both right and left hepatic ducts ( n  = 1), mid-common bile duct ( n  = 1), and peripheral branches of right hepatic duct ( n  = 1). Procedures for ERCP included endoscopic sphincterotomy (ES) with stenting in nine patients and ES with nasobiliary drainage in one patient. Bile leak resolved in all the patients in 8.5 ± 8.2 days. Biliary stents and the nasobiliary drain were removed after 36.4 ± 16.2 days of their insertion and all the patients remain asymptomatic for follow up of 33 ± 20.8 months.
Conclusions:  Therapeutic ERCP procedures like endoscopic sphincterotomy with stenting or nasobiliary drainage are effective in management of bile leaks following blunt abdominal trauma.     

ENDOSCOPIC SPHINCTEROTOMY ALONE IN THE MANAGEMENT OF LOW‐GRADE BILIARY LEAKS DUE TO CHOLECYSTECTOMY

Aim: Endoscopic retrograde cholangiopancreatography (ERCP) is important in the diagnosis and management of postoperative bile leaks. Endoscopic sphincterotomy (ES) alone, ES with stent or nasobiliary drain (NBD) placement and stent or NBD without ES are the methods of choice. In the present study, we aimed to show the efficacy of ES alone in the management of low‐grade (LGL) cystic duct stump (CDS) leaks due to cholecystectomy. Methods: Between September 2005 and January 2008, ES was carried out on 31 patients with LGL from the CDS due to cholecystectomy who were referred to the endoscopy unit of Izmir Ataturk Training and Research Hospital. Biliary leakage was detected by biliary discharge from a tube drain inserted during the operation. In cases of retaining common bile duct stones, balloon extraction was carried out. If bile discharge continued, a stent was introduced for cessation of the leak as a second procedure. Results: The success rate of ES alone was 87.1% (27 of 31 patients). In four patients (12.9%), ES alone was inadequate, therefore a stent was placed. The biliary leak ceased gradually and stopped in all patients at a mean of 11 (7–21) days. Balloon extraction of retained stones was carried out in six patients (19.6%). In two (6.5%) patients, mild hemorrhage and in two patients self‐limited pancreatitis was seen (6.5%) as complications. Conclusion: Endoscopic retrograde cholangiopancreatography is essential in the management of postoperative biliary leaks. Endoscopic sphincterotomy alone can be the initial procedure in the treatment of LGL from the CDS due to cholecystectomy.     

Sphincterotomy in patients with gallstones, elevated LFTs and a normal CBD on ERCP

BACKGROUND/AIMS: To determine whether an endoscopic sphincterotomy affects outcome in patients with symptomatic gallstones, elevated liver function tests and a normal common bile duct on endoscopic retrograde cholangiopancreatogram. METHODOLOGY: A total of 163 patients with symptomatic gallstones and elevated liver function tests, and found to have a normal common bile duct on endoscopic retrograde cholangiopancreatogram were included in the study. Endoscopic sphincterotomy was performed in 78 (47.8%) patients, while 85 (52.1%) patients did not have an endoscopic sphincterotomy. The two groups were compared for detection of small unseen common bile duct stones/debris, endoscopic retrograde cholangiopancreatogram related complications, and biliary complications after cholecystectomy. RESULTS: Small common bile duct stones/debris were recovered in 11/43 (25.5%) patients who had instrumentation of the common bile duct performed after endoscopic sphincterotomy. Common bile duct instrumentation was not performed in any of the patients without endoscopic sphincterotomy. No patient had any biliary complication after cholecystectomy, both in the immediate postoperative period and on a follow-up of 37.5 +/- 13.6 months (range 17-66). Endoscopic retrograde cholangiopancreatogram related complications occurred in 8 patients who had an endoscopic sphincterotomy and in 2 without endoscopic sphincterotomy (p < 0.05). CONCLUSIONS: Performing an endoscopic sphincterotomy in these patients increases the detection of small unseen common bile duct stones/debris without changing the clinical outcome after cholecystectomy. It also increases the endoscopic retrograde cholangiopancreatogram related complication rate, and therefore may not be necessary.     

内镜下逆行胰胆管造影术治疗老年胆总管巨大结石40例

目的探讨内镜下逆行胰胆管造影术(ERCP)治疗老年胆总管巨大结石的可行性及安全性。方法 40例老年胆总管巨大结石患者完善术前准备,密切监护下经十二指肠镜先行ERCP,发现胆总管结石后行内镜下十二指肠乳头括约肌切开(EST)和机械碎石(EML)取石,视具体情况留置鼻胆管引流及支架置入引流。结果 40例患者37例取石获得成功,成功率92.5%;其中10例经过二次取石。所有患者腹痛症状明显改善,皮肤巩膜黄染迅速消褪,发热患者48 h内体温趋于正常。术后并发轻型胰腺炎4例,乳头肌切口创面轻度渗血2例,均经内科保守治疗痊愈,未发生肠穿孔、胆道撕脱等严重并发症和死亡。结论 ERCP治疗老年胆总管巨大结石是一种安全、有效的治疗方法,应考虑作为治疗的首选方案。     

Endoscopic biliary stenting for treatment of persistent biliary fistula after blunt hepatic injury

BACKGROUND: Surgical treatment for persistent biliary fistula after blunt hepatic injury is often technically difficult. Endoscopic treatment for such fistulas has been described only infrequently. METHODS: We reviewed 6 patients who underwent endoscopic biliary stent placement with (n = 1) or without (n = 5) sphincterotomy for persistent (12 to 138 days; mean 48 days) biliary fistula after blunt hepatic injury. RESULTS: ERCP showed bile leakage from a second-order or more peripheral branch of the intrahepatic bile ducts in 5 patients but failed to reveal the fistula in 1. Stent placement was successful without complications in all patients. Bile leakage resolved within 1 to 3 days in 5 patients. After 36 to 86 days, the stent was removed and ERCP confirmed disappearance of the fistula. These patients have remained asymptomatic for a mean of 2.6 years since stent removal. In the patient in whom ERCP had not shown a fistula, bile leakage continued despite successful stent placement. CONCLUSIONS: Endoscopic biliary stent placement is a rapid, safe and effective treatment for persistent post-traumatic biliary fistula demonstrated by ERCP.     

The role of endoscopy in noniatrogenic injuries of the liver

Traumatic noniatrogenic biliary injuries, unlike iatrogenic injuries, are usually complex in nature and are frequently associated with other multiorgan trauma and infection. Bile leaks following these injuries are an important source of short-and long-term morbidity. Repeat surgery for primary repair of complex bile leaks is difficult and can be complicated by anastomotic leakage and biliary stricture formation. Endoscopic retrograde cholangiopancreatography (ERCP) was initially used only as a diagnostic technique to guide surgical repair in this setting. However, with the high success rates observed in treatment of iatrogenic bile leaks, ERCP has emerged as a nonoperative treatment option for noniatrogenic biliary leaks as well. Recent data show that ERCP is effective in managing bile leaks after blunt and sharp liver injuries, using transpapillary stenting, endoscopic sphincterotomy, or both, with greater than 80% healing rates. The evidence is not clear regarding which ERCP maneuver—endoscopic sphincterotomy, transpapillary stenting, or both—should be used.     

The role of ERCP in diagnosis and management of accessory bile duct leaks after cholecystectomy.

BACKGROUND: Endoscopic retrograde cholangiopancreatography (ERCP) plays an important role in the management of bile leaks after cholecystectomy. Although most leaks occur from the cystic duct stump, clinically significant leakage from accessory bile ducts is less common and has not been investigated systematically. We report our experience with endoscopic diagnosis and treatment of accessory bile duct leaks after cholecystectomy. METHODS: Patients with accessory bile duct leaks were identified from a computerized database. Hospital charts and cholangiograms were reviewed to determine the outcome of diagnostic and therapeutic interventions. RESULTS: Of 86 patients with postcholecystectomy leaks, 15 (17%) were diagnosed with accessory bile duct leaks. ERCP established the diagnosis of accessory bile duct leaks in 11 of 15 patients (73%); percutaneous fistulography (2) and percutaneous transhepatic cholangiography (2) were diagnostic in 4 patients. Endoscopic therapy led to resolution of the leak in 12 patients. One patient underwent successful percutaneous biliary drainage, and two patients required surgical repair. CONCLUSIONS: Accessory bile ducts are rare sites of significant bile leakage after cholecystectomy. ERCP identifies the leak in the majority of patients; percutaneous fistulography or percutaneous transhepatic cholangiography may help clarify the diagnosis if ERCP is nondiagnostic. Most patients can be successfully treated with endoscopic stenting. If endoscopic therapy fails, percutaneous drainage or surgical repair needs to be considered.     

The management of bile duct stones.

Bile duct stones are almost always associated with gallbladder stones and coexist with gallbladder stones in approximately 10% of patients. The frequency of coexisting bile duct stones increases with advancing age. In patients with stones in both the gallbladder and bile duct, therapeutic options for the latter include laparoscopic or open exploration of the bile duct, and pre-operative and post-operative endoscopic sphincterotomy and stone extraction. Endoscopic sphincterotomy remains the treatment of choice for bile duct stones after cholecystectomy. However, management algorithms in individual institutions will be influenced by surgical and endoscopic expertise and by other factors such as overall costs. After surgical or endoscopic removal of bile duct stones, estimates of the lifetime risk of recurrent stones range from 5%-20%. Increased life expectancy and the apparent absence of simple preventative measures indicate that the burden of bile duct stones on health expenditure is likely to increase in many countries.     

Endoscopic Management of Bile Leakage after Liver Transplantation

Background/Aims

Endoscopic retrograde cholangiopancreatography (ERCP) can be an effective treatment for bile leakage after liver transplantation. We evaluated the efficacy of endoscopic treatment in liver transplantation in patients who developed bile leaks.

Methods

Forty-two patients who developed bile leaks after liver transplantation were included in the study. If a bile leak was observed on ERCP, a sphincterotomy was performed, and a nasobiliary catheter was then inserted. If a bile leak was accompanied by a bile duct stricture, either the stricture was dilated with balloons, followed by nasobiliary catheter insertion across the bile duct stricture, or endoscopic retrograde biliary drainage was performed.

Results

In the bile leakage alone group (22 patients), endoscopic treatment was technically successful in 19 (86.4%) and clinically successful in 17 (77.3%) cases. Among the 20 patients with bile leaks with bile duct strictures, endoscopic treatment was technically successful in 13 (65.0%) and clinically successful in 10 (50.0%) cases. Among the 42 patients who underwent ERCP, technical success was achieved in 32 (76.2%) cases and clinical success was achieved in 27 (64.3%) cases.

Conclusions

ERCP is an effective and safe therapeutic modality for bile leaks after liver transplantation. ERCP should be considered as an initial therapeutic modality in post-liver transplantation patients.