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.