Endoscopic management of bile leaks after laparoscopic cholecystectomy

VoL7, No 3, July - September 1998

Endoscopic managementfor biliary

leaks

l6l

Endoscopic management of bile leaks after laparoscopic cholecystectomy
L.A. Lesmana

Abstrak
Kebocoran empedu didapatkan pada sebelas clari 16
Kebocoran terjadi di duktus sistikus pada 9 pasien dan di duktus
metode endoskopi. Terapi endoskopik meLiputi pemasangan stent

P
k

obilier untuk drainase pada 3 pasien.
4 prosedur tersebut. Endoskopi terape

p

Abstract
c

t inj urie s fo I low in g raparo

sc

op

ic c ho re cy s te c to my. Le ak o c c ur re d
by various endoscopic methods.
nts, and insertion of nasobiliary
significant compLications of the

Keywords : Endoscopic therapy - biliary reaks - Iaparoscopic chorecystectomy

INTRODUCTION

We report herein our experience in dealing with endo_
scopic management of biliary leaks following LC.

PATIENTS AND METHODS
From January 1993 to December

I99l

data of sixteen

return to work.

However, biliary complications after LC, noticeable
bile duct leaks, is reported from O.3Vo to 3.0Vo com_

ERCP was performed
technique under
intravenous sedation
cope (Olympus,

Japan) type JF IT 20,
me inrerval from
,g
the ERCP procedure, clinical symptoms, and
lC
liver functions were noted.
Several studies have shown the effectiveness of endo_
scopic sphincterotomy alone or in combination with

stent placement or insertion of nasobiliarv tube

drainage in healing biliary leaks.8-14

, Department of Medicine, Faculty of
Indonesia, Dr. Cipto Mangunkusumo
nesia

Diagnosis of bile Ieaks was made at ERCP demonsrrat_
ing contrast extravasation from the biliary tract. Endo_
scopic techniques to resolve the biliary lèaks included

stent placement alone or in combination with endo_
or insertion of nasobiliary
as only performed if canduct could not be achieved
with a standard diagnostic catheter. There was no cer_

162

Lesmana

Med J Indones

tain criteria in selecting the method of endoscopic

Table 2. Therapeutic ERCP interventions

interventions. A 7 Fr endoprosthesis was placed above
the site of leak in all stented patients.

Endoscopic procedure

In

general, the stent was removed after four to six
weeks of placement without control cholangiogram
except in one patient with big leak at the common bile
duct. A tube cholangiography was performed after two
weeks of insertion in patients with NBT drainage.

Stenting alone
Stent placement and sphincterotomy
Insertion of nasobiliary tube
Total

in

N

11 patients
Vn

3

46
27
27

1l

t00

5

J

Ultrasound using real time scanner (Toshiba SSA2701' Japan) and spiral CT-Scan of the abdomen
(Siemens Somatom+4, Germany) were carried out in
five and one patients respectively to evaluate the
presence of biloma.
RESULTS

Over the study period, bile leaks were detected in
eleven of l6 patients with biliary complications related
to LC. In the other five patients stricture of the common
hepatic duct was obtained in two and total duct obstruction in the remaining three patients. Diagnostic ERCP

findings of these 16 patients were shown in table
Table

l.

l.

Diagnostic ERCP findings in l6 patients with biliary
complications related to LC

q

Bile duct injury

Biliary leaks

Stricture of common hepatic duct
Total duct obstruction
Total

11

69

2

12

J

l9

16

100

Figure l. Endoscopic retograde cholangiogram in apatient
with cystic duct leak shows extravasation of contrast into
peritoneal cavity that responded to stent placement

The group study consisted of eleven patients; eight
males and three females with an average age of 46
years (range 26 to 10 years). The mean interval of LC
to the ERCP procedure was 6.3 days (range 3 to 12
days). The most common presenting symptom was
abdominal pain found in 10 of I I patients (9lVo),fever
in 7 patients and jaundice in 2 patients.
During ERCP, biliary leaks were demonstrated in all
patients. Cystic duct leak was detected in 9 patients
whereas leak at the common bile duct in the other 2
patients. Therapeutic ERCP interventions were successful in all these I I patients (table 2). Stent placement alone was performed in five of 1 I patients (figure
l), ES with bilio-endoprostheses in three patients, and

insertion of NBT drainage

in the remaining

three

patients (figure 2). In one patient with big leak at the

common bile duct (CBD) the stent placement was
extended up to 8 weeks because control cholangiography after 4 weeks still shqwed extravazation of small
amount of contrast.

F i gure

g io gram afte r lap aro s c opic c ho Ie cy s t ec t omy
biliary leak (arrow) that successfully teated by

2. Cho lan

demonstrates

insertion of nasobiliary tube drainage

Vol 7, No 3, JulS, - Septenùer 1998

Endos

Additional duct fïndings at ERCP were stones in the
CBD in five parients which being extracted wrth a
dormia basket at the same session of stent or NBT
removal. Complications of endoscopic therapy oc_
curred in three patients. Bleeding after ES occurrecl in
two patients with CBD stones which could be managed
conservatively and stent migration into the colon was
detected in the remaining one patient. The stent came
ouI spontaneously with the stool.

C
ie
la

performed in

c

op

ic nlana

g

e

nrc nt fo

r

b i Lia

ry leaks

r63

and NBT decompression, are effective methods tbr
healing post LC biliary leaks.8-la

The presumed beneflt of endoscopic therapy is tlre
of sphinter Oddi pressure. The clecrease
resistance across the ampula therefbre cliverts bilc
flow into the duodenum and away fiom the site ol'
injured bile duct. Although reducrion of ampLrllary
pressure is widely accepted as an impor[ant factr_rr in
resolving biliary leaks, the best endoscopic nrethocl to
achieve this has not been well studied.
reduction

the presence

vity and sub-

Some experts have claimed that

NBT clrainagc

has

some potential advantages compared to stenting.l3.l9

First, NBT provides maximal and direct bile

cluct

DISCUSSION
The reasons for ductal injury at LC include variation
anatomy, technically difficult dissection due to severe

patients). Stent placement is more convenient for
patients and enable them to return to their activity
faster compared to those who are receiving NBT.
occurs when loose clips dislodge or the cystic duct

remnant necroses. Our study confirms that most of the

Pain, which was detected inglVo of patients, was the
môst common symptom at clinical presentation consis_
tent with biliary peritonitis. The mean inrerval of LC
dure in our
er than that
t.e'13 Thi, d
hr be parrly
e lack of the
facilities in
our country.

Some
useful
a nega
While

hat cho
s

afterl

le out

is

a

not

institution, ERCP demonstrated the presence of bile
in l)OVo patients in our series.

leaks

Therefore, we
directly to the
Iowing LC, as

on to perform ERCP
specteà bile leaks fol_
e.r.l l'18

Our results also support the other findings that

therapeutic ERCP procedures, such as stent placement

Ste
the
t2'I
be
On
we

have also been reported

f

as

in other series.lorecent studles,dJ? ,r.n,.on
choice

for 4 to 6 weeks in most of the patients.
nt in our series required stenting fbr g
of big leak ar rhe CBD.

In conclusion, both stent placement ancl nasobiliary
tube drainage are safe and effective encloscopic
therapy for bile leaks following Iaparoscopic cholecys_
tectomy.

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