ERCP in the management of biliary complications after cholecystectomy

Bile Leakage From the Luschka Duct After Laparoscopic Sleeve Gastrectomy and Cholecystectomy: A Case Report

Bile leakage may develop as a result of traumatic or iatrogenic injuries of bile ducts during laparoscopic cholecystectomy (LC). The frequency of Luschka duct injuries during LC is extremely rare. In this case, we present a case of bile leakage due to Luschka duct injury during sleeve gastrectomy (SG) and LC. The leakage was not noticed during the surgery, and on postoperative day 2, bilious drainage was seen from the drain. Magnetic resonance imaging (MRI) was helpful to determine Luschka duct injury. Biliary leakage resolved after endoscopic retrograde cholangiopancreatography (ERCP) with stent placement.

Experience of endoscopic retrograde cholangiopancreatography with side-viewing duodenoscope in patients with previous gastric surgery

OBJECTIVES

Endoscopic Retrograde Cholangiopancreatography (ERCP) with conventional side-viewing duodenoscope can be challenging and unsuccessful at altered anatomy in the gastrointestinal tract. This study aimed to evaluate our experience with ERCP in patients with previous gastric surgery.

MATERIAL AND METHODS

Patients on whom ERCP was performed from January 2017 to August 2021 and who had previous gastric surgery were included into the study. Age, sex, comorbidity, Charlson's Comorbidity Index (CCI), ERCP indication, previous gastric surgery (indication, type of resection and reconstruction), history of cholecystectomy, and MRCP results were evaluated retrospectively. The results were compared as successful ERCP (SERCP) or unsuccessful ERCP (USERCP). Also, odds ratio ERCP failure was also evaluated.

RESULTS

Forty-three patients were included into study. Mean age was 68.8 ± 13.6 years. The most common sex was female (51.2%). The most common ERCP indication was choledocholithiasis with 44.2%, gastric surgery indication was peptic ulcer with 72.1%, gastric resection was subtotal with 67.4%, and reconstruction was gastrojejunostomy with 58.1%. The success rate of ERCP was 44.2%. Mean CCI was 4.16 ± 2.28. Only malignancy history was significantly higher in the USERCP group (p= 0.026). Male sex, non-choledocholithiasis indication, history of malignancy, CCI> 4, total gastrectomy, Roux-NY (RNY) reconstruction, history of cholecystectomy, and intercalarily to the bile duct dilatation in MRCP were likelihood for USERCP.

CONCLUSION

While history of malignancy and cholecystectomy were the only significant factor for unsuccessful ERCP, male sex, total gastrectomy, RNY anastomosis result in a higher likelihood of ERCP failure in patients with previous gastric surgery. Alternative devices to side-viewing duodenoscope will increase success in selected patients.

Impact of laparoscopic cholecystectomy on the complexity of endoscopic retrograde cholangiopancreatography

BACKGROUND AND OBJECTIVES

A scarce number of researches discussed the impact of cholecystectomies on the anatomy of common bile duct (CBD) and intern if this will affect the difficulty of endoscopic retrograde cholangiopancreatography (ERCP). The objective of present study was to assess the impact of complicated cholecystectomy on the complexity and safety of the ERCP procedure.

STUDY DESIGN

A total of 100 patients were enrolled after meeting the following inclusion criteria - study group (group A): 50 patients with previous history of complicated laparoscopic cholecystectomy and control group (group B): 50 patients with previous noncomplicated laparoscopic cholecystectomy. ERCP was performed and complexity was judged by a number of cannulation attempts, ERCP time, pancreatic cannulation and post-ERCP pancreatitis.

RESULTS

The study revealed prolonged ERCP procedure duration in noncomplicated cholecystectomy (24.2 ± 8.5 min) and it was significantly more prolonged in complicated cholecystectomy (39.6 ± 10.7 min; P = 0.03). The trials of cannulation attempts were significantly higher in the study group with complicated cholecystectomy (P = 0.009). Pancreatic duct cannulation was frequently higher in the complicated cholecystectomy group (P = 0.03). Difficult or failed stone extraction was significantly prevalent in the complicated cholecystectomy group and the occurrence of post-ERCP pancreatitis (PEP) was significantly higher than the control group.

CONCLUSION

ERCP after complicated laparoscopic cholecystectomy is more complex with increased duration liability of complications.

Early Surgical Repair of Bile Duct Injuries following Laparoscopic Cholecystectomy: The Sooner the Better

Background  We aimed to investigate the outcomes of the immediate surgical repair of bile duct injuries (BDIs) following laparoscopic cholecystectomy. Materials and Methods  Between January 2012 and May 2017, patients, who underwent immediate surgical repair (within 72 hours) for postcholecystectomy BDI, by the same surgical team expert in hepatobiliary surgery, were enrolled into the study. Data collection included demographics, type of BDI according to the Strasberg classification, time to diagnosis, surgical procedures, and outcome. Results  There were 13 patients with a mean age of 43 ± 12 years. Classification of BDIs were as follows: type E in six patients (46%), type D in three patients (23%), type C in two (15%), and types B and A in one patient each (7.6%). Mean time to diagnosis was 22 ± 15 hours. Surgical procedures included Roux-en-Y hepaticojejunostomy for all six patients with type-E injury, primary repair of common bile duct for three patients with type-D injury, and primary suturing of the fistula orifice was performed in two cases with type-C injury. Other two patients with type-B and -A injury underwent removal of clips which were placed on common bile duct during index operation and replacing of clips on cystic duct where stump bile leakage was observed probably due to dislodging of clips, respectively. Mean hospital stay was 6.6 ± 3 days. Morbidity with a rate of 30% ( n  = 4) was observed during a median follow-up period of 35 months (range: 6-56 months). Mortality was nil. Conclusion  Immediate surgical repair of postcholecystectomy BDIs in selected patients leads to promising outcome.

Percutaneous management of benign biliary disorders in children

PURPOSE

The goal of this study was to analyze the outcomes of percutaneous transhepatic management of benign biliary disorders in pediatric patients.

MATERIALS AND METHODS

This study included 11 pediatric patients who underwent percutaneous transhepatic biliary interventional procedures between September 2007 and December 2016. There were 3 males and 8 females with a mean age of 9.6±5.4 (SD)years (range: 2-17years). Technical details, complications and outcome of the procedures were evaluated.

RESULTS

The underlying pathologies were bile duct stones (n=2), bile leakage (n=4), choledochal cyst (n=3) and benign biliary stricture (n=2). The therapeutic interventional procedures were as follows; percutaneous stone removal in patients with bile duct stones, external biliary drainage in patients with choledochal cyst, bile diversion by internal-external percutaneous biliary drainage (IE-PBD) in patients with bile leakage, plastic stent placement, IE-PBD with balloon dilatation in patients with benign biliary stricture. The procedures were successful in all patients technically and clinically. One patient experienced intermittent fever.

CONCLUSION

Percutaneous transhepatic biliary interventional procedure is an effective and safe approach for the treatment of pediatric patients with bile duct stones, bile leakage, symptomatic choledochal cyst and benign biliary stricture when endoscopic procedure is unavailable or fails.

A rare case of biliary leakage after laparoscopic cholecystectomy-diagnostic evaluation and nonsurgical treatment: a case report

Although laparoscopic cholecystectomy has become a gold standard in treatment of symptomatic cholelithiasis, it is associated with higher risk of intraoperative lesions and primarily lesions of biliary ducts. In small percentage of cases biliary fistulas occur, most commonly after leakage from cystic duct stump or accessory bile ducts – Luschka’s duct. We report of a patient who had episodes of abdominal pain following routine laparoscopic cholecystectomy for acute calculous gallbladder. Results of conducted diagnostics verify the presence of biliary fistula caused by obstruction of bile pathways by stagnant pus and microcalculi of common bile duct, with development of biloma presumably caused by pressure injection of contrast material during ERCP procedure. Endoscopic sphincterectomy via ERCP enabled healing of formed biliary fistula, whilst continuous percutaneous ultrasound guided drainage of biloma was method of choice in later treatment of our patient. It is important to note that diagnostic evaluation of biliary fistula is very challenging and that timely nonsurgical treatment is of great benefit for patient.

Endoscopic management of biliary leaks after laparoscopic cholecystectomy

Laparoscopic cholecystectomy has become the procedure of choice for management of symptomatic cholelithiasis. Although it has distinct advantages over open cholecystectomy, bile leak is more common. Endoscopic retrograde cholangiopancreatography is the diagnostic and therapeutic modality of choice for management of postcholecystectomy bile leaks and has a high success rate with the placement of plastic biliary stents. Repeat endoscopic retrograde cholangiopancreatography with placement of multiple plastic stents, a covered metal stent, or possibly cyanoacrylate therapy may be effective in refractory cases. This review will discuss the indications, efficacy, and complications of endoscopic therapy.

Clinical outcome of single plastic stent treatment of benign iatrogenic biliary strictures: is the outcome predetermined?

Endoscopic retrograde cholangiopancreatography (ERCP) is used for the management of benign iatrogenic biliary strictures after cholecystectomy and liver transplantation. Multiple stents can injure biliary circulation. If resolution of reversible ductal edema and/or ischemia is the mechanism for successful therapy then single stent placement for benign biliary stricture should work. Retrospectively reviewed ERCP records between November 1999 and 2012 provided 25 patients with repeat ERCPs performed at 10-week intervals or if symptoms of stent occlusion were present. If strictures did not improve between stent changes and if removal was not an option, hepaticojejunostomy was used. Strictures resolved in 72% of patients. Seven patients underwent hepaticojejunostomy. Three had ERCP-related complications. No stricture recurrence occurred during the follow-up period. Endoscopic single plastic stent treatment of benign biliary iatrogenic strictures has comparable success to multiple stenting. Many postsurgical strictures may have reversible ischemic/edematous component with stenting to maintain bile drainage.

Traumatic bile leaks from blunt liver injury in children: a multidisciplinary and minimally invasive approach to management

BACKGROUND

Selective non-operative management (NOM) of hemodynamically stable pediatric patients with blunt hepatic trauma is the standard of care. Traumatic bile leaks (TBL) are a potential complication following liver injury. The use of endoscopic retrograde cholangiopancreatography (ERCP) in the diagnosis and treatment of TBL is described in adults, but limited in the pediatric literature. We report our experience with a multidisciplinary and minimally invasive approach to the management of TBL.

METHODS

This was an IRB-approved 13-year retrospective review (January 1999-December 2012) of an institutional pediatric trauma registry; 294 patients (≤ 17 years old) sustained blunt hepatic injury. Those with TBL were identified. Patient demographics, mechanism of injury, management strategy and outcomes were reviewed.

RESULTS

Eleven patients were identified with TBL. Hepatobiliary iminodiacetic scan (HIDA) was diagnostic. Combinations of peri-hepatic drain placement, ERCP with biliary stenting and/or sphincterotomy were performed with successful resolution of TBL in all cases. No child required surgical repair or reconstruction of the leak. Cholangitis developed in one child. There were no long-term complications.

CONCLUSIONS

A multidisciplinary and minimally invasive approach employing peri-hepatic external drainage catheters and ERCP with sphincterotomy and stenting of the ampulla is a safe and effective management strategy for TBL in children.

Placement of a new fully covered self-expanding metal stent for postoperative biliary strictures and leaks not responding to plastic stenting. Surg Laparosc Endosc Percutan Tech. 2013;23:159-162. [PMID: 23579510 DOI: 10.1097/sle.0b013e318278c201]

Fully covered self-expanding metal stents (FCSEMSs) are now being used to treat postoperative biliary strictures (BSs) and biliary leaks (BLs). The aim of this study was to assess the safety and effectiveness of a new FCSEMS (Wallflex) in patients with postoperative BSs and BLs after failure of traditional endoscopic treatment. Between January 2010 and December 2011, 16 patients (10 patients with postcholecystectomy BSs, 4 with postcholecystectomy BLs, and 2 with postorthotopic liver transplantation BSs) were enrolled. The technical and clinical success rate was 100%. All FCSEMSs were removed after a mean of 141 days. Complications occurred in 7 cases: 2 postprocedure pain, 2 mild pancreatitis, 1 early distal, and 2 late proximal FCSEMS migration. The overall long-term clinical success rate was 94% after a mean follow-up of 13 months. In our experience, the placement of FCSEMSs is an effective and secure method of treating refractory postoperative BSs or BLs.

Fully covered, self-expandable metal stents for first-step endoscopic treatment of biliary leaks secondary to hepato-biliary surgery: a retrospective study

BACKGROUND

Fully covered self-expanding metal stents are now being used to treat benign biliary diseases.

AIMS

To assess the outcomes of these stents as first-step therapy in patients with biliary leaks secondary to hepato-biliary surgery.

METHODS

Thirty patients (56.7% males; mean age: 60.2 ± 13 years) were retrospectively evaluated. The data collected included technical and clinical success, adverse events and follow-up findings (1, 3 and 6 months).

RESULTS

Technical and clinical success rates were 100%. One early mild post-procedure pancreatitis occurred and resolved spontaneously. Three late stent distal migrations occurred, however cholangiography showed correct leak sealing in all patients. Stents were removed after a mean of 55.9 days. During follow-up no other complications occurred.

CONCLUSION

In our experience fully covered self-expanding metal stent placement was safe and efficacious as first-step therapy for post-operative biliary leaks. However, prospective comparative studies with plastic stents are required to validate these findings.

Safety and efficacy of therapeutic endoscopic interventions in the management of biliary leak

Endoscopic procedures which reduce the trans-papillary pressure gradient are the treatment of choice for management of biliary leaks. We analyzed the data of 102 patients with biliary leak managed by various endoscopic procedures like endoscopic sphincterotomy (ES), ES with stenting, stenting alone or nasobiliary drainage (NBD) alone; 90 of these patients had developed a leak after cholecystectomy. In the post-cholecystectomy group, cannulation was successful in 79 patients; therapeutic intervention was not possible in 14 of them due to complete transection of common bile duct in 6, and leak proximal to ligature in 8. In the remaining 65 patients, ES with stenting was done in 52, stent alone in 6, ES alone in 5 and NBD alone in 2. All 12 patients in other etiology group were treated with ES plus stenting. The leak closed in a mean of 3 (1-10) days in all patients. Stents were removed after 6-8 weeks. Endoscopic procedures are effective in managing biliary leaks.

Surgical control of life-threatening post-ERCP bleeding with a gelatin matrix-thrombin hemostatic agent

INTRODUCTION

Several conventional techniques have been developed in order to control surgical bleeding. Their greatest disadvantage, though, is their inability to control bleeding in areas where access is very difficult. In such cases the application of topical hemostatic agents may prove particularly useful.

PRESENTATION OF CASE

We describe the case of an 82-year old patient with life-threatening post-ERCP bleeding which was intraoperatively controlled with infusion of a topical gelatin matrix-thrombin hemostatic agent into the distal portion of the common bile duct.

DISCUSSION

Most iatrogenic cases of post-ERCP bleeding occur at the site of sphincterotomy at the level of the ampulla of Vater and may be relatively easily controlled by repeat endoscopy and local hemostatic measures. More rarely, however, significant and difficult to control bleeding may occur within the lower portion of the common bile duct (CBD) where routine hemostatic techniques may prove unsuccessful. Under these circumstances, we successfully employed a novel hemostatic technique using a gelatin matrix-thrombin agent in a patient with life-threatening bleeding after ERCP.

CONCLUSION

This novel technique might prove particularly useful for bleeding control in surgically challenging anatomical areas such as the lower portion of the CBD.

Assessment of need for repeat ERCP during biliary stent removal after clinical resolution of postcholecystectomy bile leak

OBJECTIVES

In patients who have undergone endoscopic retrograde cholangiopancreatography (ERCP) with biliary stent placement for postcholecystectomy bile leak there is limited evidence to support the repeat ERCP at the time of stent removal. Esophagogastroduodenoscopy (EGD) with biliary stent removal may suffice. The aim of this study was to describe the clinical course of patients who underwent biliary stent placement for a postcholecystectomy bile leak and determine whether repeat ERCP is necessary.

METHODS

We identified all adult patients who underwent biliary stent placement for postcholecystectomy bile leak from 1 January 1996 to 31 October 2008. Demographic data, cholecystectomy details, and procedural data were collected, specifically focusing on closure of the bile leak. Time to resolution of leak was calculated, up to either the date of the first repeat ERCP that demonstrated no persistent leak or the date of removal of any radiologically placed percutaneous drain, whichever came first.

RESULTS

Sixty-four patients underwent repeat ERCP with biliary stent removal. The median time to repeat ERCP was 36 days (interquartile range (IQR) 26-48). Fifty-seven (89%) patients had resolved the leak by time of repeat ERCP. Of those in whom the leak had not resolved, 6 had a repeat exam within 14 days of stent placement; 4 of these resolved the leak by day 39. There were no procedure-related complications in the ERCP group. Thirteen patients underwent EGD with stent removal after a median of 29 days (IQR 23-38). None had adverse events, with a median follow-up of 38 months. Overall, the median time to resolution of biliary leak was 33 days (IQR 22-44). Importantly, repeat ERCP altered the management in only one patient in whom bile duct stones were found.

CONCLUSIONS

Patients with uncomplicated postcholecystectomy bile leak who have clinically resolved their leak do not require cholangiography at the time of stent removal. In these patients, EGD with stent removal at 4-6 weeks seems to be sufficient and significantly less expensive.