Management of patients who return to the hospital with a bile leak after laparoscopic cholecystectomy

Risk factors for complications after cholecystectomy for common bile duct stones: An EAST multicenter study

BACKGROUND

We sought to prospectively identify risk factors for biliary complications and 30-day readmission after cholecystectomy for choledocholithiasis and gallstone pancreatitis across multiple US hospitals.

METHODS

We performed a prospective, observational study of patients who underwent same admission cholecystectomy for choledocholithiasis and gallstone pancreatitis between 2016 and 2019 at 12 US centers. Patients with prior history of endoscopic retrograde cholangiopancreatography or diagnosis of cholangitis were excluded. We used logistic regression to determine associations between preoperative demographics, labs, and imaging on primary outcomes: postoperative biliary complications and 30-day readmission.

RESULTS

There were 989 patients in the cohort. There were 16 (1.6%) patients with postoperative biliary complications, including intra-abdominal abscesses, endoscopic retrograde cholangiopancreatography-induced pancreatitis, and biliary leaks. Increasing operative time (odds ratio 1.01, 95% confidence interval 1.00-1.01, P = .02), worsening leukocytosis (odds ratio 1.16, 95% confidence interval 1.07-1.25, P = .0002), and jaundice (odds ratio 3.25, 95% confidence interval 1.01-10.42, P = .04) were associated with postoperative biliary complications. There were 36 (3.6%) patients readmitted within 30 days owing to a surgical complication. A prior postoperative biliary complication (odds ratio 7.8, 95% confidence interval 1.63-37.27, P = .01), male sex (odds ratio 2.42, 95% confidence interval 1.2-4.87, P = .01), and index operative duration (odds ratio 1.01, 95% confidence interval 1.00-1.01, P = .03) were associated with 30-day readmission.

CONCLUSION

Among patients undergoing cholecystectomy for common bile duct stones, jaundice, worsening leukocytosis, and longer operations are associated with postoperative biliary complications. A prior biliary complication is also predictive of a 30-day readmission. Surgeons should recognize these factors and avoid prematurely discharging at-risk patients given their propensity to develop complications and require readmission.

Current Scenario of Postcholecystectomy Bile Leak and Bile Duct Injury at a Tertiary Care Referral Centre of Nepal

Objective

With the adoption of safe cholecystectomy principles at an academic institute, the risk of major bile duct injury has decreased. This study aims at evaluating the present status of bile duct injury, compared to the study published in 2013 by index centre.

Methods

This is a retrospective review of a prospectively maintained database of bile leak and bile duct injury from 2014 to 2019. Patients who completed postcholecystectomy bile leak or bile duct injury treatment and were on regular follow-up were included.

Results

Eighteen patients (0.78%) among 2,300 consecutive cholecystectomies presented with bile duct injury, including 8 (0.35%) major bile duct injuries and 10 (0.43%) bile leaks compared to major bile duct injury rate of 0.68% (92/11,345 cholecystectomies) between 2001 and 2010. Injuries were classified as Strasberg's type A (52.9%), type D (5.9%), and type E (41.1%). Eight patients (47%) of bile leak were managed conservatively with drains, while two required laparotomy and lavage. The mean time for spontaneous closure of bile leak was 11 days. Intraoperative repair was done in three cases: Roux en Y hepaticojejunostomy in 2 and end-to-end repair over T-tube in 1 for sharp transection of the duct. Delayed repair (Roux-en-Y hepaticojejunostomy) was done in five patients. The median postcholecystectomy hospital stay was 8 days, with no mortality. There was no restricture at a median follow-up of 13 months.

Conclusion

With the adoption of a safe culture of cholecystectomy, the major bile duct injury rate has decreased currently. Repair of bile duct injury by experienced hepatobiliary surgeon results in excellent outcome.

ATOM Classification of Bile Duct Injuries During Laparoscopic Cholecystectomy: Analysis of a Single Institution Experience

PURPOSE

Bile duct injuries (BDIs) are more frequent during laparoscopic cholecystectomy (LC). Several BDI classifications are reported, but none encompasses anatomy of damage and vascular injury (A), timing of detection (To), and mechanism of damage (M). Aim was to apply the ATOM classification to a series of patients referred for BDI management after LC.

METHODS

From 2008 to 2016, 26 patients (16 males and 10 females, median age 63 years, range 34-82 years) with BDIs were observed. Fifteen patients were managed by percutaneous transhepatic cholangiography (PTC)+endoscopic retrograde cholangiopancreatography (ERCP); five and six underwent PTC and ERCP alone, respectively. Median overall follow-up duration was 34 months. Three patients died from sepsis.

RESULTS

Out of 26 patients, 20 presented with main bile duct and six with nonmain bile duct injuries. Using the ATOM classification, every aspect of the BDI in every case was included, unlike with other classifications (Neuhaus, Lau, Strasberg, Bergman, and Hanover).

CONCLUSIONS

The all-inclusive European Association for Endoscopic Surgery (EAES) classification contains objective data and emphasizes the underlying mechanisms of damage, which is relevant for prevention. It also integrates vascular injury, necessary for ultimate management, and timing of discovery, which has diagnostic implications. The management complexity of these patients requires specialized referral centers.

Endoscopic management of bile leakage after cholecystectomy: a single-center experience for 12 years

BACKGROUND/AIMS

Bile leakage is an uncommon but serious complication of cholecystectomy. The aim of this study is to evaluate the efficacy of the endoscopic management of bile leakage after cholecystectomy.

METHODS

A total of 32 patients who underwent endoscopic retrograde cholangiopancreatography (ERCP), because of bile leakage after cholecystectomy, from January 2000 to December 2012 were reviewed retrospectively. The clinical parameters, types of management, and procedure-related complications were documented.

RESULTS

Most bile leakages presented as percutaneous bile drainage through a Hemovac (68.8%), followed by abdominal pain (18.8%). The sites of bile leaks were the cystic duct stump in 25 patients, intrahepatic ducts in four, liver beds in two, and the common bile duct in one. Biliary stenting with or without sphincterotomy was performed in 22 and eight patients, respectively. Of the four cases of bile leak combined with bile duct stricture, one patient had severe bile duct obstruction and the others had mild stricture. Concerning endoscopic modalities, endoscopic therapy for bile leak was successful in 30 patients (93.8%). Two patients developed transient post-ERCP pancreatitis, which was mild, and both recovered without clinical sequelae.

CONCLUSIONS

The endoscopic approach of ERCP should be considered a primary modality for the diagnosis and treatment of bile leakage after cholecystectomy.

Endoscopic management of bile leakage after cholecystectomy: a single-center experience for 12 years

Background/Aims

Bile leakage is an uncommon but serious complication of cholecystectomy. The aim of this study is to evaluate the efficacy of the endoscopic management of bile leakage after cholecystectomy.

Methods

A total of 32 patients who underwent endoscopic retrograde cholangiopancreatography (ERCP), because of bile leakage after cholecystectomy, from January 2000 to December 2012 were reviewed retrospectively. The clinical parameters, types of management, and procedure-related complications were documented.

Results

Most bile leakages presented as percutaneous bile drainage through a Hemovac (68.8%), followed by abdominal pain (18.8%). The sites of bile leaks were the cystic duct stump in 25 patients, intrahepatic ducts in four, liver beds in two, and the common bile duct in one. Biliary stenting with or without sphincterotomy was performed in 22 and eight patients, respectively. Of the four cases of bile leak combined with bile duct stricture, one patient had severe bile duct obstruction and the others had mild stricture. Concerning endoscopic modalities, endoscopic therapy for bile leak was successful in 30 patients (93.8%). Two patients developed transient post-ERCP pancreatitis, which was mild, and both recovered without clinical sequelae.

Conclusions

The endoscopic approach of ERCP should be considered a primary modality for the diagnosis and treatment of bile leakage after cholecystectomy.

Percutaneous transhepatic biliary drainage in patients with postsurgical bile leakage and nondilated intrahepatic bile ducts

OBJECTIVE AND BACKGROUND

Bile leakage is a serious postoperative complication and percutaneous transhepatic biliary drainage (PTBD) may be an option when endoscopic treatment is not feasible. In this retrospective study, we established technical and clinical success rates as well as the complication rates of PTBD in a large group of patients with postoperative bile leakage.

METHODS

Data on all patients with nondilated intrahepatic bile ducts who underwent a PTBD procedure for the treatment of bile leakage between January 2000 and August 2012 were retrospectively assessed. Data included type of surgery, site of bile leak, previous attempts of bile leak repair, interval between surgery and PTBD placement. Outcome measures were the technical and clinical success rates, the procedure-related complications, and mortality rate.

RESULTS

A total of 63 patients were identified; PTBD placement was technically successful in 90.5% (57/63) after one to three attempts. The clinical success rate was 69.8% (44/63). Four major complications were documented (4/63; 6.3%): liver laceration, pneumothorax, pleural empyema, and prolonged hemobilia. One minor complication involved pain.

CONCLUSIONS

PTBD is an effective treatment with low complication rates for the management of postsurgical bile leaks in patients with nondilated bile ducts.

Management of CBD stones in patients having laparoscopic cholecystectomy in a private setting in Australia

INTRODUCTION

Laparoscopic bile duct exploration at the time of laparoscopic cholecystectomy has been promoted as being equally successful as endoscopic bile duct clearance. Further, if successful it offers the possibility of reducing the number of interventions required and therefore reducing overall costs. However, there is little in the literature that describe current treatment patterns in the Australian environment.

METHODS

Medicare data were obtained for the number of patients undergoing laparoscopic cholecystectomy, intraoperative cholangiography, laparoscopic transcystic bile duct exploration, laparoscopic choledochotomy and bile duct exploration, endoscopic retrograde cholangiopancreatography (ERCP), sphincterotomy and endoscopic biliary stent insertion.

RESULTS

Although there was significant state-to-state variation in the prevalence of laparoscopic bile duct exploration (0.6-3.7%), ERCP remained the predominant method of bile duct clearance in the setting of laparoscopic cholecystectomy (5.4%). Transcystic bile duct exploration is far more common than laparoscopic choledochotomy, which is a rare procedure. This suggests that patients with a dilated common bile duct and large or multiple stones are typically undergoing ERCP rather than laparoscopic bile duct clearance.

CONCLUSION

Despite the apparent attractiveness of laparoscopic bile duct exploration at the time of cholecystectomy, ERCP remains the most common method of dealing with choledocholithiasis in the setting of an intact gallbladder in Australia.

Endoscopic retrograde cholangiopancreatography for non-gastroenterologists: what you need to know

Endoscopic retrograde cholangiopancreatography (ERCP) represents the most powerful and widely employed platform for pancreaticobiliary interventions. Endoscopic retrograde cholangiopancreatography allows diagnosis and treatment of a broad spectrum of diseases of the pancreaticobiliary tree that are both benign and malignant in nature. Endoscopic retrograde cholangiopancreatography continues to evolve rapidly, and non-gastroenterologists need to understand the indications, contraindications, limitations, and role of ERCP to effectively manage and coordinate the care of patients with known or suspected pancreaticobiliary disease. This article will review the role of ERCP in detail to further an understanding of the procedure as a whole and to assess when referral of a patient for an ERCP or other related test is indicated.