Outcomes of Endoscopic Management among Patients with Bile Leak of Various Etiologies at a Tertiary Care Center

Abstract

Background/aims: Bile leak is a common complication of cholecystectomy, and it is also observed in other conditions such as ruptured liver abscess, hydatid cyst, and trauma. Endoscopic retrograde cholangiopancreatography (ERCP) is the first-line management for such conditions. However, studies on the outcomes of endoscopic management for bile leaks with etiologies other than post-cholecystectomy injury are extremely limited.

Methods: We conducted a retrospective review of patients with symptomatic bile leak who were referred to a tertiary care center and who underwent ERCP between April 2016 and April 2019. The primary outcome was complete symptomatic resolution without extravasation of the contrast medium during the second ERCP conducted after 6 weeks.

Results: In total, 71 patients presented with symptomatic bile leak. The etiologies of bile leak were post-cholecystectomy injury in 34 (47.8%), liver abscess in 20 (28.1%), and post-hydatid cyst surgery in 11 (15.4%) patients. All patients were managed with ERCP, sphincterotomy, and stent placement for 6 weeks, except for one who underwent surgery. The primary outcome was achieved in 65 (91.5%) of 71 patients. There was no significant difference in terms of outcome in relation to the interval between the diagnosis of bile leak and ERCP.

Conclusion: Most patients with bile leak can be successfully managed with ERCP even when performed on an elective basis.

Keywords: Bile duct leak; Cystic duct injuries; Endoscopic retrograde cholangiopancreatography; Laparoscopic cholecystectomy; Liver abscess.

Fig. 1.

Strasberg classification [13]. (A) bile leak from the cystic duct or liver bed without injury, (B) partial occlusion of the biliary tree, most commonly from the aberrant right hepatic duct, (C) bile leak from the duct (aberrant right hepatic duct) without communication with the common bile duct, (D) lateral injury of the biliary system without loss of continuity, and (E) circumferential injury of the biliary tree with loss of continuity: (E1) transected main bile duct with a stricture >2 cm from the hilum, (E2) transected main bile duct with a stricture <2 cm from the hilum, (E3) stricture of the hilum with communication between the right and left ducts, (E4) stricture of the hilum with separation of the right and left ducts, and (E5) stricture of the main bile duct and the right posterior sectorial duct.

Fig. 2.

Leak from the right hepatic duct (arrow) in a patient with liver abscess.

Fig. 3.

Large bile duct injury at the common hepatic duct level with left hepatic duct draining through a leak (arrow).

Fig. 4.

Cystic duct stump leak (arrow) with calculus in the proximal common bile duct (arrowhead).

Fig. 5.

Bile duct injury at the common hepatic duct (arrow) with axis deviation at the level of injury with opacification in both the right and left hepatic ducts.

Fig. 6.

Duration of hospital stay of the non-surgical (N) and surgical (S) groups, showing a significant difference between the groups (p=0.0001).