Endoscopic management of bile leaks after laparoscopic cholecystectomy

VoL7, No 3, July - September 1998

Endoscopic management of bile leaks

after

L.A.

Lesmana

Endoscopic managementfor biliary

leaks

l6l

laparoscopic cholecystectomy

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

obilier untuk drainase pada 3 pasien.

k

4 prosedur tersebut. Endoskopi terape

p

Abstract

c t inj urie s _fo I low in g raparo s c 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

return to

work.

However,

biliary

complications after LC,

noticeable

bile duct

leaks,

is reported from

O.3Vo

to

3.0Vo com_

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

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

ERCP

was

performed

technique

_under

intravenous

sedation

cope

(Olympus,

Japan)

type JF

IT

20,

_me

inrerval

from

lC

,g

the

ERCP

procedure,

clinical

symptoms,

and

liver

functions

were noted.

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

162 Lesmana

tain

criteria

in

selecting the method

of

endoscopic

interventions.

A

7

Fr

endoprosthesis was placed above the site

of

leak

in all

stented patients.

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.

Ultrasound

using real

time

scanner

(Toshiba

SSA-2701'

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

obstruc-tion

in

the

remaining

three patients.

Diagnostic

ERCP

findings of

these

16

patients were shown

in

table

l.

Table

l.

Diagnostic ERCP findings

in l6

patients with biliary complications related to LC

Bile duct injury

[image:2.595.200.538.104.693.2]

Med J Indones

Table 2. Therapeutic ERCP interventions

in

11 patients

Endoscopic procedure N Vn

Stenting alone

Stent placement and sphincterotomy Insertion of nasobiliary tube

5

J

3

46 27 27

Total

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

suc-cessful

in

all

these

I

I

patients (table

2).

Stent place-ment 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

cholangiog-raphy after 4 weeks

still

shqwed extravazation

of small

amount

of

contrast.

Total

Figure

l.

Endoscopic retograde cholangiogram in apatient

with cystic duct leak shows extravasation of contrast into peritoneal cavity that responded to stent placement

F i gure 2. Cho lan g io gram afte r lap aro s c opic c ho Ie cy s t ec t omy

demonstrates biliary leak (arrow) that successfully teated by

insertion of nasobiliary tube drainage

t00 1l

q

Biliary leaks

Stricture of common hepatic duct

Total duct obstruction

11

2 J

69 12

l9

[image:2.595.51.285.399.482.2] [image:2.595.312.547.419.693.2]

Endos c op ic nlana g e nrc nt _fo r b i Lia ry leaks r63 Vol 7, No 3, JulS, - Septenùer 1998

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

performed

in

ie

the presence

la

vity

and

sub-DISCUSSION

The

reasons

for ductal injury

_at

LC include

variation

anatomy,

technically difficult

dissection

_due

to

_severe

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

hat

_cho

useful

_s

afterl

a

nega

le out a

While

is not

institution, ERCP

demonstrated the

presence

of

bile

leaks

in

l)OVo

patients

in

our

series.

Therefore,

we

on to

perform

_ERCP

directly to

the

specteà

bile

leaks

fol_

Iowing LC,

as

e.r.l

l'18

Our

results also

support

the other findings

that

therapeutic ERCP

procedures, such as stent

placement

and

NBT

decompression,

are

effective methods

tbr

healing

post

LC

biliary

leaks.8-la

The

presumed

beneflt

of

endoscopic therapy

is

tlre

reduction

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.

Some

experts have claimed that

NBT

clrainagc

_has

some

potential

advantages

compared

to

stenting.l3.l9

First, NBT

provides maximal and

direct bile

cluct

patients). Stent placement

is

more convenient for

patients and enable them

to

return

to

their

activity

faster

compared to

those

who

are

receiving

NBT.

Ste

have also

_been

reported

_as

the

t2'I

f

choice

in

other

series.lo-recent

studles,dJ?

,r.n,.on

be

for

4 to 6 weeks

in

most

of

the patients.

On

nt in our

series

required stenting

fbr

g

we

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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