Mohammad Salih ( Department of Medicine, The Aga Khan University Hospital, Karachi. )
Hasnain Ali Shah ( Department of Medicine, The Aga Khan University Hospital, Karachi. )
Zaigham Abbas ( Department of Medicine, The Aga Khan University Hospital, Karachi. )
Wasim Jafri ( Department of Medicine, The Aga Khan University Hospital, Karachi. )
Objective: To evaluate the diagnostic and therapeutic efficacy of ERCP in the management of biliary leaks.
Methods: The study recruited 35 out of total 436 ERCP patients with post surgical biliary leaks, who presented to our department between January 1, 2001 and September 30, 2004. Unsuccessful ERCP and/or completely transected CBD injuries were handed over to surgery.
Results: ERCP was successful in 33 (94%) patients. Of these 25 (75%) had cystic stump leaks, 3 (9%) had transected CBD, 2 (6%) had leakage from gall bladder (GB) bed, 2 (6%) had persistently draining T-tube with retained CBD stones and one (3%) patient had a leak from the right hepatic duct. CBD stenting was done successfully in 23 (92%) patients with a cystic stump leak. The other 3 patients with leakage from GB bed and right hepatic duct injury were successfully dealt with CBD stenting. The retained CBD stones were endoscopically removed. The overall therapeutic success was 93% and stents were removed after 6-8 weeks without further complications. Three patients with transected CBD were treated surgically.
Conclusion: Iatrogenic Biliary system Injuries can be diagnosed and managed efficiently through Endoscopic Retrograde Cholangiopancreatography (ERCP) (JPMA 57:117;2007).
Iatrogenic biliary injuries occur in 0.2-2.0% of cases after cholecystectomy.1 Initially laparoscopic cholecystectomy (LC) was associated with more biliary injuries but as experience has grown, the incidence of complications is similar to that of open cholecystectomy (OC).2,3 Both OC and LC may result in various biliary injuries like major duct transections or excisions, major ductal leaks and/or strictures, cystic stump leaks (CSL) or gall bladder (GB) bed leaks.4 CSL is the most common type of injury and occurs most often with LC than OC.1,5,6
The presentation is usually with biliary collection, biliary peritonitis, jaundice or a persistently draining T-tube. The diagnosis and management is challenging. If the liver biochemistry or biliary drainage is not settling after OC and LC in 72 hours, then prompt investigations are needed which comprise of ultrasonography and computerized tomographic (CT) scan, and visualization of biliary tract by magnetic resonance cholangiopancreatography or ERCP: the latter is more cost effective if the chance of providing therapeutics is 50% or more.7,8
Patients and Methods
Thirty five patients (8%), out of 436 total ERCP, presented with post surgical biliary leaks/ iatrogenic biliary injuries between January 1, 2001 and September 30, 2004. Twenty five (71.4%) patients sustained injuries during LC while the remaining underwent OC. All patients had either cholestatic biochemical profile and/or evidence of biliary leak, jaundice or biliary peritonitis. All patients underwent imaging (abdominal ultrasound/ CT scan).
All ERCP procedures were performed under deep sedation (Profofol, Midazolam, and Fentanyl) monitored by an experienced anaesthetist. Bowel relaxation was achieved with intravenous hyoscine butyl bromide as needed. Continuous pulse oximetry, heart rate and blood pressure was monitored peri-procedure. ERCP was considered successful with the opacification of the CBD and demonstrating the injury.
A third generation cephalosporin was prophylactically administered intravenously before the procedure to patients not already receiving antibiotics. Patients who could not be stented and cases with completely transected CBD were handed over to surgery for definitive treatment.
A total of 35 patients underwent ERCP between 1st January, 2001 and 30th September, 2004 for post cholecystectomy biliary injuries, 22 (62.8%) were females and 13 (37.1%) males. Twenty five (71.4%) patients sustained injuries during LC while the remaining underwent OC (Figure 1). Of the 33 patients, 25 (75%) had cystic stump leak, 3 (9%) had transected CBD, 2 (6%) had leakage from gall bladder bed (GB), 2 (6%) had persistently draining T-tube with retained CBD stones and one (3%) patient had a leak from the right hepatic duct (Figure 2).
Twenty two of the 25 (88%) CSL were post LC patients.
ERCP was successful in demonstrating the biliary injury in 94% (33/35 patients). Thirty patients were considered for endoscopic therapeutics. Sphincterotomy and CBD stenting was done successfully in 26 out of 28 (92.8%) patients. Twenty three out of 25 patients (92%) with cystic stump leak were dealt successfully, while deep cannulation of CBD could not be achieved in 2 of the 25 (8%) patients in this group.
The other 3 patients with leakage from GB bed and right hepatic duct injury were successfully dealt with sphincterotomy and CBD stenting. The retained CBD stones were endoscopically removed in two patients with successful removal of T-tube.
Three patients (9%) had ERCP related complications; pancreatitis in two (6%) and post sphincterotomy minor bleed in one (3%) patient. Pancreatitis was mild in both patients and they were managed conservatively without any sequelae. The sphincterotomy related minor bleed was successfully dealt with endoscopically in the same session; at follow up the haemoglobin remained stable and did not require blood transfusions.
The overall therapeutic success was 93% and stents were removed after 6-8 weeks without further complications. The three cases with CBD transaction were managed surgically. Patients with biliary leaks on ERCP, who could not be stented endoscopically, were referred to surgery for definitive therapy.
Iatrogenic bile duct injuries are not uncommon and can lead to high morbidity and mortality due to life threatening peritonitis.1 In this study CSL was the most common type of injury and 88% of these patients underwent laparoscopic cholecystectomy (LC) which usually results from slipping of cystic stump clip or inadequately applied clip especially if there is papillary stenosis or retained CBD stones.5,6,9 All these patients were subjected to ERCP as the chances of therapeutic ERCP were high and initial MRCP would have not proved cost effective in this set of patients.10-12 Ryan ME, et al in a multicentric study has concluded that endoscopic sphincterotomy, stent placement, or sphincterotomy with stent are effective in healing biliary leaks after laparoscopic cholecystectomy.13 We had a diagnostic success rate of 94%. The overall therapeutic success was achieved in 26 out of 28 (92.8%), while 23 of 25 patients (92%) with CSL cases were effectively managed endoscopically. These results are comparable to De Palma et al, who had 96.9% success rate in post cholecystectomy biliary leaks endoscopically.14
ERCP is a safe and feasible mode of therapy for patients presenting with suspected bile duct injuries, with accepted rates of ERCP related complications. The overall complications rate may be as high as 15% with severe complications like severe Pancreatitis/ major bleed or procedure related perforation up to 1%.15,16 In this study the over all complication rate was 9% (Pancreatitis in 5% and minor bleed in 3%). The complications rate in this subset of patients with iatrogenic injuries is comparable to Yamaner S; et al, who noted 13.6% ERCP-related morbidity.17 This form of intervention should be considered as the initial step in the diagnosis and treatment of post cholecystectomy complications.
In conclusion, ERCP is a safe and efficient mode of therapy for patients presenting with suspected bile duct injuries. Most iatrogenic biliary system injuries, other than complete CBD transactions can be managed efficiently through ERCP. The predominant iatrogenic biliary injuries are cystic stump leaks, which respond well to a sphincterotomy and CBD stent placement, preferably across the cystic stump. This form of intervention should be considered as the initial step in the diagnosis and treatment of post cholecystectomy complications.
1. Jan YY, Chen HM, Wang CS, Chen MF. Biliary complications during and after laparoscopic cholecystectomy. Hepatogastroenterology. 1997; 44:370-5.
2. Larson GM, Vitale GC, Casey J, Evans JS, Gilliam G, Heuser L, et al. Multipractice analysis of laparoscopic cholecystectomy in 1,983 patients. Am J Surg 1992; 163: 221-26.
3. Regoly-Merel J, Ihsaz M, Sreberin Z, Sandor J, Mate M. Biliary tract complications in laparoscopic cholecystectomy: a multicenter study of 148 biliary tract injuries in 26440 operations. Surg Endosc 1998; 12: 294-300.
4. Woods MS, Traverso LW, Kozarek RA, Tsao J, Rossi RL, Gough D, Donohue JH. Characteristics of biliary tract complications during laparoscopic cholecystectomy: a multi-institutional study. Am J Surg 1998; 167: 27-32.
5. Kaman L, Behera A, Singh R, Katariya RN. Management of major bile duct injuries after laparoscopic cholecystectomy. Surg Endosc. 2004; 18:1196-9.
6. Woods MS, Shellito JL, Santoscoy GS, Hagan RC, Kilgore WR, Traverso LW, et al. Cystic duct leaks in laparoscopic cholecystectomy. Am J Surg 1994; 168: 560-5.
7. Kupferschmidt H, Havelka J, Schwery S, Bernardi M, Buhler H. Endoscopic therapy of bile leakage following laparoscopic cholecystectomy. Schweiz Med Wochenschr (Suppl)) 1996; 79:89S-93S.
8. Ainsworth AP, Rafaelsen SR, Wamberg PA, Pless T, Durup J, Mortensen MB. Cost-effectiveness of endoscopic ultrasonography, magnetic resonance cholangiopancreatography and endoscopic retrograde cholangiopancreatography in patients suspected of pancreaticobiliary disease. Scand J Gastroenterol 2004; 39:579-83.
9. Foutch PG, Harlan JR, Hoefer M. Endoscopic therapy for patients with a post-operative biliary leak. Gastrointestinal Endosc 1993; 39: 416-21.
10. Al-Karawi MA, Sanai FM. Endoscopic management of bile duct injuries in 107 patients: experience of a Saudi referral center. Hepatogastroenterology 2002; 49:1201-7.
11. Park DH, Kim MH, Lee SS, Lee SK, Kim KP, Han JM, et al. Accuracy of magnetic resonance cholangiopancreatography for locating hepatolithiasis and detecting accompanying biliary strictures. Endoscopy 2004; 36:987-92.
12. Munir K, Bari V, Yaqoob J, Khan DB, Usman MU. The role of magnetic resonance cholangiopancreatography (MRCP) in obstructive jaundice. J Pak Med Assoc. 2004; 54:128-32.
13. Ryan ME, Geenen JE, Lehman GA, Aliperti G, Freeman ML, Silverman WB, et al. Endoscopic intervention for biliary leaks after laparoscopic cholecystectomy: a multicenter review. Gastrointest Endosc 1998; 47:261-6.
14. De Palma GD, Galloro G, Iuliano G, Puzziello A, Persico F, Masone S, et al. Leaks from laparoscopic cholecystectomy. Hepatogastroenterology 2002; 49:924-5.
15. Cheng CL, Sherman S, Watkins JL, Barnett J, Freeman J, Geenen J et al. Risk factors for post-ERCP Pancreatitis: a prospective multicenter study. Am J Gastroenterol 2006; 101:139-47.
16. Ong TZ, Kher JL, Selamat DS, Yeoh KG, Ho KY. Complications of endoscopic retrograde cholangiography in the post-MRCP era: a tertiary center experience. World J Gastroenterol 2005; 11:5209-12.
17. Yamaner S, Bilsel Y, Bulut T, Bugra D, Buyukuncu Y, Akyuz A, et al. Endoscopic diagnosis and management of complications following surgery for gallstones. Surg Endosc 2002; 16:1685-90.