The role of ERCP in the management of biliary leaks following laparoscopic cholecystectomy (LC)

Background: Despite its distinct advantages and overall safety, LC has its complications, including biliary leak. The role of ERCP in the diagnosis and treatment of post-LC bile leaks is still evolving. We review a tertiary referral center experience of ERCP in this setting. Methods: The Duke GI-Endoscopy Database was searched for pts undergoing ERCP after LC or LC conversion to open cholecystectomy. Pts with leaks were identified. Data were collected from endoscopy reports, pt files, cholangiograms, and telephone interviews. Results: Between 6/93 and 11/95, 59 ERCPs were performed on 33 pts with bile leaks after LC. There were 25 women and 8 men (median age: 43 years, range 18-80 years). 24 pts (73%) had LC performed at an outside hospital, 9 (27%) were referred from within our institution. The median time from LC to first ERCP was 6 days (range 2-16 days). Leaks occurred at the cystic duct (CD) remnant (n=19), the extrahepatic bile duct (excluding CD) (n=7), intrahepatic/accessory ducts (IHD, n=4), and no site identified in 3 pts. Nine pts had significant bilomas drained percutaneously. Three pts had complete biliary transection requiring surgery as primary therapy. One pt felt to have a clinically insignificant leak was not treated. Endoscopic therapy using biliary stents was attempted in the remaining 29 pts and was successful in 27 pts (93.1%), leading to complete resolution of leak and symptoms within a median of 29 days. Two patients had concomitant CBD stones which were successfully cleared after sphincterotomy. One pt underwent PTC with stenting after failed endoscopic cannulation. Another required surgical repair for persistent leakage after 3 months despite repeated stenting. Conclusions: Greater than 90% of post-LC biliary leaks are identified by ERCP and effectively treated by stenting alone. Accessible bilomas should be drained percutaneously. Leaks associated with major ductal disruption require reoperation.