Endoscopic treatment of biliary leakage after laparoscopic cholecystectomy

Biliary leakages are more frequent in laparoscopic than in open cholecystectomy. The aim of our study was to evaluate the diagnostic and therapeutic value of endoscopic retrograde cholangiography (ERC) in the management of bile leakages after laparoscopic cholecystectomy. The primary management was endoscopic sphincterotomy and extraction of remaining gallstones in the common bile duct to provide a decrease of biliary pressure, allowing closure of the fistulas. We report on 20 patients with bile leakage at ERCP, presenting between January 1991 and October 1995 with persistent bile discharge out of drainages, increasing fluid collections subhepatic (termed bilomas) or in the free peritoneal cavity (cholascos), abdominal pain, fever, cholestasis, intraoperatively diagnosed choledocholithiasis, and subhepatic abscess in one case. In 19 cases, after fluoroscopic visualization of the biliary tree and the leak, endoscopic sphincterotomy was performed. The biliary leaks were located at the cystic duct remnant (n = 12), at the gallbladder fossa (n = 5), or at lesions at the hepatic or common bile duct (n = 2). In 7 patients residual common bile duct stones were endoscopically removed. Most patients had localized small subhepatic fluid collections (n = 13) and the others had cholascos (n = 6). The leaks closed with endoscopic sphincterotomy alone in 11 patients, 4 patients had endoscopic sphincterotomy plus percutaneous or laparoscopic drainage of the bile collections, and 4 patients underwent laparotomy. All 6 cases with cholascos but only 2 of the 13 patients with localized collections underwent a second therapeutic procedure (drainage, laparotomy). Five of these procedures were performed within 7 days of ERCP, in most cases due to persistent bile leak. We conclude that biliary leakages after laparoscopic cholecystectomy require laparotomy only exceptionally. Endoscopic sphincterotomy combined with percutaneous drainage in the case of large collections, represents a safe and successful strategy ensuring closure of the leaks in most cases.