Endoscopy for treating minor post-cholecystectomy biliary fistula A review of the literature

AIM: Laparoscopic cholecystectomy for gallstone disease is the most common surgical procedures performed in Western countries and bile leaks remain a significant cause of morbidity. A recognized treatment for minor biliary injury is internal biliary decompression by endoscopic retrograde cholangiopancreatography. The aim of this study was to assess the effectiveness of endoscopic strategy in the management of minor biliary injuries. MATERIAL OF STUDY: Twenty-two patients with a bile leak following laparoscopic cholecystectomy were recorded consecutively between 2007 and 2017 and they were all treated with endoscopic approach, with ERCP in order to confirm the nature of the injury and decompress the bile duct with sphincterotomy, stent insertion, or the placement of nasobiliary drains. In 15 patients, the leak was diagnosed by persistent bile drainage, in the other 7 patients without a drain the biliary leak was suspected because of symptoms in the immediate postoperative period. RESULTS: Controlled biliary fistulae were established in all 22 patients (100%), without further intervention. A complete cholangiogram was obtained in all patients (100%). The most common sites of minor leak were the cystic duct stump and the Luschka duct, but in one patients the site of the leak was unclear. DISCUSSION: Early in the series, sphincterotomy alone or nasobiliary tube placement was performed. Subsequently patients underwent sphincterotomy with stent insertion, in order to promote preferential drainage of bile into the duodenum. The median time to resolution after successful ERCP was 4 days. Two patients underwent ERCP complicated by mild pancreatitis. The median hospital stay was 15 days (range, 10-31 days) post-laparoscopic cholecystectomy. ERCP was performed 4-6 weeks later to document healing of the leaking point and to remove the stent. Routine follow was at median 50 days. CONCLUSIONS: This review confirms that postoperative minor biliary injuries can be successful managed by endoscopic ERCP biliary decompression.