Decreasing Intrabiliary Pressure

The first aim of endoscopic therapy is to decrease or abolish the tone of the sphincter of Oddi, which diverts bile flow away from the leak site. This can be achieved with biliary endoscopic sphincterotomy (ES). Since ES does cut the sphincter completely, we recommend transpapillary stent placement to bypass residual sphincter muscle (Fig. 41.1). Stent placement alone is preferred in patients at high risk for post-ES bleeding.

Fig. 41.1 Endoscopic sphincterotomy and transpapillary stenting in a patient with a tear of the common bile duct. After stenting, the biliary drainage is improved and the pressure inside the biliary ducts is reduced.

Bypassing Bile Flow

In addition to reducing the pressure, the stent diverts bile toward the papilla and reduces flow through the leak site. This contributes indirectly to the closure of the leak (Fig 41.2). Considering the low morbidity of plastic stents, we recommend the combined use of ES and stent placement to maximally reduce intrabiliary pressure.

Fig. 41.2 A, Common bile duct tear in a 52-year-old woman after a laparoscopic cholecystectomy. B, Final position of the stent bridging the leak site.

Traditionally, plastic stents have been used but covered self-expandable metal stents (SEMS) have recently been used. Bioabsorbable self-expandable stents may be an option in the future and would eliminate the need for endoscopic removal.¹

Nasobiliary tubes can also be used as an alternative to stent placement in the treatment of biliary leaks after LC. Advantages include avoidance of sphincterotomy, easy removability, and ability to obtain interval tube cholangiograms to assess leak closure.² However, because of patient discomfort and potential for dislodgement, nasobiliary tubes are not routinely used.

Sealing the Leak

In patients with biliopleural fistulae, negative pressure pulls bile into the thoracic cavity. Application of sealants may be necessary to obtain prompt control of the leak. ERCP can allow application of sealants to close the leak.^3,4 However, because of the theoretical risk of glue pulmonary embolism, we reserve this treatment for highly selected cases of biliopleural fistulae and bilioperitoneal fistulae refractory to combined treatment with ES and plastic stent placement (Fig. 41.3).

Fig. 41.3 A 68-year-old man after segmental liver resection. A, Central biliary leakage treated with Hystoacryl injection. B, After emptying of contrast, radiopaque cyanoacrylate is noted to occlude the injured duct.

Stricture Dilation

Benign biliary strictures require dilation followed by multiple stent placements and exchanges. This approach is described in detail in Chapter 40 and offers a minimally invasive alternative to choledochojejunostomy and hepaticojejunostomy in the management of postoperative biliary strictures.⁵

Occlusion of plastic stents due to biofilm accumulation leads to the need for repeated exchanges, though data show that the interval to exchange can be extended when multiple side-by-side plastic stents are placed.⁶ Stent occlusion not only causes cholangitis but also leads to patient discomfort and morbidity related to repetitive procedures. Bioabsorbable biliary stents and covered self-expandable metal prostheses have been described with promising results.⁷

Several studies have shown benefit of SEMS for benign biliary diseases with stent removal possible in nearly all patients, high rates of stricture resolution and leak closure, and low rates of removal-related adverse events such as cholangitis, self-limited bleeding, and acute pancreatitis. These findings support the use of SEMS in benign biliary diseases but longer follow-up and randomized comparative studies to conventional plastic stents are needed.

Despite data showing efficacy of endoscopic therapy of ERCP for the treatment of biliary injuries based on physiologic mechanisms described, there are no randomized clinical trials to determine the best strategy. We suggest maximal reduction of intraductal biliary pressure inside the biliary ducts, using combined ES and stent placement. In selected cases endoscopic cyanoacrylate application could be considered (Box 41.1).

Nature and Magnitude of Biliary Injury

Continuity of the injured bile duct is the most important factor concerning the nature and magnitude of the injury and its relation to endoscopic management.

If there is continuity of the injured bile duct (Strasberg types A, C, and D), ERCP is considered the primary therapy. Endoscopic therapy is generally precluded for injuries with complete bile duct transection and presence of clips at the distal stump or lack of continuity between segments (Strasberg type E).^10,11

CBD resection requires surgical management to reestablish ductal continuity. ERCP is helpful only to determine the type and extent of the injury while percutaneous transhepatic cholangiography (PTC) is complementary and allows determination of the proximal biliary anatomy.¹² Magnetic resonance cholangiography (MRC) can also be used to define biliary anatomy.

Complete CBD transection without resection nearly always requires surgical reconstruction. Even though some patients with complete transection of the CBD can be successfully treated endoscopically with or without the use of PTC,¹³ it is technically difficult and the long-term outcome of this approach is unknown.

Aberrant ducts usually drain liver parenchyma in direct contact with the gallbladder (ducts of Luschka) or the CBD and they uncommonly have communications to the left or right biliary systems. If an aberrant damaged duct is misidentified during surgery (Strasberg type C), ERCP is a useful therapy. If the injured duct is visualized, it confirms communication with the biliary system. Endoscopic therapy includes ES, stent placement, and glues (for refractory leaks). If the injury cannot be detected by cholangiography, scintigraphy or MRC is required and surgery is also required.

Flow through the Leak

Clinically significant bile leak occurs in 0.1% to 0.5% of patients following open cholecystectomy, and initially was higher with LC. Because of a decrease in operator skill with open cholecystectomy, the injury rate may be increasing.¹⁴

The most common site of leakage is the cystic duct (78%), followed by peripheral right hepatic ducts of Luschka (13%) and other sites (9%), including the common hepatic duct, CBD, and T-tube tracts.¹⁵

High output leaks were traditionally considered an indication for surgery. However, endoscopic therapy has become the main approach (Table 41.1). Shanda et al. defined a low-grade leak as a leak identified only after opacification of the intrahepatic biliary radicals with contrast and a high-grade leak as a leak observed fluoroscopically before intrahepatic opacification.¹⁵ Endoscopic therapy should be attempted even for high-grade leaks.

Table 41.1 Published Series Using an Endoscopic Approach to Treat Bile Leaks

ES, Endoscopic sphincterotomy; n, number of patients; NT, nasobiliary tube.

Time to Diagnosis

If the injury is identified intraoperatively, it is often repaired surgically.

Laparoscopically placed intraoperative biliary stents can be used to prevent stenosis at the choledochotomy and as an alternative method of closure of a choledochotomy.¹⁶

Treatment of Infected Biliary Collections and Related Infectious Adverse Events

The first step in the treatment of iatrogenic biliary injuries causing sepsis is infection control and patient stabilization. Septic adverse events are mainly due to loculated collections and require drainage.

Most collections and bilomas are treated with percutaneous catheter placement and administration of systemic antibiotics. If percutaneous drainage is inadequate, minimally invasive laparoscopic surgical techniques can be used. There are reports of endoscopic transmural drainage of bilomas.¹⁷

The role of ERCP in the modern minimally invasive approach treatment of infected bilomas and septic collections is to diagnose and control underlying bile leaks.

Surgical Risk

High surgical risk is considered a contraindication to open surgical repair. As a consequence, minimally invasive procedures have been used in these patients. ERCP was initially used for patients in whom open surgery was the only alternative. Though ERCP is safe and effective, it should be considered in the context of a multidisciplinary approach including hepatobiliary surgeons, interventional radiologists, and biliary endoscopists.

It is impossible to establish a rigorous evidence-based approach for patients with iatrogenic and postsurgical biliary injuries. We propose a guideline for the management of these patients (Table 41.2). In summary, most patients are candidates for therapeutic ERCP in the setting of a known or suspected biliary adverse event following LC. As shown in the proposed algorithm (Fig. 41.5), ERCP is a widely accepted therapy for high output fistulas and low-risk patients. Only types B and E lesions without continuity to the CBD and injuries identified intraoperatively leave ERCP as a secondary or adjuvant therapy to surgical repair (Box 41.2).

Table 41.2 Factors Influencing Endoscopic versus Surgical Treatment of Biliary Tree Injuries

CBD, Common bile duct; ERCP, endoscopic retrograde cholangiopancreatography.

^*Absent communication to CBD branches leads to late liver resection.

^†Only if aberrant system communicates with CBD branches.

^‡Stenting only if continuity can be established.

^§ERCP seems as effective as surgery; other factors should be considered.

^‖Drainage is priority; after drainage, endoscopic therapy should be used.

Fig. 41.5 ERCP for treatment of adverse events after laparoscopic cholecystectomy (LC). *In selected cases of septic collections and/or biloma, open surgery is indicated as primary treatment. **Consider open surgery only if laparascopic management is not feasible.

Box 41.2

Contraindications to Endoscopic Treatment of Adverse Events Following Laparoscopic Cholecystectomy

 Injuries identified during surgery

 Injuries with loss of common bile duct continuity

 Strasberg type B

 Strasberg type C