Endoscopic Treatment of Biliary Leaks After Laparoscopic Cholecystectomy: Cut or Plug?

Excerpt

Biliary leaks, a well-recognized and much-feared complication of biliary tract surgery, have increased in frequency in the era of laparoscopic cholecystectomy, with estimates of the frequency of biliary leaks after laparoscopic cholecystectomy estimated at 0.3–0.5% [1]. Leakage post-cholecystectomy most commonly arises from the cystic duct or a duct of Luschka (Amsterdam type A leaks). Although readily amenable to endoscopic intervention, prompt diagnosis and therapy are essential to prevent further complications. Although the diagnosis is readily apparent if bile is leaking from a percutaneous drain placed at the time of cholecystectomy, leaks may also manifest as abdominal pain, jaundice, bilious ascites, or a biloma. Although imaging modalities such as cholescintigraphy (HIDA scan), computed tomography (CT), and magnetic resonance imaging (MRI)/magnetic resonance cholangiopancreatography (MRCP) are useful to confirm the diagnostic suspicion, endoscopic retrograde cholangiopancreatography (ERCP) with demonstration of the site of duct leakage is needed to not only definitively confirm the diagnosis, but also to exclude the presence of retained stones and strictures prior to initiating therapy. Biliary leaks can be characterized as high grade or low grade on the basis of ERCP findings [2]. Low-grade leaks are identified simultaneously or immediately after full opacification of the intrahepatic ducts, whereas contrast extravasation prior to intrahepatic duct filling is the hallmark of high-grade leaks. …