Accessory bile duct leaks after cholecystectomy: Diagnosis and treatment

Background: Postoperative bile leak is a common indication for ERCP after cholecystectomy. Aberrant or "accessory" bile duct leaks (ABDL) are difficult to recognize; appropriate treatment is often delayed. The purpose of this study is to review the management of ABDL at a tertiary medical center. Methods: We reviewed our endoscopic database to identify patients with bile duct leaks seen by our service between 9/89 and 9/96. After identification of all patients with post-cholecystectomy bile leaks, patient records (medical charts, cholangiograms, and interventional radiological studies) were reviewed to assess whether leaks were from an accessory bile duct. We then reviewed the diagnostic and therapeutic interventions performed to assess overall utility of these procedures. Diagnostic interventions included ERCP, PTC, and percutaneous fistulography. Therapeutic interventions included ERCP with stent placement, ERCP with sphincterotomy (ES), PTC with percutaneous biliary drainage (PBD), and surgery. As a policy, all bilomas were drained percutaneously. Results: 13 patients were identified. In 10 patients, a definite diagnosis of ABDL was made. In 3 patients, no definite source of the leak was identified. (However, pooling of contrast suggested ABDL.) Mean age was 56 (range 36-81). 11 were female. ERCP was attempted in 12 patients and diagnostic in 6. PTC was diagnostic in 2 patients after nondiagnostic ERCP. A percutaneous fistulogram was diagnostic in 2 patients (one after nondiagnostic ERCP). All 13 patients were successfully treated. In 8, ERCP with stent placement was successful. 1 patient had ERCP with ES 3 patients required surgical repair of their leak. 1 patient healed with a PBD. Our results are reviewed below. Table 1 -Diagnostic Procedures Table 2-TherapeuticProcedures Procedure N Success Rate Procedure H Success Rate ERCP 6 6/12 ERCP/stent 8 8/11 PTC 2 2/2 ERCP/ES 1 1/1 Fistulography 2 2/2 PBD 1 1/1 Surgery 3 3/3 Conclusions: 1) ABDL is a unique subset of post-cholecystectomy bile leaks. 2) ERCP is diagnostic in just half of patients with ABDL. 3) Interventional radiology (PTC, PBD, fistulography) is a useful adjunct to define and treat these leaks if ERCP fails.

Duke Scholars

Author Malcolm Stanley Branch Medicine, Gastroenterology

Author Paul Simon Jowell Medicine, Gastroenterology

Author Theodore N. Pappas Surgery, Minimally Invasive Surgery