Original article
Minimally invasive management of biliary complications after laparoscopic cholecystectomy

https://doi.org/10.1016/j.ejim.2009.07.010Get rights and content

Abstract

Background

We conducted this prospective study to evaluate the efficacy of percutaneous catheter drainage as a minimally invasive treatment in the management of symptomatic bile leak following biliary injuries associated with laparoscopic cholecystectomy.

Methods

Twenty two patients with symptomatic bile leak following laparoscopic cholecystectomy underwent percutaneous drainage of the bile collection under ultrasound control. In patients with jaundice and in those with persistent drainage, endoscopic retrograde cholecysto-pancreatography (ERCP) was performed immediately for diagnostic and for therapeutic intervention when appropriate. In other patients, ERCP was performed 4–6 weeks after the discharge from the hospital to document the healing of the leaking site.

Results

Five patients with jaundice were initially treated by a combination of endoscopic plus percutaneous drainage. One of them required surgical treatment following diagnosis of a major duct injury. The other 17 were treated by percutaneous drainage initially and for 14 of them it was definitive treatment. Three patients required sphincterotomy as additional treatment for stopping the leak. There were no complications related to the percutaneous drainage procedure.

Conclusions

Most patients with bile leakage can be managed successfully by percutaneous drainage. If biliary output does not decrease, endoscopy is needed. In patients with jaundice endoscopic diagnostic and therapeutic procedures should be performed immediately.

Introduction

Recently laparoscopic cholecystectomy has been accepted by the surgeons as a convenient method and has replaced conventional ‘open’ cholecystectomy as a treatment of choice for symptomatic cholecystolithiasis. Laparoscopic cholecystectomy is associated with less postoperative pain, shorter hospital stay and recovery period, earlier return to work, and a better abdominal cosmetic outcome compared to open cholecystectomy. Laparoscopic cholecystectomy does, however, carry an increased risk for biliary tract injury, with fluid accumulation in the operating and the right subdiaphragmal area, resulting in significant morbidity and high financial costs [1], [2], [3], [4]. The rate of bile duct injury during open cholecystectomy has been estimated to be 0.1%–0.2% and 0.3%–0.6% in patients after laparoscopic cholecystectomy [3]. The fluid can be the mixture of blood, inflammatory filtrate and bile. It causes abdominal pain and other symptoms as nausea, vomiting, abdominal distension, fever and jaundice [5].

In several series, a combination of endoscopic and radiological or laparoscopic procedures was used in the management of symptomatic bile leak following minor biliary injuries associated with laparoscopic cholecystectomy, avoiding the need for open intervention, but requiring general anesthesia for laparoscopy. Most published series focus on the role of ERCP (endoscopic retrograde cholecysto-pancreatography) in the diagnosis of bile leak after laparoscopic cholecystectomy, although in many cases endoscopic management can also treat the original cause of the problem. In those series, percutaneous drainage was performed as a supplementary measure to solve the localized or diffuse bile collections secondary to the leak [4], [5], [6], [7], [8], [9]. However, ERCP or/and laparoscopy as more aggressive methods, requiring general anesthesia for the latter, are not very appropriate for critically ill patients with complications after laparoscopic cholecystectomy. Besides, we do not believe that it is mandatory to reach the diagnosis immediately in such patients, but to solve their critical condition as soon as possible, no matter what caused the problem. Therefore, if percutaneous drainage was initially performed before ERCP, that would in no way deteriorate the patients' condition and would alleviate the symptoms immediately. Additionally, the quantity and dynamics (progression or regression) of the drained liquid monitored daily could be a good indicator of the magnitude of the problem, which would further guide our treatment. If the quantity was large and/or with increasing tendency, then more aggressive procedures could be employed, both as diagnostic and therapeutic tools. However, if the drainage decreased and eventually stopped and the lesion was healed spontaneously, they could be postponed for 4–6 weeks when the patients were stabile.

Therefore, we conducted this study to evaluate the efficacy of percutaneous catheter drainage as a minimally invasive treatment in the management of symptomatic bile leak following biliary injuries associated with laparoscopic cholecystectomy.

Section snippets

Patients and methods

From January 1, 2001 to December 31, 2008, all consecutive patients who were admitted to our hospital and managed for symptomatic bile leak after laparoscopic cholecystectomy were included in this prospective study. All patients gave written informed consent. This study was approved by the local ethics committee.

All patients were clinically evaluated and subjected to routine investigations such as blood film, liver function tests, coagulation parameters and abdominal ultrasonography (US) or

Results

Symptomatic bile leak with fluid collection after laparoscopic cholecystectomy was diagnosed in 22 patients during the study period. Ten of them were referred from other hospitals. There were 7 men and 15 women, with a mean age of 46.2 (± 11.7) years (range 23–63). Prior to our intervention, patients were symptomatic for a median of 5 days (interquartile range 3–8.1 days). The symptoms were fever in 20 patients (90.9%), right upper quadrant abdominal pain in 14 patients (63.7%), diffuse abdominal

Discussion

Our study shows that percutaneous treatment with continuous catheter drainage in the management of symptomatic bile leak following minor biliary injuries associated with laparoscopic cholecystectomy can be performed safely and effectively in most cases. After the initial percutaneous drainage, we observed either complete clinical recovery or clinical improvement in all patients. Healing of the leaking site and complete clinical recovery were achieved in about 2/3 of patients using continuous

Learning points

  • Percutaneous drainage can be performed as an initially treatment in the management of symptomatic bile leak following biliary injuries associated with laparoscopic cholecystectomy in patients without jaundice.

  • In patients with jaundice, percutaneous drainage and ERCP should be performed simultaneously.

  • If percutaneous drainage was initially performed before ERCP, that would in no way deteriorate the patients' condition and would alleviate the symptoms immediately. Additionally, the quantity and

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