Endoscopic Management of Post-Surgical Biliary Leaks: A Two-Center Experience

Aims Post-surgical biliary leaks (PSBL) are one of the most prevalent and significant complications emerging after liver or biliary tract surgeries, possibly leading to life-threatening complications. Different surgical interventions can result in different types, locations or extent of the leaks, nevertheless the mechanism that maintains the leak is always related to the pressure gradient within the biliary tree. Endoscopic retrograde cholangiopancreatography (ERCP) alone or combined with a percutaneous transhepatic approach (Rendez Vous) as treatment of PSBL obtains optimal outcomes due to the possibility to modify the pressure gradient in the biliary tree.

Methods A retrospective double-center study was conducted in two tertiary centers. Consecutive patients who underwent at least one attempt of PSBL correction by ERCP or Rendez Vous procedure between January 2018 and August 2023 were included. The primary outcome was the endoscopic clinical success, while the secondary outcome was the hospital stay exceeding five days. Both univariate and multivariate analyses were used to assess outcomes.

Results 59 patients were included (67% female; mean age 58.9 years). 28 (47%) had a PSBL after cholecystectomy, 17 (29%) after liver transplant, 9 (15%) after hepatectomy and 5 (8%) after cholecystectomy with gallbladder bed resection. Endoscopic clinical success after one or more procedures was achieved in 51 (86%) patients. 42 (71%) patients had a hospital stay length longer than five days. Patients with one or more leaks had more possibility to achieve the endoscopic clinical success compared to those with one or more biliary stenosis associated to the leak (95% vs 62.5%, p-value 0.004); this data was confirmed during multivariate analyses. Leaks occurring on the main biliary duct had less probability (64%) to achieve the endoscopic clinical success compared to those in the end-to-end anastomosis (87%), in the resection plan or biliary stump (96%) or first or secondary order biliary branches (100%, p-value 0.04). A leak-bridging stent positioning had more probability to achieve the primary outcome compared to a not leak-bridging stent (100% vs 77%, p-value 0.038). Finally, only ASA-score was statistically significant and correlated to hospital stay exceeding five days (p-value 0.036). Adverse events were reported in 10% of cases, but none were grade 3 or higher according to the Clavien-Dindo Classification.

Conclusions ERCP and Rendez Vous procedures are safe and effective for treating PSBL, regardless of the type of preceding surgery, even if technical or clinical success was not achieved on first attempt. Stent positioning is suggested and, if possible, the stent has to be placed leak-bridging to enhance treatment efficacy.

Conflicts of interest

Authors do not have any conflict of interest to disclose.

Publication History

Article published online:
15 April 2024