Endoscopic plastic stent therapy for bile leaks following total vs subtotal cholecystectomy

Abstract

Background and study aims Plastic biliary stents are standard therapy for treatment of post-cholecystectomy bile leaks. An increasing proportion of patients now undergo subtotal cholecystectomy and are at perceived risk for high-grade bile leak. Data are limited regarding the optimal endoscopic therapy following subtotal cholecystectomy. The aim of this study was to compare outcomes of endoscopic plastic stent therapy for treatment of bile leak following total vs subtotal cholecystectomy.

Patients and methods A retrospective cohort of patients with bile leak following cholecystectomy and treated with biliary stent was identified from an institutional database. Primary outcome was defined as cholangiographic resolution of leak at follow-up endoscopic retrograde cholangiopancreatography (ERCP).

Results Sixty-one subjects met study inclusion criteria, 27 following total cholecystectomy and 34 following subtotal cholecystectomy. A single plastic biliary stent was placed in 87 % of subjects (53/61), while a fully covered self-expanding metal stent (FCSEMS) was placed in 13 % (8/61). Leak resolution was evident at first follow-up ERCP in 96 % of subjects (26/27) who had undergone total cholecystectomy and 91 % of subjects (31/34) who had undergone subtotal cholecystectomy (P = 0.25). Among subjects who had received a plastic stent at index ERCP, leak resolution was evident at first follow-up ERCP in 96 % (23/24) of those who had undergone total cholecystectomy and 90 % (26/29) of those who had undergone subtotal cholecystectomy (P = 0.62).

Conclusions High rates of leak resolution can be achieved with placement of a single plastic biliary stent for treatment of post-cholecystectomy bile leaks, including after subtotal cholecystectomy.

Publication History

Received: 30 June 2020

Accepted: 05 October 2020

Article published online:
27 November 2020

• References

• 1 Barkun AN, Rezieg M, Mehta SN. McGill Gallstone Treatment Group. . et al. Postcholecystectomy bile leaks in the laparoscopic era: risk factors, presentation, and management. Gastrointest Endosc 1997; 45: 277-282
• 2 Sandha GS, Bourke MJ, Haber GB. et al. Endoscopic therapy for bile leak based on a new classification: results in 207 patients. Gastrointest Endosc 2004; 60: 567-574
• 3 Kaffes AJ, Hourigan L, De Luca N. et al. Impact of endoscopic intervention in 100 consecutive patients with suspected postcholecystectomy bile leak. Gastrointest Endosc 2005; 61: 269-275
• 4 Strasberg SM, Pucci MJ, Brunt LM. et al. Subtotal cholecystectomy – “fenestrating” vs “reconstituted” subtypes and the prevention of bile duct injury: definition of the optimal procedure in difficult operative conditions. J Am Coll Surg 2016; 222: 89-96
• 5 Elshaer M, Gravante G, Thomas K. et al. Subtotal cholecystectomy for “difficult gallbladders”: systematic review and meta-analysis. JAMA Surg 2015; 150: 159-168
• 6 Lidsky ME, Speicher PJ, Ezekian B. et al. Subtotal cholecystectomy for the hostile gallbladder: failure to control the cystic duct results in significant morbidity. HPB (Oxford) 2017; 19: 547-556
• 7 Coté GA, Slivka A, Tarnasky P. et al. Effect of covered metallic stents compared with plastic stents on benign biliary stricture resolution: a randomized clinical trial. JAMA 2016; 315: 1250-1257
• 8 Kahaleh M, Sundaram V, Condron SL. et al. Temporary placement of covered self-expandable metallic stents in patients with biliary leak: midterm evaluation of a pilot study. Gastrointest Endosc 2007; 66: 52-59
• 9 Canena J, Liberato M, Meireles L. et al. A non-randomized study in consecutive patients with postcholecystectomy refractory bile leaks who were managed endoscopically with the use of multiple plastic stents or fully-covered self-expandable metal stents (with videos). Gastrointest Endosc 2015; 82: 70-78
• 10 Cotton PB, Lehman G, Vennes J. et al. Endoscopic sphincterotomy complications and their management: an attempt at consensus. Gastrointest Endosc 1991; 37: 383-393
• 11 Harris PA, Taylor R, Thielke R. et al. Research electronic data capture (REDCap)-a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform 2009; 42: 377-381
• 12 Sabour AF, Matsushima K, Love BE. et al. Nationwide trends in use of subtotal cholecystectomy for acute cholecystitis. Surgery 2020; 167: 569-574
• 13 Canena J, Horta D, Coimbra J. et al. Outcomes of endoscopic management of primary and refrctory postcholecystectomy bile leaks in a multicentre review of 178 patients. BMC Gastroenterol 2015; 15: 105