Turk J Gastroenterol 2005; 16 (1): 21-28

Treatment of biliary leakages after cholecystectomy and

importance of stricture development in the main bile
duct injury
Kolesistektomi sonras safra kaaklarnn tedavisi ve ana safra duktus hasarnda
darlk gelimesinin nemi

Erkan PARLAK, Bahattin EK, Seluk DBEYAZ, Sedef zdal KURAN, Dilek OUZ,
Burhan AHN
Trkiye Yksek htisas Hospital, Department of Gastroenterology, Ankara

Background/aims: Endoscopic treatment of biliary leakages Ama: Kolesistektomi sonras safra kaaklarnn tedavisinde
after cholecystectomy, though widely accepted, has some restric- endoskopik tedaviler baz snrlamalar olmakla birlikte kabul
tions. The efficacy and safety of endoscopic treatments in this grmtr. Bu almada bu hasta grubunda endoskopik teda-
patient group are evaluated in this study, and the problem of bi- vinin etkinlii ve gvenlii yannda ana safra kanal hasarnda
liary stricture development in time after biliary ductal injuries
is also emphasized. Methods: Seventy-four patients (20 male, biliyer darlk gelime problemi incelendi. Yntem: ERCP iin
54 female, mean age 50.921 years) referred for ERCP between 1992-2002 yllar arasnda bavuran 74 hasta (20 erkek, 54 ka-
1992-2002 were included in the study. Minor leakages (cystic dn, ortalama ya 50.921 yl almaya alnd. Minor kaaklar
duct leaks, accessory bile duct leaks) were managed by nasobi- (sistik kanal kaaklar, aksesuar safra kanal kaaklar) nazo-
liary drainage endoscopic sphincterotomy; major leakages we- biliyer drenaj endoskopik sfinkterotomi; major kaaklar nazo-
re managed by nasobiliary drainage endoscopic sphinctero- biliyer drenaj endoskopik sfinkterotomi stentleme ile tedavi
tomy stenting. Results: Twenty-seven patients with cystic edildiler. Bulgular: Sistik kanal kaa olan 27 hasta ve akse-
duct leaks and 6 patients with accessory bile duct leaks were
successfully treated with nasobiliary drainage. Endoscopic tre- suar safra kanal kaa olan 6 hasta nazo biliyer drenajla te-
atment could not be performed on patients with total bile duct davi edildi. Total safra duktus obstrksiyonu olan (7 hasta) ve
obstruction (7 patients) and aberrant bile duct injury (7 pati- aberran safra kanal kaa olan (7 hasta) hastalara endoskopik
ents). All leakages from main bile ducts were closed (27 pati- tedavi yaplamad. Ana safra kanaldan olan kaaklarn hepsi
ents). Six of 27 patients had strictures at the beginning and they (27 hasta) kapand. Bu 27 hastann altsnda balangta dar-
were treated by stenting. Twenty-one patients had no strictures lk vard, bunlar stentleme ile tedavi edildiler. Yirmibir hasta-
at the beginning. Eight of 21 were treated by stenting and only nn balangta darl yoktu. Bu hastalarn sekizi stentleme ile
1 of them developed biliary stricture. Seven of 13 patients who
had been treated by nasobiliary drainage developed biliary tedavi edildiler ve bunlarn sadece birinde darlk geliti. Nazo-
strictures. There were no mortalities due to procedure. biliyer drenajla tedavi edilen dier 13 hastann yedisinde dar-
Conclusions: ERCP is an effective and safe method for diagno- lk geliti. leme bal mortalite grlmedi. Sonu: ERCP ko-
sis and management of bile leakages after cholecystectomy. lesistektomi sonras safra kaaklarnn tan ve tedavisinde etki-
Stricture development in the main bile duct leakages was an li ve gvenlidir. Ana safra kanal kaaklarnda darlk gelime-
important complication. si nemli komplikasyonudur.

Key words: Cholecystectomy, biliary complication, ERCP Anahtar kelimeler: Kolesistektomi, biliyer komplikasyon, ERCP

INTRODUCTION
Cholecystectomy has been the treatment of choice dence of bile duct injuries than OC (0.6% vs
for symptomatic gallstones. Laparoscopic cho- 0.3%)(1-3). There are also some reviews which ha-
lecystectomy (LC) has recently become the more ve reported the incidence of biliary leakages as up
preferred operation over open cholecystectomy to 1.1% (4).
(OC). Although LC has shortened hospitalization Endoscopic therapies for bile duct leaks after cho-
and decreased mortality and morbidity, reviews lecystectomy have been widely accepted after the
have reported that LC has a two-fold higher inci- early postoperative period due to the restrictions

Address for correspondence: Erkan PARLAK Manuscript received: 23.06.2004 Accepted: 01.02.2005
Trkiye Yksek htisas Hospital, Department of Gastroenterology
06100 Yeniehir, Ankara, Turkey
Phone: +90 312 306 10 00 Fax: +90 312 312 41 22
E-mail: [email protected]

*This work was presented during UEGW-2004.

22 PARLAK et al.

of percutaneous (5, 6) and surgical (7-11) therapy mes were used for precutting. Guide-wires of 0.021
(12-29). or 0.035 inches and straight tip or thigh J tip we-
Cystic duct and accessory bile duct leaks are gene- re used for cannulation.
rally treated easily without a problem. Stricture Endoscopic sphincterotomy was performed if pre-
development after endoscopic treatment of main cut was needed for selective cannulation or if the-
bile duct leaks, even in patients without stricture re was a stone to extract. Stones were extracted by
at the beginning, is a remarkable point (15, 24, 31). balloon or baskets.
The aim of this study was to share endoscopic ex- All patients with minor leakages were treated by
perience of our tertiary care center for diagnosis nasobiliary drainage (NBD) (Figure 1, 2). Aber-
and treatment of bilary leakages after cholecystec- rant bile duct injuries (Figure 3, 4) could not be
tomy and to emphasize the problem of stricture treated by ERCP because there was no communi-
development after endoscopic treatment of main cation with endoscopically reached bile ducts and
bile duct leaks. site of leakage. These patients were treated accor-
ding to referring center preference.
MATERIALS AND METHODS
The results of endoscopic retrograde cholangi-
opancreatography (ERCP) performed between Ja- a b
nuary 1992 and December 2002 in the treatment
of biliary complications after cholecystectomy we-
re evaluated retrospectively. Biliary leakages
which developed for other reasons such as from
trauma or from surgeries other than cholecystec-
tomy were not included in the study. The results
of 74 patients with biliary leakages after cholecys-
tectomy are reviewed.
Biliary leakages were classified in this study ac-
cording to anatomic localizations at ERCP. Cystic
duct leakages (CDLs) were described as type 1,
and leakages from accessory bile duct (Luschkas
ducts) were classified as type 2. These types of le- Figure 1: a) Retrograde cholangiogram showing extravasation of
contrast medium from the divided duct of Luschka and common
akages were accepted as minor leakages. Common
bile duct stones, b) Cholangiogram through the nasobiliary tube
bile duct leakages (CBDLs) and leakages from showing closure of the fistula seven days after its placement
common hepatic duct (CHDLs) were accepted as
major leakages and described as type 3. Leakages
from aberrant bile ducts were considered type 4.
The exact diagnosis of type 4 was done by percuta-
neous transhepatic cholangiography (PTC).
ERCP was performed with diagnostic or therape-
utic endoscopes (Olympus JF 1T10, JF 1T20 and
TJF 240) under concious sedation with midazolam
meperidine. Duodenal peristalsis was inhibited
by IV administration of hyoscine N-butylbromide.
Antibiotics were routinely administered prophy-
lactically before endoscopic procedure. Informed
consent was obtained before each procedure.
Tapered or normal tip ERCP catheters or sphinc-
terotomes were used during diagnostic cholangiog-
raphy. Precutting was needed for cannulation in
some patients. Sphicterotomes with 2-3 cm cutting Figure 2: a) Retrograde cholangiogram showing extravasation
wire and 7 F diameters or with 2 cm cutting wire of contrast medium from the cystic duct in patient with Billroth
with 5 F diameters, or needle-knife sphincteroto- II gastroenterostomy
Cholecystectomy and biliary leakage 23

Figure 2: b) Cholangiogram through the nasobiliary tube show-

ing closure of the fistula seven days after its placement
Figure 5: a) Biliary leak from common bile duct after
laparoscopic cholecystectomy in the region of several surgical
clips

a b

Figure 3: a) Retrograde balloon occluded cholangiogram sho-

wing the nonfilling of a segment of the right hepatic lobe (ar-
rows) b) Percutaneous transhepatic cholangiography demonstra-
ting a dilated disconnected right hepatic duct with leakage into Figure 5: b) Two 10 F biliary endoprotheses were placed
subhepatic bilioma

Patients with major bilary leakages were treated

by NBD in the early years. Stenting was not per-
a b
formed on these patients if there was no stricture
after leakage was resolved. These patients were
treated by stenting recently as if they had strictu-
re. NBD was performed transiently if there was a
stone which was not extracted or if the patient had
cholangitis.
Thirteen patients with type 3 leakages were tre-
ated by NBD. Stenting was performed first if the-
re was no significant leakage output or if the pati-
ents condition was satisfactory (8 patients)
(Figure 5, 6). If there was a stricture with leakage,
NBD was done first and stenting was performed
Figure 4: a) Cholangiogram through the nasobiliary tube showing
the nonfilling of a segment of the right hepatic lobe (arrows) b) later (6 patients). Biliary strictures were dilated
Contrast injection into bilioma drain showing disconnected ducts with 6 or 8 mm pneumatic biliary dilatation ballo-
24 PARLAK et al.

Stenting was performed on patients with strictu-

res every three months until optimal bile duct ope-
ning was constructed. Effort was made to insert as
many stents as possible at every ERCP period in
order to correct biliary strictures.
Results are reported as mean standard deviati-
on or median. Leakage closure time after NBD or
stent insertion was calculated by the life table
analysis according to Kaplan and Meier.

Figure 5: c) Fistula was sealed with common bile duct stricture

at the time of removal

on or 5, 7 or 10 F bougie. Amsterdam type pol-

yethylene stents with 7.2 or 10 F were used for
stenting. Follow-up of patients with NBD was do-
ne with weekly injection of contrast material thro-
ugh nasobiliary catheter tip. Leakages were accep-
c
ted as resolved and NBDs were extracted if leaka-
ge was observed as stopped. Follow-up ERCPs of
patients with stents were done three months later.

Figure 6: b) Three 10 F biliary endoprotheses were placed.

c) Fistula was sealed without stricture at the time of removal

RESULTS

The results of 74 patients who were followed up

Figure 6: a) Biliary leak from common bile duct after open
properly during this 10-year period are included
cholecystectomy (20 males, 54 females, mean age 50.921 years).
Cholecystectomy and biliary leakage 25

Most of the patients had LC and the most common operation (3 patients at the 4th week, 2 patients at
presentation was biliary leakage from operation the 2nd week, 1 patient at the 1st week). Five of the
site or bilioma. Detailed information about pati- patients with stones had type 1 leakage, 3 had
ents before biliary procedures is given in (Table 1). type 3, and 2 had type 2.
If patients were evaluated according to leakage Surgery was performed on 7 patients who had to-
type, 34 patients (45.9%) had type 3; 27 patients tal cut with leakages and on 1 patient with type 3
(36.5%) had type 1; 7 patients (9.4%) had type 4 leakage in whom it was not possible to advance
and 6 patients (8.1%) had type 2 leakages. Seven the guide-wire in the common bile duct. Seven pa-
patients had total cut. Ten of 74 patients (13.5%) tients could not be treated endoscopically due to
had stones with leakages. aberrant bile ducts (Figure 3, 4). Treatment of the-
Technical success of ERCP procedure to establish se patients was done by referring center. Treat-
the pathology was 100%. Seventy of 74 patients ment of 2 patients with CBDLs is continuing, so
had cannulation during first ERCP session, and 4 their results were not included in this study. Thus,
during the second session. Forty patients (54%) results of endoscopic treatment of 57 patients are
had cannulation without the necessity of precut- included.
ting; 26 patients (35.1%) had cannulation with Leakages were resolved in all patients who were
precutting. Needle-knife sphincterotomes were treated endoscopically (100%). Mean period for he-
used for cannulation in 8 (10.8%) patients. Sixty- aling was 11.812.9 days (median 7 days) (Figure
two patients (83.3%) had endoscopic sphinctero- 7). Overall success rate of endoscopic therapy was
tomy (ES), 55 patients (74.3%) had NBD for the- 77% (57/74).
rapy. The stones of 10 patients were extracted. All minor leaks were closed by NBD if minor leaks
One patient had perforation retroperitoneally du- were evaluated separately (Figure 1, 2). The ratio
ring ES and 1 patient had mild pancreatitis. They of patients with resolution of CDLs at the 1st week
were treated medically. follow-up was 81.5% (22/27), at the 2nd week 11.2%
Thirteen of 74 patients (17.6%) had strictures with (2/27), and at the 3rd week 7.4% (2/27). Four pati-
biliary leakages at the initial procedure (7 pati- ents who had accessory bile duct leakages (ABDL)
ents had total cut, 6 patients had partial strictu- were fully recovered at the 1st week, 1 patient at
res). ERCP were performed on patients who had the 2nd week, and 1 patient at the 3rd week.
partial strictures at approximately 2.5 weeks after Six of 28 patients with major leakage had strictu-
re in the beginning. These patients were treated
by 26.4 french (14-30) stents and average stent pe-
Table 1. Patients characteristics before endoscopic riod was 2.2 (1-3). Thirteen of 21 patients without
procedure stricture in the beginning were treated by NBD; 8
Features of operation
Open cholecystectomy (OC), n (% 26 (35.1)
Laparoscopic cholecystectomy (LC), n (%) 48 (64.9)
LC converted OC at the same session, n (%) 5 (10.4)
CBD exploration and T tube, n (%) 16 (21.6)
Repair at the same session, n (%) 2 (2.7)
Re-operation, n (%) 3 (4.1)
Duration for re-operation, mean SD, day 20 13.2
Duration between operation and admission 21.744.0 day
(2 day -1 year)
Presentation
Biliary leakage from surgical drain, n (%) 37 (50)
Bilioma, n (%) 25 (33)
Bile peritonitis, n (%) 6 (8.1)
Cutaneous fistula, n (%) 2 (2.7)
Icterus, n (%) 11 (14.9)
Cholangitis, n (%) 10 (13.5)
Laboratory (meanSD)
ALT, U/L 122116
AST, U/L 7551
ALP, U/L 506328
GGT, U/L 218200
T Bilirubin, mg/dl 8.46.4
D Bilirubin, mg/dl 4.35.2 Figure 7. Leakage closure time
26 PARLAK et al.

of 21 were treated by stenting (median=22.4 F, 14- DISCUSSION

30 F). Five of 6 patients who were followed up wit- This study evaluated 74 patients with biliary le-
hout stents around 45 (4-81) months still have had akages after cholecystectomy and indicated that
no recurrences. One patient still has stents at 3rd ERCP was an effective and safe method for diag-
stent period. nosis and treatment of biliary leakages.
Seven of 21 patients (25.8%) who had no strictures It is accepted that LCs cause more bile duct inju-
in the beginning with type 3 leakages developed ries than OCs (1-3). Since 1994, when LC was ini-
strictures at the site of leakages later. Six were tiated in our country, we have seen an increase in
the patients who were treated with NBD in the be- biliary injuries. Laparoscopic cholecystectomy was
ginning (6/13). Only 1 of 8 patients treated by performed in 64.9% of patients with biliary leaka-
stents developed strictures (Figure 5). When pati- ges (Table 1). It should be kept in mind, however,
ents were admitted with biliary symptoms, stric- that LC is performed more than OC and this pre-
tures were diagnosed 12.2 (1-15) months after re- ference can account in part for the high ratio.
covery of leakages. Six of these patients had been
According to the series which have evaluated bili-
followed up without stents at 2.6 (1-6) stent period ary leakages, there is a common opinion that the
after stenting with 24.3 F(14-30F) stents. These most common site of biliary leakage is the cystic
patients were followed up 32.6 months (4 months- duct (15, 18, 20, 22-24). We found more CHD and
8 years). One of these patients developed recur- CBDL than CDLs in our series. The reason could
rence of stricture at the 4th month during follow-up be that our hospital is a tertiary hospital and most
without stents. The therapy of this patient is con- surgeons from peripheral areas send their compli-
tinuing with stenting. One patient who was ad- cated LC patients to our hospital. Leakages from
mitted to hospital with jaundice after the 5th aberrant ducts and Luschkas ducts were seen less
month of NBD therapy had such a severe strictu- frequently in our series, which is similar to the li-
re that surgery was required, as it was not possib- terature (9.4% vs 8.1%).
le to reach the proximal side of the stricture with
Some surgeons have managed leakages after bili-
a guide-wire.
ary surgery by open surgical therapy (7, 8). More
In 1 of 2 patients with aberrant bile duct leakages than one surgery is needed for these patients (7).
due to LC, the leakage was noticed during opera- There are also high mortality (8%) and morbidity
tion and clamped in the same session. The other rates, especially in the early postoperative period
patients leakage developed after OC and resolved (9, 10). There are some studies which indicate la-
at the 4th day of relaparotomy. These patients we- paroscopic correction or drainage is successful in
re referred to our clinic due to persistence of the patients who have no jaundice or biliary stones.
leakages. Diagnosis of these patients was done by But this method is not suggested for major leaka-
PTC (Figure 3). They were followed up with medi- ges (11). Percutaneous therapy has some disad-
cal treatment and their leakages resolved sponta- vantages as well. It is difficult to puncture the bi-
neously 2 and 2.5 months after operation, respec- liary tree when it is not dilated. There is also the
tively. There were no clinical problems at 8 and 10 fear of hemorrhage and biliary leak during sten-
months of follow-up, respectively. One patient ting with large diameters (30). But some studies
with aberrant bile duct leakage was diagnosed by have shown percutaneous treatment as effective
fistulography (Figure 4). The treatment of this pa- (5, 6).
tient was decided by the referring clinic, which fol- We prefer ERCP as the first choice of treatment
lowed the patient medically.There was no biliary for biliary leakages after cholecystectomy. Percu-
fistula at the 3rd month of follow-up. Biliary leaka- taneous treatment is used when endoscopic proce-
ge of 1 patient after OC was diagnosed with fistu- dures are not successful, cannot be performed, or
lography, and fistulojejunostomy was performed show accessory ducts. We believe surgical treat-
by the Department of Gastroenterologic Surgery ment is only indicated for patients with biliary le-
at our hospital. We have no information about the akages who were not successfully treated endosco-
follow-up of the other 3 patients who were referred pically or percutaneously (Figure 8).
from other hospitals. In fact, minor leakages can heal spontaneously.
Two patients died during the follow-up period, but Endoscopic treatment accelerates the healing pe-
for reasons other than their primary diseases. riod by decompressing the biliary system by remo-
Cholecystectomy and biliary leakage 27

3RVWFKROHF\VWHFWRP\ Luschkas ducts was 100%, similar to rates repor-

ELOLDU\ILVWXOD
ted in the literature (12-29).
37&
(5&3 )DLOXUH 05&3
According to our results, biliary leakages after
6XFFHVV
cholecystectomy are not the only cause of morta-
lity. Two patients died in the early postoperative
0LQRUOHDNDJH
0DMRUOHDNDJH $EHUUDQW ELOHGXFWOHDNDJH
period because of other health problems. There
are some studies which show that post cholecys-
3DUWLDOLQMXU\ &RPSOHWHLQMXU\WRWDOFXW 37&DQGRU05&3
tectomy leakages could have a worse prognosis.
1%'RUVWHQWLQJ(6 6WHQWLQJ(61%' VXUJHU\ 6XUJHU\RUIROORZXS
Hillis et al. (7) noted death due to subhepatic abs-
cess in their series. Deaths were due to sepsis in
Figure 8. Our postcholecystectomy biliary leakage management the series of Davids et al. (15).
program
With appropriate treatment, major biliary leaka-
ges can close during the early post- operative peri-
od. Strictures due to fibrosis were the long-term
ving bile. Endoscopic treatments, in addition to sequela. Seven of 21 patients who had type 3 le-
decompressing the biliary system, close the defect akages without stricture in the beginning develo-
physically and act as a bridge at the site of extra- ped strictures. If we include the 13 patients who
vasation for major leakages. Stenting also acts as had strictures in the beginning, a total of 20 pati-
a mold and prevents stricture formation during ents (58.8%) had strictures with leakages. Two of
the recovery period. the type 3 leakages and all of the total cut under-
Stenting is a more accepted treatment than NBD went surgery for correction. Others were treated
according to the literature. The pressure gradient by endoscopic stenting. Today we prefer to treat
between the biliary tree and duodenum disappe- CBDLs or CHDLs as if there was stricture even in
ars through stents and biliary flow becomes easi- the absence of stricture at the time (at least 2 10 F
er. We use NBD more than stenting as we believe plastic stents), taking into account the frequency
of stricture development during NBD treatment
it shortens the recovery period with the help of a
periods. Stricture development has been reported
higher bilioathmospheric gradient than biliodu-
in some other series. Davids et al. (15) reported a
odenal gradient. Furthermore, it is possible to mo-
stenosis rate of 6% after stent removal. Bergman
nitor the leakage without risk of second endosco-
et al. (23) reported 3 of 11 patients with strictures:
pic procedure and premedication. Although carr-
2 were treated by hepaticojejunostomy and 1 by
ying NBD is not comfortable, this is an important
stenting. Costamagna et al. (31) also suggested
advantage.
stenting in order to prevent stricture develop-
We found an overall success rate of 77% if we con- ment.
sidered all patients with leakages. Most of the pa- According to our results, ERCP is an effective and
tients who were unable to be treated endoscopi- safe method for management of postoperative bili-
cally were those with either a total cut or with ary leakages. ERCP can be used for diagnosis of
aberrant biliary leakages without any communica- strictures and stones as well. It should be kept in
tion with the main biliary system. mind that strictures can develop as a result of ma-
The success rate for leakages from cystic ducts or in bile duct injuries during the recovery period.

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