Br. J. Surg. 1992, Vol. 79, December,
1339-1 341
J. Mortensen and A. Kruse Surgical Gastroenterology Department, Arhus Kommunehospital, DK- 8000 h h u s C. Denmark Correspondence to: Dr J. Mortensen
Endoscopic management of postoperative bile leaks Thirty-two patients aged 15-89 years developed postoperative bile leakage. Twenty-eight had undergone cholecystectomy, with choledocholithotomy in I I , and four had had miscellaneous operations. Endoscopic retrograde cholangiopancreatography ( E R C P ) was performed 2- 75 days after operation and revealed leakage from the cystic duct stump in 19 cases, f r o m a T tube track in five, f r o m the gallbladder and liver abscess cavity in two and from the major bile ducts in six. Major bile duct lesions were not generally amenable to endoscopic treatment, but the remaining 26 patients were treated successfully with internal stenting ( 2 2 ) or endoscopic sphincterotomy cfour); bile secretion in all cases stopped within I week. One patient with cholangitis after an E R C P procedure was managed by antibiotics; no other complication occurred and there were no deaths related to the procedure. E R C P procedures are well tolerated in the postoperative period and may be performed under sedation. E R C P is the method of choice for dealing with bile leakage and ERCP procedures are efective f o r the most common causes of postoperative bile leakage; complications are rare.
Bile leakage is a rare but serious complication that may occur after biliary tract surgery. Usually the leak is from the cystic duct stump or common bile duct (CBD). Although cystic duct stump leakage often heals spontaneously, leakage from any site may cause accumulation of large quantities of bile in the peritoneal cavity, a potential hazard to the patient. Previously it was necessary to treat the leak surgically, with external drainage of any bile collection'.*, but reoperation involves certain risks. In recent years, promising non-operative alternatives have been introduced into clinical practice3-'. This paper reports results with endoscopic treatment of patients with postoperative bile leakage.
peritonitis, one for retained common duct stones (twice) and one tor persistent bleeding (twice). ERCP was performed under sedation, with the patient in the oblique left lateral position, using Olympus duodenoscopes types JFB3, J F l T or JFlTlO (Olympus, Tokyo, Japan). Ifstenting was performed, a 7-Fr polytetrafluoroethylene double-pigtail catheter was used. ERCP showed leakage from the cystic duct stump in 19 patients, from a T tube track in five, from the gallbladder or a liver abscess cavity in two, and from major bile ducts in six (Table 2). One patient with leakage after simple cholecystectomy had been reoperated on because of cholascos, and a T tube was placed in the CBD. When the T tube was removed the patient developed severe bile secretion. Seven patients had
Table 2 Sites of bile leakage and nature of treatment in 32 patients
Patients and methods
Treatment
The case records of patients with iatrogenic biliary leakage in the period 1981-1989 were reviewed. There were 32 patients, 15 male and 17 female, with a median age of 54 (range 15-89) years. The primary operation was cholecystectomy in 17,cholecystectomy and choledocholithotomy in 11, and miscellaneous procedures in four (Table 1 ) . Indications for postoperative endoscopic retrograde cholangiopancreatography (ERCP) were production of several hundred millilitres of bile through a drain in the early postoperative period, clinical signs of cholascos, or persistent bile secretion through a drain or cutaneous fistula. ERCP was performed at a median of 17 (range 2-75) days after the primary operation. Eight patients underwent reoperation before ERCP was performed: six for biloma or biliary
Leakage site
No.
Cystic duct stump
19 5
T tube track
Gallbladder Liver abscess cavity Major ducts
Internal stent 17 4 1 0 2*
1
1 6
CBD stones
ES
2
4t 3t 0 0 0
1
0 1
1
ES, endoscopic sphincterotomy ;CBD, common bile duct. * Nasobiliary catheter in one case; tstones removed endoscopically
Table 1 Primary operation and site of bile leakage in 32 patients Leakage site Operation
No.
Cholecystectomy Cholecystectomy and choledocholithotomy Hepatic lobe resection Liver abscess surgery Gallbladder abscess surgery Surgery for traumatic bleeding
17 11 1
0007-1 323,Y2/12 1339-03
t
1 1
1
1992 Butterworth-Heinemann Ltd
Cystic duct stump 14
5 0 0 0 0
T tube track 1 4 0 0 0 0
Gallbladder or liver cavity 0 0 0 1 1
0
Major ducts
2 2 1 0 0 1
1339
Endoscopy in postoperative bile leaks: J. Mortensen and A. Kruse
with major duct lesions underwent reconstructive surgery; it is doubtful whether the endoscopic procedure had any effect other than mapping anatomical structures. One patient developed mild cholangitis after internal stenting and was managed by antibiotics. N o bleeding or stricture occurred after stenting or ES. Four patients died. This could not, however, be ascribed to the endoscopic procedure in any instance, but was the result of age and general postoperative complications.
Discussion
Figure 1 Endoscopic retrograde cholungiopuncreui(~~ruphy 5 duy.7 ufier operution .shon,ing cystic ducr .stump lrukuge in u 33-.veur-old womun W/KJ d e ~ e k ~ p signs d of' choluscos u f t r r cho1ecy.stectomy
retained stones in the CBD ( T a b l e 2 ) , four with leakage from the cystic duct stump and three from a T tube track. All retained stones were removed endoscopicdliy.Cystic duct stump leakage (Figure I ) was treated with internal stenting in 17 instances ( F i g u r r 2 ) and with endoscopic sphincterotomy ( E S ) in two. T tube track leakage was treated with internal stenting in four instances and ES in one; leakage from thc gallbladder was treated with intcrnal stenting and from a liver cavity with ES. Major duct leakage in the patient after liver resection was caused by erosion of a suture line by a drain, which was, accordingly, withdrawn. Three CBD lesions were palliated with internal stenting, nasobiliary catheterization or ES, whereas n o endoscopic treatment was possible in two patients with major duct lesions. When stenting was performed In patients without retained stones in the CBD, sphincterotomy was not performed. Additionally, fivc patients ( f o u r with cystic duct stump and one with T tube track leakage) wcrc treatcd by ultrasonographically guided drainage of subhepatic o r subphrenic biloma or abscess.
Results Bile secretion through a drain or cutaneous fistula decreased immediately after treatment in all 27 patients with leakage from the cystic duct stump, T tube track, gallbladder, liver cavity or suture line of the liver resection and had stopped within I week. In all 22 patients undergoing internal biliary stenting, healing of leakage was revealed by ERCP when the stent was removed 1-3 months later. Two of the patients had an additional operation performed, one immediately after endoscopy to obtain sufficient drainage of cholascos and one 4 weeks after endoscopy because of a subhepatic abscess that was intractable to drainage by ultrasonographic methods. Five of the patients
1340
Bile leakage after biliary tract surgery may present through a cutaneous fistula or drain without affecting the patient's general condition, or it may present with severe abdominal symptoms requiring acute intervention. Surgery in such conditions carries certain risks; often the source of the bi;e leak is unknown and may be difficult to define in an inflamed area. ERCP has the potential for mapping the precise anatomy of the biliary tract and at the same time allowing a therapeutic procedure. General anaesthesia is not needed and the procedure can be performed under mild sedation within 30 min in most cases. Stress to the patient is, therefore, minimal. The present results demonstrate that the method is excellent for treating the most common sources of bile leakage after biliary tract surgery. All retained stones in the CBD could be removed and bile secretion stopped soon after either internal stenting or ES, indicating a quick healing of the fistula. The complication rate was very low. We prefer internal stenting to ES when there is leakage from the biliary ducts, both to be sure that the region of the sphincter of Oddi is effectively bypassed and to preserve the sphincter of Oddi itself, although it is necessary to perform a second endoscopic procedure to remove the drain. However, ES is probably equally effective because the resistance of the sphincter of Oddi is eliminated. Equally good results have been obtained in two other series3.'. The authors of these reports have used ES in cystic duct stump leakage and reserved internal stenting as a prophylactic measure for patients with signs of stricture distal to the leakage. They believe a long-standing stent carries certain risks in itself, especially of cholangitis. In the present series there was one case of cholangitis, managed by antibiotics. In a recent report a nasobiliary catheter was recommended instead of an internal stent in the treatment of cystic duct stump leakage8. This enables cholangiography to be performed to establish closure of the leakage and eliminates the need for a second endoscopic procedure. On the other hand, nasobiliary catheters are not able to transport more than about one-third of daily bile production, even when suction is applied', because they are long and thin and transport is partly against gravity, unlike in an internal stent. They may, therefore, not be as effective as an internal stent; furthermore, they are much more uncomfortable for the patient. The single patient in the present series so treated suffered great discomfort. Another non-surgical method of treating bile leakage is by percutaneous transhepatic d r a i ~ ~ a g ewhich ~ . ~ , also seems to be effective in experienced hands. Retained stones in the CBD are a frequent cause of leakage3 and it is more difficult to remove calculi by such a method. Also, the bile ducts are usually of normal calibre when there is leakage, which makes the procedure difficult. ERCP-related procedures are probably more widespread in clinical practice today and should, therefore, be the method of choice. Generally, intraperitoneal bile collections are treated by surgical d r a i r ~ a g e ~ and . ~ several patients in this series were operated on for that reason, especiall;) before endoscopic procedures were performed. Recent data strongly suggest that surgery should be replaced by percutaneous drainage guided by ultrasonographyy.'O, making treatment much more convenient for the patient. A prerequisite is probably that ERCP is performed as soon as bile leakage is suspected, so that it is treated at once, minimizing the risks of bile collection and
Br. J. Surg., Vol. 79,
No. 12, December 1992
Endoscopy in postoperative bile leaks: J. Mortensen and A. Kruse
abscess formation. Major lesions cannot be treated endoscopically, but a diagnostic procedure is relevant to define the nature and site of the lesion. In conclusion, ERCP is the method of choice in suspected postoperative bile leakage. Endoscopic treatment is very effective for the most common types of bile leak and carries a low complication rate. Together with ultrasonography it will probably replace surgery as the treatment for most bile leaks in the future.
5.
6. 7. 8.
References 1.
2. 3.
4.
Corbett CRR, Fyfe NCM, Nicholls RJ, Jackson BT. Bile peritonitis after removal of T tubes from the common bile duct. Br J Surg 1986; 73: 641-3. Singh RP. Bile peritonitis after cholecystectomy. Int Surg 1972; 57: 651 -3. Huibregtse K. Endoscopic Biliary and Pancreatic Drainage. Stuttgart: Georg Thieme, 1988: 68-73. Kaufman SL, Kadir S, Mitchell SE et al. Percutaneous
Br. J. Surg., Vol. 79,
No. 12, December 1992
9. 10.
transhepatic biliary drainage for bile leaks and fistulas. A J R A m J Roentgenol 1984; 144: 1055-8. Ponchon T, Gallez J-F, Valette P-J, Chavaillon A, Borg R. Endoscopic treatment of biliary tract fistulas. Gastrointest Endosc 1989; 35: 490-8. Sauerbruch T, Weinzierl M, Holl J, Pratschle E. Treatment of postoperative bile fistulas by internal endoscopic biliary drainage. Gastroenterology 1986; 90: 1998-2003. Zuidema GD, Cameron JL, Sitzmann JV et ul. Percutaneous transhepatic management of complex biliary problems. Ann Surg 1983; 197: 584-93. Barthel JS, Sastri SV, Landsbaum C. Closure ofcystic duct stump leak by nasobiliary tube drainage. J Clin Gastroenterol 1989; 11: 574-7. Mueller PR, Ferruci J T Jr, Simeone JF et al. Detection and drainage of biliomas: special considerations. A J R A m J Roentgenol 1983; 140: 715-20. Papanicolaou N, Mueller PR, Ferruci J T et al. Abscess-fistula association: radiologic recognition and percutaneous management. A J R A m J Roenlgenol 1984; 143: 811-15.
Paper accepted 16 June 1992
1341
1339-1 341
J. Mortensen and A. Kruse Surgical Gastroenterology Department, Arhus Kommunehospital, DK- 8000 h h u s C. Denmark Correspondence to: Dr J. Mortensen
Endoscopic management of postoperative bile leaks Thirty-two patients aged 15-89 years developed postoperative bile leakage. Twenty-eight had undergone cholecystectomy, with choledocholithotomy in I I , and four had had miscellaneous operations. Endoscopic retrograde cholangiopancreatography ( E R C P ) was performed 2- 75 days after operation and revealed leakage from the cystic duct stump in 19 cases, f r o m a T tube track in five, f r o m the gallbladder and liver abscess cavity in two and from the major bile ducts in six. Major bile duct lesions were not generally amenable to endoscopic treatment, but the remaining 26 patients were treated successfully with internal stenting ( 2 2 ) or endoscopic sphincterotomy cfour); bile secretion in all cases stopped within I week. One patient with cholangitis after an E R C P procedure was managed by antibiotics; no other complication occurred and there were no deaths related to the procedure. E R C P procedures are well tolerated in the postoperative period and may be performed under sedation. E R C P is the method of choice for dealing with bile leakage and ERCP procedures are efective f o r the most common causes of postoperative bile leakage; complications are rare.
Bile leakage is a rare but serious complication that may occur after biliary tract surgery. Usually the leak is from the cystic duct stump or common bile duct (CBD). Although cystic duct stump leakage often heals spontaneously, leakage from any site may cause accumulation of large quantities of bile in the peritoneal cavity, a potential hazard to the patient. Previously it was necessary to treat the leak surgically, with external drainage of any bile collection'.*, but reoperation involves certain risks. In recent years, promising non-operative alternatives have been introduced into clinical practice3-'. This paper reports results with endoscopic treatment of patients with postoperative bile leakage.
peritonitis, one for retained common duct stones (twice) and one tor persistent bleeding (twice). ERCP was performed under sedation, with the patient in the oblique left lateral position, using Olympus duodenoscopes types JFB3, J F l T or JFlTlO (Olympus, Tokyo, Japan). Ifstenting was performed, a 7-Fr polytetrafluoroethylene double-pigtail catheter was used. ERCP showed leakage from the cystic duct stump in 19 patients, from a T tube track in five, from the gallbladder or a liver abscess cavity in two, and from major bile ducts in six (Table 2). One patient with leakage after simple cholecystectomy had been reoperated on because of cholascos, and a T tube was placed in the CBD. When the T tube was removed the patient developed severe bile secretion. Seven patients had
Table 2 Sites of bile leakage and nature of treatment in 32 patients
Patients and methods
Treatment
The case records of patients with iatrogenic biliary leakage in the period 1981-1989 were reviewed. There were 32 patients, 15 male and 17 female, with a median age of 54 (range 15-89) years. The primary operation was cholecystectomy in 17,cholecystectomy and choledocholithotomy in 11, and miscellaneous procedures in four (Table 1 ) . Indications for postoperative endoscopic retrograde cholangiopancreatography (ERCP) were production of several hundred millilitres of bile through a drain in the early postoperative period, clinical signs of cholascos, or persistent bile secretion through a drain or cutaneous fistula. ERCP was performed at a median of 17 (range 2-75) days after the primary operation. Eight patients underwent reoperation before ERCP was performed: six for biloma or biliary
Leakage site
No.
Cystic duct stump
19 5
T tube track
Gallbladder Liver abscess cavity Major ducts
Internal stent 17 4 1 0 2*
1
1 6
CBD stones
ES
2
4t 3t 0 0 0
1
0 1
1
ES, endoscopic sphincterotomy ;CBD, common bile duct. * Nasobiliary catheter in one case; tstones removed endoscopically
Table 1 Primary operation and site of bile leakage in 32 patients Leakage site Operation
No.
Cholecystectomy Cholecystectomy and choledocholithotomy Hepatic lobe resection Liver abscess surgery Gallbladder abscess surgery Surgery for traumatic bleeding
17 11 1
0007-1 323,Y2/12 1339-03
t
1 1
1
1992 Butterworth-Heinemann Ltd
Cystic duct stump 14
5 0 0 0 0
T tube track 1 4 0 0 0 0
Gallbladder or liver cavity 0 0 0 1 1
0
Major ducts
2 2 1 0 0 1
1339
Endoscopy in postoperative bile leaks: J. Mortensen and A. Kruse
with major duct lesions underwent reconstructive surgery; it is doubtful whether the endoscopic procedure had any effect other than mapping anatomical structures. One patient developed mild cholangitis after internal stenting and was managed by antibiotics. N o bleeding or stricture occurred after stenting or ES. Four patients died. This could not, however, be ascribed to the endoscopic procedure in any instance, but was the result of age and general postoperative complications.
Discussion
Figure 1 Endoscopic retrograde cholungiopuncreui(~~ruphy 5 duy.7 ufier operution .shon,ing cystic ducr .stump lrukuge in u 33-.veur-old womun W/KJ d e ~ e k ~ p signs d of' choluscos u f t r r cho1ecy.stectomy
retained stones in the CBD ( T a b l e 2 ) , four with leakage from the cystic duct stump and three from a T tube track. All retained stones were removed endoscopicdliy.Cystic duct stump leakage (Figure I ) was treated with internal stenting in 17 instances ( F i g u r r 2 ) and with endoscopic sphincterotomy ( E S ) in two. T tube track leakage was treated with internal stenting in four instances and ES in one; leakage from thc gallbladder was treated with intcrnal stenting and from a liver cavity with ES. Major duct leakage in the patient after liver resection was caused by erosion of a suture line by a drain, which was, accordingly, withdrawn. Three CBD lesions were palliated with internal stenting, nasobiliary catheterization or ES, whereas n o endoscopic treatment was possible in two patients with major duct lesions. When stenting was performed In patients without retained stones in the CBD, sphincterotomy was not performed. Additionally, fivc patients ( f o u r with cystic duct stump and one with T tube track leakage) wcrc treatcd by ultrasonographically guided drainage of subhepatic o r subphrenic biloma or abscess.
Results Bile secretion through a drain or cutaneous fistula decreased immediately after treatment in all 27 patients with leakage from the cystic duct stump, T tube track, gallbladder, liver cavity or suture line of the liver resection and had stopped within I week. In all 22 patients undergoing internal biliary stenting, healing of leakage was revealed by ERCP when the stent was removed 1-3 months later. Two of the patients had an additional operation performed, one immediately after endoscopy to obtain sufficient drainage of cholascos and one 4 weeks after endoscopy because of a subhepatic abscess that was intractable to drainage by ultrasonographic methods. Five of the patients
1340
Bile leakage after biliary tract surgery may present through a cutaneous fistula or drain without affecting the patient's general condition, or it may present with severe abdominal symptoms requiring acute intervention. Surgery in such conditions carries certain risks; often the source of the bi;e leak is unknown and may be difficult to define in an inflamed area. ERCP has the potential for mapping the precise anatomy of the biliary tract and at the same time allowing a therapeutic procedure. General anaesthesia is not needed and the procedure can be performed under mild sedation within 30 min in most cases. Stress to the patient is, therefore, minimal. The present results demonstrate that the method is excellent for treating the most common sources of bile leakage after biliary tract surgery. All retained stones in the CBD could be removed and bile secretion stopped soon after either internal stenting or ES, indicating a quick healing of the fistula. The complication rate was very low. We prefer internal stenting to ES when there is leakage from the biliary ducts, both to be sure that the region of the sphincter of Oddi is effectively bypassed and to preserve the sphincter of Oddi itself, although it is necessary to perform a second endoscopic procedure to remove the drain. However, ES is probably equally effective because the resistance of the sphincter of Oddi is eliminated. Equally good results have been obtained in two other series3.'. The authors of these reports have used ES in cystic duct stump leakage and reserved internal stenting as a prophylactic measure for patients with signs of stricture distal to the leakage. They believe a long-standing stent carries certain risks in itself, especially of cholangitis. In the present series there was one case of cholangitis, managed by antibiotics. In a recent report a nasobiliary catheter was recommended instead of an internal stent in the treatment of cystic duct stump leakage8. This enables cholangiography to be performed to establish closure of the leakage and eliminates the need for a second endoscopic procedure. On the other hand, nasobiliary catheters are not able to transport more than about one-third of daily bile production, even when suction is applied', because they are long and thin and transport is partly against gravity, unlike in an internal stent. They may, therefore, not be as effective as an internal stent; furthermore, they are much more uncomfortable for the patient. The single patient in the present series so treated suffered great discomfort. Another non-surgical method of treating bile leakage is by percutaneous transhepatic d r a i ~ ~ a g ewhich ~ . ~ , also seems to be effective in experienced hands. Retained stones in the CBD are a frequent cause of leakage3 and it is more difficult to remove calculi by such a method. Also, the bile ducts are usually of normal calibre when there is leakage, which makes the procedure difficult. ERCP-related procedures are probably more widespread in clinical practice today and should, therefore, be the method of choice. Generally, intraperitoneal bile collections are treated by surgical d r a i r ~ a g e ~ and . ~ several patients in this series were operated on for that reason, especiall;) before endoscopic procedures were performed. Recent data strongly suggest that surgery should be replaced by percutaneous drainage guided by ultrasonographyy.'O, making treatment much more convenient for the patient. A prerequisite is probably that ERCP is performed as soon as bile leakage is suspected, so that it is treated at once, minimizing the risks of bile collection and
Br. J. Surg., Vol. 79,
No. 12, December 1992
Endoscopy in postoperative bile leaks: J. Mortensen and A. Kruse
abscess formation. Major lesions cannot be treated endoscopically, but a diagnostic procedure is relevant to define the nature and site of the lesion. In conclusion, ERCP is the method of choice in suspected postoperative bile leakage. Endoscopic treatment is very effective for the most common types of bile leak and carries a low complication rate. Together with ultrasonography it will probably replace surgery as the treatment for most bile leaks in the future.
5.
6. 7. 8.
References 1.
2. 3.
4.
Corbett CRR, Fyfe NCM, Nicholls RJ, Jackson BT. Bile peritonitis after removal of T tubes from the common bile duct. Br J Surg 1986; 73: 641-3. Singh RP. Bile peritonitis after cholecystectomy. Int Surg 1972; 57: 651 -3. Huibregtse K. Endoscopic Biliary and Pancreatic Drainage. Stuttgart: Georg Thieme, 1988: 68-73. Kaufman SL, Kadir S, Mitchell SE et al. Percutaneous
Br. J. Surg., Vol. 79,
No. 12, December 1992
9. 10.
transhepatic biliary drainage for bile leaks and fistulas. A J R A m J Roentgenol 1984; 144: 1055-8. Ponchon T, Gallez J-F, Valette P-J, Chavaillon A, Borg R. Endoscopic treatment of biliary tract fistulas. Gastrointest Endosc 1989; 35: 490-8. Sauerbruch T, Weinzierl M, Holl J, Pratschle E. Treatment of postoperative bile fistulas by internal endoscopic biliary drainage. Gastroenterology 1986; 90: 1998-2003. Zuidema GD, Cameron JL, Sitzmann JV et ul. Percutaneous transhepatic management of complex biliary problems. Ann Surg 1983; 197: 584-93. Barthel JS, Sastri SV, Landsbaum C. Closure ofcystic duct stump leak by nasobiliary tube drainage. J Clin Gastroenterol 1989; 11: 574-7. Mueller PR, Ferruci J T Jr, Simeone JF et al. Detection and drainage of biliomas: special considerations. A J R A m J Roentgenol 1983; 140: 715-20. Papanicolaou N, Mueller PR, Ferruci J T et al. Abscess-fistula association: radiologic recognition and percutaneous management. A J R A m J Roenlgenol 1984; 143: 811-15.
Paper accepted 16 June 1992
1341
