Experience on endoscopic management of Iatrogenic bile duct injuries following laparoscopic cholecystectomy

Abstract

INTRODUCTION: Clinically significant bile leaks due to iatrogenic bile duct injuries following laparoscopic cholecystectomy is not infrequent. Endoscopic procedures have become the treatment of choice for the management of biliary leakage following iatrogenic bile duct injuries. GENERAL OBJECTIVE: To assess the therapeutic outcome of endoscopic therapy of the patients who had iatrogenic biliary injury and biliary leakage following laparoscopic cholecystectomy. METHODS: Prospective descriptive study was performed on32 patients who underwent therapeutic endoscopic procedures for iatrogenic injuries following laparoscopic cholecystectomy for symptomatic gall stone disease in the National Hospital of Sri Lanka. Bile leaks were diagnosed by the presence of persistent abdominal pain, jaundice with cholangitis, abdominal distension and persistent bile flow to the skin surface through and around the existing drains. All the patients underwent abdominal ultra-sonography or CT scan. The presences of bile leaks were confirmed by ERCP. RESULTS: Patients who had bile leaks were diagnosed by, persistent abdominal pain 30 % (9/30), jaundice with cholangitis 6.6% (2/30), abdominal distension 16.6% (5/30), and persistent bile flow to the skin surface through and around the existing drains, 46.6%(14/30). The median duration between initial surgery and detection of bile leak was 3 days (range 0-12 days). Twenty-three patients 76.6% had high-grade bile leaks and 7(23.4%) had low-grade leaks. The iatrogenic bile duct injuries were; cystic duct injuries 10(33.3%) (3 high grade: 7 low grade bile leaks), the common bile duct injuries 16(53.3%) and the right hepatic duct injuries 4(13.3%). All patients were subjected to therapeutic procedures, which consisted of Sphincterotomy with stone extraction followed by biliary stenting (10 patients), Sphincterotomy with biliary stenting (15 patients) and Sphincterotomy alone (5 patients). Bile leaks stopped in all patients at a median of 4 days (range 2-14 days) after endoscopic interventions. Drains were removed at a median duration of time of 6 days (range 5-16 days) after endoscopic procedures. Stents were removed at a 6-8 weeks’ interval. Three (3/6) who had low-grade cystic duct bile leaks, who underwent Sphincterotomy alone, had mean 3.6±0.88SEM days for complete cessation of bile leakage from the drains. Other three patients (3/6) who underwent Sphincterotomy and stent placement had mean of 3.0±0.57SEM days cessation of bile leakage (P=0.52, t-test). All high-grade bile leak (3/10) patients were offered Sphincterotomy and stent placement and had mean 6.8±0.5SEM days for complete cessation of bile leakage from the drains. CONCLUSIONS: Iatrogenic bile duct injuries occur commonly in the common bile duct. Residual stones are found in one-third of cases. No significant difference in healing was seen between the patients who had low-grade bile leaks due to cystic duct injuries and whom were offered either Sphincterotomy alone and Sphincterotomy and stenting.