Tailored Minimally Invasive Treatment of Biliary Leaks

Jan M Krzak, MD, Ada M Krzak, Poul Bak Thorsen, MD, PhD, Miroslaw Szura, MD, PhD, Lars Stig Jorgensen, MD. Department of Surgery, Sygehus Lillebaelt, Kolding, Denmark.

OBJECTIVES
The goal of this study was to find the most optimal treatment for biliary leaks after a surgery.

METHODS
Records from secondary referral centre ERCP database of 47 consecutive patients (22 women and 27 men) with biliary leaks, treated between November 2006 and July 2013, in the setting of Sygehus Lillebaelt, Kolding, Denmark,were analyzed. All patients were treated according to the minimally invasive management protocol, which included drainage, Endoscopic Ret-rograde Cholangiopancreatography (ERCP), endoscopic transpapillary biliary stent place-ment with or without endoscopic sphincterotomy (ES). Three major groups were identified and compared. Patients from group 1 were treated with drainage, ERCP with endoscopic sphincterotomy and endoscopic transpapillary biliary stent placement. Group 2 and group 3 were treated with drainage and endoscopic transpapillary biliary stent placement, however in group 3 the preventive stent placement during primary operation was performed as a rendez-vous procedure, when the biliary leak observed during the primary procedure was difficult to treat.

All data were analyzed statistically using T-tests for continuous variables distributed nor-mally, and Mann-Whitney Ranksum tests for continuous variables not-normally distributed. Statistical significance level was set to 5%. The software package SPSS ver. 17.0 was used for the statistical analyses in this paper.

RESULTS
The groups consisted of 16, 26 and 5 patients respectively. All patients were treated with drains placed either during primary procedure or radiologically guided. ERCP were per-formed in groups 1 and 2 between 1 and 13 days after the primary procedure (mean 3,62 (±2,64) days). In two cases two ERCP attempts with 4 days interval were needed to place a stent. Leak stops were observed between 1 and 9 days (mean 3,52 (±1,94) days). There were no statistically significant differences between the intervals in which the biliary leak stopped in group 1 and 2. In group 3, with preventive placed stent, two patients had bile leaks in 1 and 2 days respectively while in tree others bile was only observed in drains without leak. The stents were removed between 14 and 90 days (mean 48 (±17,2) days.

Detailed results including timing of ERCP after primary procedures, intervals of biliary leak stops and complications will be presented.

CONCLUSIONS
Minimally invasive management of biliary leaks including all modalities like drainage, endo-scopic transpapillary biliary stent placement and preventive stent placements as well as sphincterotomy when needed is an effective and safe treatment. Preventive ERCP with stent-ing as a rendezvous procedure is technically demanding but safe and feasible option when available for avoidance of biliary leaks when visualisation of bile leak localisation is difficult.
 

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