Bile leaks after videolaparoscopic cholecystectomy: duct of Luschka. Endoscopic treatment in a single centre and brief literature review on current management.

BACKGROUND

Laparoscopic cholecystectomy (LC) for gallstone disease is the most common surgical procedures performed in Western countries and bile leaks remain a significant cause of morbidity (0.2-2%). The bile ducts of Luschka (DL)are small ducts which originate from the right hepatic lobe, course along the gallbladder bed, and usually drain in the extrahepatic bile ducts. Injuries to these ducts are the second most frequent cause of bile leaks after cholecystectomy. Aim of our study is build a literature review starting from our experience.

PERSONAL EXPERIENCE

Forty four patients with abdominal bile collections post-cholecystectomy by suspected bile leak under-went endoscopic retrograde cholagio-pancreatography (ERCP). A complete cholangiogram was obtained in 42 patients(95.5%). In according to the magnitude of bile leak daily, we subdivided the patients in two groups: a) < 180 ml/daily,and b) > 180 ml/daily. The most common site of the leak was the cystic duct stump (94.5%), followed by DL (2 patient = 5.5%). 10 Fr stent insertion after endoscopic sphincterotomy (ES) was the most common intervention. In 6 patients (14%) a 7 Fr naso-biliary drainage was inserted. On an intention-to-treat basis, endoscopic intervention at ERCP had 100% success rate for resolution of the leak. The median time for resolution of the leak was 8 and 12 days in the first and second group respectively. No mortality ERCP-related were recorded. Early minor complications occurred in 7/42 (16.5%) patients.

METHODS

A literature search using MEDLINE's Medical Subject Heading terms was used to identify recent articles.Cross-references from these articles were also used.

RESULTS

ERCP is the most common diagnostic and therapeutic method used in bile leaks post-cholecystectomy. Most patients with DL leaks are symptomatic, and most leaks are detected postoperatively during the first postoperative week. Reduction of intra-ductal pressure with ES and stent or naso-biliary tube insertion will lead to preferential flow of bile through the papilla, thus permitting DL injuries to heal. This is the most common treatment modality used. In a minority of patients,re-laparoscopy is performed. In such cases, the leaking DL is visualized directly and ligation usually is sufficient treatment.Simple drainage is adequate treatment for a small number of asymptomatic patients with low-volume leaks.

CONCLUSIONS

DL leaks occur after cholecystectomy regardless of gallbladder pathology or urgency of operation. They have been encountered more frequently in the era of LC Intraoperative cholangiography does not detect all such leaks. ERCP with ES and stent placement are the most common effective diagnostic and therapeutic methods used. Intraoperative and perioperative adjunctive measures, such as fibrin glue instillation and pharmacologic relaxation of the sphincter of Oddi,can potentially be used in lowering the incidence and in the treatment of DL leaks.