Stent Placement Better Than Sphincterotomy for Treatment of Postcholecystectomy Bile Leak

Bret T. Petersen, MD, FASGE reviewing Abbas A, et al. Gastrointest Endosc 2019 Aug.

Postcholecystectomy bile leaks are typically treated with bile duct decompression or drainage via ERCP. 

The authors of this study evaluated 1028 patients (median 56 years of age) from 5 years of the Nationwide Inpatient Sample to characterize the timing, effectiveness, and adverse events of endoscopic intervention using sphincterotomy (24%), biliary stent placement (24%), or both (52%). 

Interventions were performed expectantly (>3 days after cholecystectomy) in 51% of patients, urgently (2 to 3 days post-op) in 30%, and emergently (within 1 day) in 19%. Identifiable post-ERCP adverse events from this administrative database, including use of pressors, invasive monitoring, hemodialysis, and endotracheal intubation, occurred in 9% to 11% of patients and did not differ based upon the timing of intervention but did correlate with weekend ERCP (29% vs 8% weekday; P <.001), failure of ERCP therapy, advanced age, high comorbidity, and admission to a rural hospital. Treatment failure, defined as the need for surgical or radiologic/percutaneous salvage was least common for combination therapy (3%; odds ratio [OR], 0.2; 95% confidence interval [CI], 0.1-0.5) and stent alone (4%; OR, 0.4; 95% CI, 0.2-0.9), compared to sphincterotomy alone (11%; P <.001). In-hospital mortality varied with urgency of intervention (expectant 2%, urgent 0%, and emergent 5%; P <.001), and multivariate analysis correlated mortality with failure of ERCP (OR, 9.9; P <.001), emergent ERCP (OR, 3.8; P=0.005), nonteaching hospital (OR, 4.3; P=.009), and Southern geographic region (OR, 3.7; P=0.013).

In this study, the mode of therapy for postcholecystectomy bile leaks appeared more important than the timing, with biliary stent placement or stent plus sphincterotomy proving more effective than sphincterotomy alone. Failed ERCP carried the highest risk for mortality beyond that related to emergent procedures.

Bret T. Petersen, MD, FASGE
Bio and Disclosures

Back to Journal Scan

Abbas A, Sethi S, Brady P, Taunk P. Endoscopic management of postcholecystectomy biliary leak: When and how? A nationwide study. Gastrointest Endosc 2019;90:233-241. (