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Background: Cystic duct leak (CDL) appears to complicate laparoscopic cholecystectomy (LC) more often than open cholecystectomy (OC). No mention of CDL was found in a literature review that covered 48,822 OCs and their complications., Patients and Methods: Fifty-four patients who developed biliary tract injuries following LC were reviewed for: the time from LC to presentation, presenting symptoms, method of diagnosis, treatment, outcome, and follow-up., Results: Seventeen of 54 biliary tract complications (31%) were CDLs. The CDLs presented at a median of 4 days after LC with pain (76%) and nausea and/or vomiting (35%). Endoscopic retrograde cholangiopancreatography (ERCP) defined the diagnosis and the anatomy of the leak in 11 patients (65%). Biliary endoprosthesis placement was employed in 8 patients, with concomitant sphincterotomy in 5 (63%), and resolved CDL in every case. Seven (88%) of these patients were asymptomatic at a median interval of 10 months after stent retrieval. Six patients (35%) underwent reoperation. Five had laparotomy with ligation of the cystic duct stump and 1 underwent laparoscopic examination with reclipping of the cystic duct stump. Five (83%) were asymptomatic at a median follow-up of 26 months. CDLs may result from inaccurate clip placement, perforations proximal to the clips, and stump necrosis, as documented at reoperation., Conclusions: CDLs occur more frequently in LC than in the OCs reported in the literature. Most leaks require intervention. ERCP with stent placement is the diagnostic and therapeutic procedure of choice and has a high success rate of resolving leaks. To forestall CDLs, it is important to place clips accurately and avoid electrocautery in the vicinity of the cystic duct.

During a 2-year period in which the application of laparoscopic cholecystectomy became widespread in the Pacific Northwest, 33 patients with surgically related bile duct injury were seen by the gastroenterology section of a large multi-specialty clinic. Twenty-nine of these patients had anatomy amenable to endoscopic approach, and 25 of the 29 are symptom-free, with normal ultrasonography and serum liver function tests, at a minimum of 1 year of follow-up after undergoing a variety of endotherapeutic procedures. The authors conclude that endoscopic therapy, in conjunction with percutaneous drainage of large bilomas, is effective treatment for cystic duct leak and minor damage to the common bile duct. Further data and prolonged follow-up are required in patients with more significant biliary injury who undergo endoscopic endoprosthesis and/or dilation therapy.

Laparoscopic cholecystectomy has quickly eclipsed open cholecystectomy as the standard approach to symptomatic gallstones and acalculous biliary disease. Procedure-related morbidity and mortality continue to be defined, but a higher incidence of bile duct injuries has been reported to date using present technology and procedure. Key principles in the management of these problems include definition of the anatomy, relief of any impedance to biliary-enteric flow, and drainage of significant extrahepatic fluid collections. A cooperative, multispecialty approach involving surgeons, radiologists, and gastroenterologists is critical to successful outcomes. Future studies will help streamline the management of bile duct injuries and aid physicians in their selection of the best approach for each individual patient.

We assessed the use of endoscopic retrograde cholangiopancreatography (ERCP) after laparoscopic cholecystectomy (LC) at our hepatobiliary referral center. This assessment included patients from outside institutions with post-LC problems. Between May 1990 and September 1992, we performed 522 LCs and 1,723 ERCP examinations. There were 78 patients who underwent 143 ERCP examinations after LC, 65% of whom were referred. ERCP findings were categorized as follows: normal results (8%), problems inherent to stone disease (65%), and iatrogenic injury (27%). The types of inherent problems were common bile duct (CBD) stones, pancreatitis, and papillary stenosis/microlithiasis. Within the CBD stone group, 5 of 26 patients also had papillary stenosis, and, within the pancreatitis group, 9 of 11 patients also had papillary stenosis, making papillary stenosis the most frequent observation (55%). Almost all of these patients (96%) required endoscopic papillotomy for successful treatment. The iatrogenic injury group was comprised of 21 patients, 16% of whom had cystic duct leak and 84% of whom had CBD injury. These patients required a variety of endoscopic procedures including endoscopic papillotomy (67%), CBD endoscopic stenting (76%), percutaneous drainage of biloma (29%), and percutaneous transhepatic biliary drainage (24%). Open surgical procedures after endoscopic assessment or treatment were required in only three patients in the iatrogenic group and in none in the inherent group. At this time, long-term follow-up is not possible with regard to biliary stricture. We conclude that the majority of problems after LC are either due to papillary stenosis/microlithiasis with or without CBD stones or to biliary injury. Both can be successfully diagnosed and treated with endoscopic techniques.