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Management of a Persistent Cystic Duct Stump Leak Following Cholecystectomy With Percutaneous Transabdominal Cystic Duct Stump Embolization

Brown, Craig S. MD1; Sanogo, Mamadou MD2; Patel, Arpan MD3; Schulman, Allison R. MD, MPH3; Raghavendran, Krishnan MBBS1; Georgoff, Patrick E. MD1

doi: 10.14309/crj.0000000000000162
CASE REPORT
Open

ABSTRACT Cystic duct stump leak remains a difficult clinical problem despite advancements in endoscopic techniques. When these minimally invasive strategies fail, patients are often subject to high morbidity and mortality associated with open surgical exploration. We report the successful treatment of persistent biliary leak from the cystic duct stump following cholecystectomy using percutaneous transabdominal access of the cystic duct and coil embolization.

1Department of Surgery, Section of Acute Care Surgery, University of Michigan, Ann Arbor, MI

2Department of Radiology, Section of Interventional Radiology, University of Michigan, Ann Arbor, MI

3Department of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI

Correspondence: Craig Brown, MD, Department of Surgery, Section of Acute Care Surgery, University of Michigan, 1500 E Medical Center Dr, Ann Arbor, MI 48109 (brcraig@med.umich.edu).

Received January 21, 2019

Accepted May 31, 2019

Online date: August 23, 2019

This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.

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INTRODUCTION

Cystic duct stump leaks occur in 0.12% of cholecystectomies.1 Initial management is typically endoscopic and includes sphincterotomy or biliary stenting.2,3 With failure rates as high as 10%, alternative approaches to the treatment of cystic duct stump leaks may be required.4 We describe the management of a patient with persistent cystic duct stump leak despite the use of common bile duct (CBD) stents. A percutaneous transabdominal cystic duct stump cannulation and coil embolization technique was employed.

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CASE REPORT

A 64-year-old woman presented with signs and symptoms of acute cholecystitis. She was taken to the operating room and underwent an attempted laparoscopic cholecystectomy, which was converted to an open operation secondary to extensive adhesions and scarring. A surgical drain was left in the gallbladder fossa. On postoperative day 1, the patient developed a bile leak. Endoscopic retrograde cholangiopancreatography was performed confirming the presence of a cystic duct stump leak (Figure 1). A single plastic stent was placed with no improvement in external bilious drainage. Repeat endoscopic retrograde cholangiopancreatography confirmed ongoing leak, and 2 plastic stents were placed. She was initially hospitalized for a total of 12 days.

Figure 1

Figure 1

Four weeks later, repeat cholangiogram demonstrated that the leak persisted despite a well-placed stent (confirmed by fluoroscopy). At that point, a 10 mm × 8 cm covered metal biliary stent was placed, which traversed the cystic duct and remained in place for 3 months. Despite this intervention, 300 cc/d of bilious fluid persisted through the external drain. The patient did not show any signs of sepsis. A multidisciplinary meeting was arranged to discuss alternative treatment options. Endoscopic choledochoscopy with embolization and coiling of the cystic duct stump was attempted but despite the use of a 0.018-inch flexible guidewire, the cystic duct stump could not be deeply cannulated. Percutaneous transhepatic embolization of the cystic duct stump was also attempted but was unsuccessful in reducing the biliary leak. As an alternative to open surgical exploration and choledocho- or hepaticojejunostomy, the decision was made to attempt cystic duct stump access and coil embolization via the epithelialized percutaneous right upper quadrant drain tract under fluoroscopic guidance (Figure 2). Follow-up cholangiogram confirmed the resolution of the cystic duct stump leak, and the biliary stent was successfully removed. She had no complications from any of her endoscopic or percutaneous procedures and spent a total of 27 days as an inpatient over the course of her treatment.

Figure 2

Figure 2

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DISCUSSION

The majority of cystic duct stump leaks heal spontaneously when bile is shunted past the defect. This is most commonly accomplished with endoscopic stenting and sphincterotomy or percutaneous transhepatic biliary drainage.4 Percutaneous or endoscopic coil embolization, fibrin glue, and gelatin sponge injection are alternative approaches for refractory cases. These treatments avoid the significant morbidity of open surgical exploration.5–10 These techniques can also be utilized for biliary leaks at alternative sites, such as from the duct of Luschka or from higher-order biliary radicals.11,12 In this case, cystic duct embolization was accomplished via an existing epithelialized percutaneous drain tract. This innovative and technically challenging feat has previously been described in a few other case series. It is, however, not without complications, including migration of embolization of coils into the common bile duct causing obstruction.13,14 Endoscopic approaches involve known complications associated with cannulation of the biliary tree including perforation and postprocedural pancreatitis, among others, while percutaneous approaches may result in inadvertent solid or hollow viscus injury. This case describes the challenges associated with managing cystic duct stump leaks and highlights a multidisciplinary approach that utilizes advanced minimally invasive treatment options to avoid the morbidity associated with surgical repair.

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DISCLOSURES

Author contributions: All authors designed, wrote, and edited the manuscript. CS Brown is the article guarantor.

Financial disclosure: None to report.

Informed consent was obtained for this case report.

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REFERENCES

1. Eisenstein S, Greenstein AJ, Kim U, et al. Cystic duct stump leaks: After the learning curve. Arch Surg. 2008;143(12):1178–83.
2. Singh V, Singh G, Verma GR, et al. Endoscopic management of postcholecystectomy biliary leakage. Hepatobiliary Pancreat Dis Int. 2010;9(4):409–13.
3. Ahmad F, Saunders RN, Lloyd GM, et al. An algorithm for the management of bile leak following laparoscopic cholecystectomy. Ann R Coll Surg Engl. 2007;89(1):51–6.
4. Barkun AN, Rezieg M, Mehta SN, et al. Postcholecystectomy biliary leaks in the laparoscopic era: Risk factors, presentation, and management. McGill Gallstone Treatment Group. Gastrointest Endosc. 1997;45(3):277–82.
5. Perisetti A, Raghavapuram S, Tharian B. Refractory cystic duct stump leak treated with fibrin glue. Endoscopy. 2019;51:E170–1.
6. Wahaibi AA, Alnaamani K, Alkindi A, et al. A novel endoscopic treatment of major bile duct leak. Int J Surg Case Rep. 2014;5(4):189–92.
7. Abdel Aal AK, Jones DP, Caraway J, et al. Percutaneous embolization of cystic duct stump leak following failed endoscopic management. Radiol Case Rep. 2017;12(4):786–9.
8. Choi KM, Jang HJ, Kwak JH, et al. Management of postoperative bilomas and biliary injuries associated with laparoscopic cholecystectomy with intrabiliary ethanol ablation and micro-coil embolization. Hepatogastroenterology. 2014;61(129):27–30.
9. Schelhammer F, vom Dahl S, Heintges T, et al. A multimodal approach in coil embolization of a bile leak following cholecystectomy. Cardiovasc Interv Radiol. 2007;30(3):529–30.
10. Doshi T, Mojtahedi A, Goswami GK, et al. Persistent cystic duct stump leak managed with hydrocoil embolization. Cardiovasc Interv Radiol. 2009;32(2):394–6.
11. Kirtane T, Goyal D, Rahimi E, et al. Refractory bile leak with biliocutaneous fistula treated by endobiliary coil placement. Endoscopy. 2017;49(12):1280–1.
12. Salsano G, Paparo F, Valdata A, et al. Management of bile leak from Luschka ducts after laparoscopic cholecystectomy: An original procedure for coil embolization. Cardiovasc Interv Radiol. 2016;39(3):483–6.
13. Sandroussi C, Lemech LD, Grunewald B, et al. Late complication following coil embolization of a biliary leak. Anz J Surg 2005;75(7):614–5.
14. Oliva VL, Nicolet V, Soulez G, et al. Bilomas developing after laparoscopic biliary surgery: Percutaneous management with embolization of biliary leaks. J Vasc Interv Radiol. 1997;8(3):469–73.
© 2019 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of The American College of Gastroenterology.