Biliary Leaks: Role of ERCP in Post-operative Biliary Complications

  • Jörg G. AlbertEmail author


Iatrogenic bile duct injury (BDI) might be sequel of surgical interventions and requires ERCP to establish a diagnosis and—in many cases—to offer an effective treatment. Patients’ presentation in post-operative biliary complications is often non-specific and symptoms may range from pruritus, fatigue, jaundice, and abdominal pain to frank cholangitis and sepsis. The treatment plan should be based on an interdisciplinary discussion amongst interventionalists and hepato-biliary surgeons. This survey highlights several classification systems of BDI to illustrate differential indication of interventional vs. surgical repair. Thereby, a high overall success rate can be achieved by tailoring percutaneous, endoscopic, and surgical approaches to the types of lesions. Transpapillary plastic stent insertion together with sphincterotomy is usually preferred, bridging the leakage if feasible and—most important—decreasing the intraductal pressure by opening the sphincter. The role of covered metal stents is promising for sealing a leak (e.g., from the cystic stump) or to treat concurrent CBD stricture and leak, but still experimental. For plastic stents, 6–8 weeks stenting is usually sufficient. Initial percutaneous drainage can usually be removed shortly after successful ERCP. For large defects and refractory leakage, hepato-jejunal anastomosis or other reconstructive surgery might be necessary.


Bile duct injury Biliary leak Bile leakage ERCP PTCD Percutaneous transhepatic cholangiodrainage Endoscopic retrograde cholangiopancreatography 



Bile duct injury


Computed tomography


common bile duct


common hepatic duct


Endoscopic-retrograde cholangiography


Endoscopic retrograde cholangiopancreatography


Endoscopic ultrasound


Hepatobiliary iminodiacetic acid


left hepatic duct


Magnetic resonance cholangiopancreatography


Magnetic resonance imaging


Percutaneous transhepatic cholangiodrainage


right hepatic duct


Percutaneous ultrasound


  1. 1.
    Rainio M, Lindström O, Udd M, Haapamäki C, Nordin A, Kylänpää L. Endoscopic therapy of biliary injury after cholecystectomy. Dig Dis Sci. 2018;63(2):474–80. Epub 2017 Sep 25. Scholar
  2. 2.
    Archer SB, Brown DW, Smith CD, Branum GD, Hunter JG. Bile duct injury during laparoscopic cholecystectomy: results of a national survey. Ann Surg. 2001;234(4):549–58. discussion 558-9.CrossRefGoogle Scholar
  3. 3.
    Schmidt SC, Settmacher U, Langrehr JM, Neuhaus P. Management and outcome of patients with combined bile duct and hepatic arterial injuries after laparoscopic cholecystectomy. Surgery. 2004;135:613–8.CrossRefGoogle Scholar
  4. 4.
    Strasberg SM, Hertl M, Soper NJ. An analysis of the problem of biliary injury during laparoscopic cholecystectomy. J Am Coll Surg. 1995;180:101–25.PubMedGoogle Scholar
  5. 5.
    Moreels TG. Endoscopic retrograde cholangiopancreatography in patients with altered anatomy: how to deal with the challenges ? World J Gastrointest Endosc. 2014;16:345–51.CrossRefGoogle Scholar
  6. 6.
    Albert JG, Tal A, Bechstein WO, Trojan J, Schnitzbauer A. Three late adverse events of choledochoduodenostomy of which the endoscopist should be aware: direct retrograde cholangioscopy is helpful for diagnosis and therapy. Gastrointest Endosc. 2015;81(2):463–4. pii: S0016-5107(14)01822-7. Scholar
  7. 7.
    Albert JG, Finkelmeier F, Friedrich-Rust M, Kronenberger B, Trojan J, Zeuzem S, Sarrazin C. Identifying indications for percutaneous (PTC) vs. endoscopic ultrasound (EUS)-guided “rendezvous” procedure in biliary obstruction and incomplete endoscopic retrograde cholangiography (ERC). Z Gastroenterol. 2014;52(10):1157–63. Epub 2014 Oct 14. Scholar
  8. 8.
    Bismuth H, Majno PE. Biliary strictures: classification based on the principles of surgical treatment. World J Surg. 2001;25:1241–4.CrossRefGoogle Scholar
  9. 9.
    Way LW, Stewart L, Gantert W, Liu K, Lee CM, Whang K, Hunter JG. Causes and prevention of laparoscopic bile duct injuries: analysis of 252 cases from a human factors and cognitive psychology perspective. Ann Surg. 2003;237:460–9.PubMedPubMedCentralGoogle Scholar
  10. 10.
    Neuhaus P, Schmidt SC, Hintze RE, Adler A, Veltzke W, Raakow R, Langrehr JM, Bechstein WO. Classification and treatment of bile duct injuries after laparoscopic cholecystectomy. Chirurg. 2000;71:166–73.CrossRefGoogle Scholar
  11. 11.
    Bektas H, Schrem H, Winny M, Klempnauer J. Surgical treatment and outcome of iatrogenic bile duct lesions after cholecystectomy and the impact of different clinical classification systems. Br J Surg. 2007;94:1119–27.CrossRefGoogle Scholar
  12. 12.
    Bergman JJ, van den Brink GR, Rauws EA, de Wit L, Obertop H, Huibregtse K, et al. Treatment of bile duct lesions after laparoscopic cholecystectomy. Gut. 1996;38:141–7.CrossRefGoogle Scholar
  13. 13.
    Pitt HA, Sherman S, Johnson MS, Hollenbeck AN, Lee J, Daum MR, Lillemoe KD, Lehman GA. Improved outcomes of bile duct injuries in the 21st century. Ann Surg. 2013;258(3):490–9. Scholar

Copyright information

© Springer Nature Switzerland AG 2020

Authors and Affiliations

  1. 1.Hepatologie und EndokrinologieAbteilung für Gastroenterologie, Robert-Bosch-KrankenhausAuerbachstraßeGermany

Personalised recommendations