D0048 - Abutting Percutaneous Drains Can Jeopardize Healing of Post-Cholecystectomy Bile Leaks

Tuesday, October 25, 2022

10:00 AM – 12:00 PM ET

Location: Crown Ballroom

Presenting Author(s)

Setarah Mohammad Nader, MD

Indiana University School of Medicine
Indianapolis, IN

Mingjun Song, MD¹, Setarah Mohammad Nader, MD¹, Evan Fogel, MSc, MD², Stuart Sherman, MD¹, Lee McHenry, MD², Benjamin Lo Bick, MD¹
¹Indiana University School of Medicine, Indianapolis, IN; ²Indiana University, Indianapolis, IN

Introduction: Endoscopic retrograde cholangiopancreatography (ERCP) is an effective treatment for post-cholecystectomy (CCY) biliary leaks (BL). However, the presence of a Jackson Pratt (JP) drain abutting on the site of BL may prevent ERCP interventions from being effective.

Case Description/Methods: In this case series, we present 5 cases of CCY induced BL with JP drains noted to be abutting the site of BL by the endoscopist during initial ERCP therapy. We reviewed the ERCP fluoroscopic images and confirmed that the tip of the JP drains was in proximity (within 1cm) or right against the site of contrast extravasation. The details of each case are summarized in Table 1 including the ERCP interventions and the intervals between ERCPs. All 5 cases had a persistent BL documented on repeat ERCP with their JP drains remaining in the same position on fluoroscopic images. For case no. 1, the JP drain was left in-situ after the 1^st and 2^nd ERCPs and a persistent BL from the cystic duct stump can be seen flowing directly into the adjacent JP drain tip on the 3^rd ERCP (Panel A of Image). In Panel B, the endoscopist withdrew the JP drain by about 3cm. In Panel C, the JP drain was already removed prior to the 4^th ERCP, and the BL has resolved. Case no. 2 had ERCP earlier than scheduled due to cholangitis, while case no. 4 returned for an earlier ERCP due to persistently high JP drain output of 900-1000ml a day. For cases no. 2 to 4, when a persistent BL was found, the endoscopist communicated with the surgical team and the JP drain was either retracted by 1-3cm or removed on the same day. After JP drain adjustment, the patients did well, and their BL had resolved by the time of their subsequent ERCP 4 to 23 weeks later. For case no. 5, the JP drain was left in position for 14 weeks after intraoperative placement, and the drain tip was found to have eroded into the biliary duct during the 3^rd ERCP for the persistent BL. In this case, the surgeon on call was contacted who repositioned the drain in the endoscopy unit. The JP drain output decreased and was subsequently removed; the BL resolved on subsequent ERCP 22 weeks later.

Discussion: From these cases, we observed that a JP drain abutting onto the site of BL can create a bigger pressure gradient between the bile duct defect and the drain, making ERCP interventions less effective for promoting transpapillary bile flow. This can be remedied by withdrawing the JP drain by 1-3cm.

Figure: A: A persistent bile leak is seen at the cystic duct stump (arrow) draining directly into the Jackson Pratt drain with its tip abutting the site of leakage during the patient’s 3rd ERCP. The biliary metallic stent had been removed at time of this fluoroscopic image. B: A plastic biliary stent was placed. The Jackson Pratt drain was pulled back. C: The cystic duct bile leak resolved during the 4th ERCP. Prior to this ERCP, the patient had both abdominal drains removed by her surgical team due to low output.

Case Index	Patient demographic	Type of Bile leak	1st ERCP Interventions	2nd ERCP Interventions	3rd ERCP Interventions	4th ERCP
1	42 YO female	Strasberg A BL from CD	BES + Single PS (JP drain left in place)	Persistent BL on ERCP 4 weeks later. SEMS placed. (JP drain left in place.)	Persistent BL on ERCP 4 weeks later. Single PS placed (JP drain retracted by endoscopist.)	*BL resolved on ERCP 4 weeks later
2	58 YO male	Strasberg A BL from CD	BES + Single PS (JP drain left in place)	Persistent BL on ERCP 1 week later. Two PS placed. (Surgical team consulted and JP drain retracted.)	*BL resolved on ERCP 4 weeks later .	N/A
3	75 YO female	Strasberg A BL from CD	BES + Single PS (JP drain left in place)	Persistent BL on ERCP 6 weeks later. SEMS placed. (Surgical team contacted and JP drain retracted.)	*BL resolved on ERCP 23 weeks later .	N/A
4	69 YO male	Strasberg A BL from CD	7Fr Single PS (JP drain left in place)	Persistent BL on ERCP 1 week later. BES+ 10 Fr Single PS placed. (JP drain removed by surgeon on same day post ERCP.)	*BL resolved on ERCP 5 weeks later.	N/A
5	72 YO male	Strasberg D BL from CHD	BES + incomplete stone extraction + Single PS (JP drain left in place)	Persistent BL on ERCP 1 day later. Stone extraction with Spyglass with EHL + Two PS (JP drain left in place.)	Persistent BL on ERCP 8 weeks later. SEMS + two PS placed. (Spyglass cholangioscopy found abutting JP drain had eroded into CHD. Surgeon was contacted who repositioned the JP drain on same day.)	*BL resolved on ERCP 22 weeks later.

Table: Table 1: Case Summaries. Abbreviations: YO: Years old. CD: Cystic duct. CHD: Common hepatic duct. BES: Biliary endoscopic sphincterotomy. PS: Plastic stent. SEMS: Self-expandable metal stent. EHL: Electrohydraulic lithotripsy. JP: Jackson Pratt. BL: Bile leak. *Jackson Pratt drain was removed prior to time of ERCP.

Disclosures:

Mingjun Song: Boston Scientific – Stock-privately held company. Olympus – Stock-privately held company.

Setarah Mohammad Nader indicated no relevant financial relationships.

Evan Fogel indicated no relevant financial relationships.

Stuart Sherman: Boston Scientific – Consultant.

Lee McHenry indicated no relevant financial relationships.

Benjamin Lo Bick: Alcreseta Therapeutics – Grant/Research Support.

Mingjun Song, MD¹, Setarah Mohammad Nader, MD¹, Evan Fogel, MSc, MD², Stuart Sherman, MD¹, Lee McHenry, MD², Benjamin Lo Bick, MD¹. D0048 - Abutting Percutaneous Drains Can Jeopardize Healing of Post-Cholecystectomy Bile Leaks, ACG 2022 Annual Scientific Meeting Abstracts. Charlotte, NC: American College of Gastroenterology.