D0450 - Outcomes of Post-Hepatectomy Bile Leaks With Endoscopic Therapy

Mingjun Song, MD¹, Setarah Mohammad Nader, MD¹, Stuart Sherman, MD¹, Evan Fogel, MSc, MD², Mark A. Gromski, MD¹, James Watkins, MD², Jeffrey J. Easler, MD², Aditya Gutta, MD², Yan Tong, PhD², Benjamin Lo Bick, MD^1
1Indiana University School of Medicine, Indianapolis, IN; ²Indiana University, Indianapolis, IN

Introduction: Post-hepatectomy bile leak (H-BL) can occur in up to 30% of cases and lead to higher post-operative morbidity. Endoscopic retrograde cholangiopancreatography (ERCP) is considered a good treatment option although current literature is limited to small cohort studies.

Methods: We created a retrospective database of H-BL cases referred for ERCP between 2011 to 2021. Data collected included endoscopic reports, fluoroscopic imaging, patient demographics, type of H-BL and ERCP outcomes. A high-grade bile leak (HGBL) was defined as visualization of contrast extravasation from the bile duct before filling of intrahepatic biliary branches with contrast. Initial ERCP failure was defined as persistence of H-BL seen on the 2^nd ERCP evaluation.

Results: In total, 48 cases of H-BL (30 for malignancy, 9 for liver abscess, 1 for large liver cyst) were referred for ERCP. None of them had hepaticojejunostomy. After excluding cases with transected bile ducts, 43 cases underwent initial therapeutic ERCP – 20/43 were HGBL involving the left or right hepatic duct (9/20), main extrahepatic duct (9/20) or peripheral intrahepatic ducts (2/20); in contrast, 23/40 low-grade leaks were mainly from peripheral intrahepatic ducts (16/23). 40 patients were able to return for their 2^nd ERCP evaluation. Of these, 38 patients had received biliary endoscopic sphincterotomy (BES) with one or multiple plastic stents and 2 received only plastic biliary stents. 50% of H-BL resolved after initial ERCP and the rest underwent repeat ERCP interventions with eventual resolution of H-BL in 33/38 (86.8%) of cases. Univariate logistic regression analysis identified that high grade leak and presence of biloma were associated with significantly higher odds for H-BL persistence after initial ERCP (Table 1). On multivariate analysis, presence of a high-grade leak (OR 11.02, CI 1.58 – 76.78, p = 0.015) remained significant for persistent H-BL after initial ERCP therapy. Adverse events occurred in 3/40 (7.5%) cases after initial ERCP – 1 case of pancreatitis and 2 cases of cholangitis.

Discussion: Our study suggests that ERCP remains an effective treatment for H-BL, although 50% of our cohort needed more than one ERCP. 15/20 of initial ERCP failures had underlying malignancy, which may have negatively affected healing (OR for initial ERCP 2.72 [0.57 – 12.91]), although this was not statistically significant. Patients with HGBL should undergo more persistent endoscopic therapy such as a longer stent indwell time.




Disclosures:


Mingjun Song, MD¹, Setarah Mohammad Nader, MD¹, Stuart Sherman, MD¹, Evan Fogel, MSc, MD², Mark A. Gromski, MD¹, James Watkins, MD², Jeffrey J. Easler, MD², Aditya Gutta, MD², Yan Tong, PhD², Benjamin Lo Bick, MD¹. D0450 - Outcomes of Post-Hepatectomy Bile Leaks With Endoscopic Therapy, ACG 2022 Annual Scientific Meeting Abstracts. Charlotte, NC: American College of Gastroenterology.