The role of ERCP in diagnosis and management of accessory bile duct leaks after cholecystectomy

Background: Endoscopic retrograde cholangiopancreatography (ERCP) plays an important role in the management of bile leaks after cholecystectomy. Altho ugh most leaks occur from the cystic duct stump, clinically significant lea kage from accessory bile ducts is less common and has not been investigated systematically. We report our experience with endoscopic diagnosis and tre atment of accessory bile duct leaks after cholecystectomy. Methods: Patients with accessory bile duct leaks were identified from a com puterized database. Hospital charts and cholangiograms were reviewed to det ermine the outcome of diagnostic and therapeutic interventions. Results: Of 86 patients with postcholecystectomy leaks, 15 (17%) were diagn osed with accessory bile duct leaks. ERCP established the diagnosis of acce ssory bile duct leaks in II of 15 patients (73%); percutaneous fistulograph y (2) and percutaneous transhepatic cholangiography (2) were diagnostic in 4 patients. Endoscopic therapy led to resolution of the leak in 12 patients . One patient underwent successful percutaneous biliary drainage, and two p atients required surgical repair. Conclusions: Accessory bile ducts are rare sites of significant bile leakag e after cholecystectomy. ERCP identifies the leak in the majority of patien ts; percutaneous fistulography or percutaneous transhepatic cholangiography may help clarify the diagnosis if ERCP is nondiagnostic. Most patients can be successfully treated with endoscopic stenting. If endoscopic therapy fa ils, percutaneous drainage or surgical repair needs to be considered.