Introduction
Bile duct leaks (BDLs) can arise as a complication of surgery or trauma to the biliary
system. Although rare, common surgeries that can cause BDLs include cholecystectomy,
hepatectomy, liver transplant, and the Whipple procedure. BDLs lead to accumulation
of bile in the abdominal cavity, which can cause symptoms such as pain, nausea, vomiting,
fever, and jaundice. Early diagnosis is essential as unrecognized BDLs can lead to
sepsis and death. Endoscopic retrograde cholangiopancreatography (ERCP) can safely
and effectively manage bile duct leaks [1]. The goal of treatment includes creating a low-pressure system to promote flow to
the duodenum. This, in turn, can help to decrease a biliary leak and thus create an
environment in which the bile duct can heal [1].
Techniques that are commonly used include bile duct sphincterotomy, bile duct stenting,
or a combination of both [2]
[3]. Recent studies have evaluated the clinical efficacy and outcomes of these techniques,
but the results have been varied and controversial [4]
[5]
[6]. Studies also have assessed optimal timing of ERCP [7]
[8]
[9]
[10]
[11], typically referencing literature on the timing of endoscopy for gastrointestinal
bleeding [12]
[13]
[14]. There is a lack of standardized guidelines regarding the effective management of
BDLs. The American Society for Gastrointestinal Endoscopy (ASGE) recommends biliary
decompression by either sphincterotomy alone or nasobiliary drain placement, with
or without sphincterotomy [15]. However, the European Society for Gastrointestinal Endoscopy (ESGE) recommends
biliary stent placement only without sphincterotomy to avoid both short- and long-term
adverse events (AEs) [16].
In addition to the variation seen in endoscopic technique for repairing BDLs, the
timing of intervention varies between different centers. Prior studies have divided
the timing of intervention into emergent (< 1 day), urgent (2–3 days), and expectant
(> 3 days) [4]. There are no standardized guidelines regarding the optimal timing of intervention
for BDLs [1]
[4]. The primary aim of our study was to evaluate the efficacy, complications, and clinical
outcomes of ERCP timing for management of BDLs. The secondary aim was to assess the
impact of BDL etiology on ERCP timing and outcomes and to evaluate the efficacy of
different ERCP techniques.
Patients and methods
Database
This was a retrospective cohort study using Explorys [17], a prospectively maintained electronic medical record (EMR) dataset (IBM Corporation,
Somers, New York, United States). Explorys is a multi-institution, de-identified EMR
database with over 70 million covered patient lives spanning from 1999 to 2020. De-identified
data from virtual healthcare systems (EPIC, Amalga, Eclipsys, etc.) are standardized
and normalized by the Explorys web-based platform. Specific diagnoses, procedures,
and medications are mapped into the systematized nomenclature of medicine clinical
terms (SNOMED-CT). Each unique search allows users to further specify associated medications,
comorbidities, demographics, and vital signs. All data are live and updated once every
24 hours [1]. Each participating organization has access to a password-protected web-based application
(https://popex.explorys.com). Explorys is a Health Insurance Portability and Accountability Act (HIPAA)- and
Health Information Technology for Economic and Clinical Health Act (HITECH)-compliant
platform, and institutional review board approval for its use is not required. This
study was reported according to the Strengthening the Reporting of Observational Studies
in Epidemiology (STROBE) guidelines for observational cohort studies [2].
Study design
Patients with BDL were identified using the diagnosis of “injury of bile duct: in
the Explorys database. Etiology of BDL was categorized into cholecystectomy, trauma,
and liver transplant. Patients who underwent ERCP were identified using the procedure
code of “endoscopic retrograde cholangiopancreatography.” The Explorys database allows
for establishing temporal relationships between factors such as certain diagnoses,
procedures, and medications to ensure they occurred after a specific event. Using
this function, we were able to categorize the timing of ERCP after BDL and subsequently
identify AEs and ERCP complications. To avoid duplication of patients who leave and
enter the healthcare system, Explorys uses a patient matching engine, which ensures
that a patient is captured only once throughout their life within the health platform.
This temporal relationship methodology was applied to our primary and secondary analysis
as follows.
ERCP timing was defined as emergent if it occurred within 1 day, urgent if it occurred
in 2 to 3 days, and expectant if it occurred 3 days after the BDL. AEs included one
of the following if they occurred within 2 weeks of ERCP: intubation, invasive hemodynamic
monitoring, central venous cannula insertion, hemodialysis, transfusion of blood product,
insertion of tracheostomy, total parenteral nutrition, abscess of liver, drainage
of subphrenic abscess, shock, sepsis, or pneumonia. These specific complications were
included to maintain consistency with prior research evaluating BDLs [4]. Post-ERCP complications included one of the following, if they occurred within
7 days of ERCP: pancreatitis, ascending cholangitis, duodenal perforation, or duodenal
hemorrhage. Rehospitalization rates included diagnosis of one of the following within
3 months: bile peritonitis, abdominal abscess, or persistent bile duct leak. Patients
with persistent BDL were identified as those who had a repeat diagnosis of bile duct
injury within 3 months of ERCP.
Type of ERCP intervention was categorized into sphincterotomy, bile stent placement,
and combination of sphincterotomy and bile stent placement. ERCP failure was defined
as need for salvage biliary surgery, which included percutaneous transhepatic biliary
drainage or bile duct repair.
Subgroup analysis was attempted based on the etiology of the BDL as mentioned above.
Patients who had cholecystectomy-related BDL were included in the study.
Limited analysis could be performed on patients with trauma-related BDL. For HIPAA-compliant
statistical de-identification purposes, the Explorys database does not allow reporting
on sample sizes less than 10 and all population counts above 10 are rounded to the
nearest 10. Liver transplant-related BDL was excluded from the analysis due to extremely
small sample size.
Statistical analysis
The proportion of patients based on ERCP timing, procedure type, AEs, ERCP failure,
and post-ERCP complications were reported as percentages. Descriptive characterization
of baseline demographics was done in patients who developed AEs after emergent, urgent,
and expectant ERCP. A chi-square test of independence was used to analyze the relationship
between ERCP timing and AEs, ERCP timing and ERCP complications, and ERCP technique
and failure rates. Social Science Statistic, an online statistical tool audited for
accuracy compared to SPSS, was used to calculate the chi-squared test statistic.
Results
There were 1260 patients with BDL included in the study. The etiology of BDL was cholecystectomy
(52.38 %), trauma (25.4 %), and liver transplant (1.59 %). Baseline demographics for
patients who underwent emergent, urgent, and expectant ERCP can be found in [Table 1]. There was no statistical difference based on demographic parameters between the
three groups.
Table 1
Baseline demographics in bile duct leak (BDL) patients who receiving endoscopic retrograde
cholangiopancreatography (ERCP) based on procedure timing.
|
Demographics
|
Emergent (n = 200)
|
Urgent (n = 100)
|
Expectant (n = 300)
|
P value
|
|
Age
|
|
|
70 (35 %)
|
40 (40 %)
|
120 (40 %)
|
0.19
|
|
|
80 (40 %)
|
30 (30 %)
|
90 (30 %)
|
|
|
50 (25 %)
|
30 (30 %)
|
90 (30 %)
|
|
Gender
|
|
|
70 (35 %)
|
40 (40 %)
|
120 (40 %)
|
0.49
|
|
|
130 (65 %)
|
60 (60 %)
|
180 (60 %)
|
|
Race
|
|
|
150 (75 %)
|
80 (80 %)
|
240 (80 %)
|
0.39
|
|
|
30 (15 %)
|
20 (20 %)
|
40 (13 %)
|
|
Insurance
|
|
|
100 (50 %)
|
50 (50 %)
|
160 (53 %)
|
0.80
|
|
|
60 (30 %)
|
30 (30 %)
|
100 (33 %)
|
|
|
40 (20 %)
|
20 (20 %)
|
50 (17 %)
|
|
Tobacco abuse
|
50 (25 %)
|
20 (20 %)
|
70 (23 %)
|
0.62
|
|
Alcohol abuse
|
10 (5 %)
|
10 (10 %)
|
20 (7 %)
|
0.26
|
|
Obesity
|
80 (40 %)
|
40 (40 %)
|
120 (40 %)
|
1
|
|
HTN
|
120 (60 %)
|
60 (60 %)
|
180 (60 %)
|
1
|
|
HLD
|
80 (40 %)
|
40 (40 %)
|
140 (47 %)
|
0.25
|
|
DM
|
60 (30 %)
|
40 (40 %)
|
90 (30 %)
|
0.14
|
|
CAD
|
40 (20 %)
|
20 (20 %)
|
60 (20 %)
|
1
|
|
HF
|
40 (20 %)
|
20 (20 %)
|
50 (17 %)
|
0.57
|
|
CKD
|
40 (20 %)
|
20 (20 %)
|
50 (17 %)
|
0.57
|
|
COPD
|
40 (20 %)
|
20 (20 %)
|
60 (20 %)
|
1
|
HTN, hypertension; HLD, hyperlipidemia; DM, diabetes mellitus; CAD, coronary artery
disease; HF, heart failure; CKD, chronic kidney disease; COPD, chronic obstructive
pulmonary disease.
Impact of ERCP timing
Six hundred patients (47.62 %) underwent ERCP after a BDL; 200 (33.33 %) were done
emergently, 100 (16.67 %) were done urgently, and 300 (50 %) were done expectantly.
The rate of AEs in patients who underwent ERCP emergently or urgently was higher compared
to patients who underwent the procedure expectantly (30 % vs 16.67 %, P = 0.004). The rate of ERCP complication between patients who had the procedure done
emergently compared to expectantly (5 % vs 6.67 %, P = 0.44) was not statistically significant. Rehospitalization rates were higher in
emergent and urgent ERCP compared to expectant (40 % vs 40 % vs 20 %, P < 0.001) ([Fig. 1]). Patients with COPD were more likely to have an AE if the ERCP was performed emergently
compared to expectant management (17 % vs 0 %, P = 0.002). Other demographics parameters were not statistically significant for patients
based on procedure timing ([Table 2]).
Fig. 1 Comparison of various outcomes based on ERCP timing.
Table 2
Baseline demographics in patients who had adverse events based on ERCP timing.
|
Demographics
|
Emergent (n = 60)
|
Expectant (n = 50)
|
P value
|
|
Age > 65
|
20 (33 %)
|
20 (40 %)
|
0.44
|
|
Female
|
30 (50 %)
|
30 (60 %)
|
0.29
|
|
White
|
40 (67 %)
|
40 (80 %)
|
0.12
|
|
Private
|
20 (33 %)
|
20 (40 %)
|
0.44
|
|
Medicare
|
30 (50 %)
|
20 (40 %)
|
0.29
|
|
Obesity
|
20 (33 %)
|
20 (40 %)
|
0.44
|
|
HTN
|
40 (67 %)
|
30 (60 %)
|
0.44
|
|
HLD
|
20 (33 %)
|
20 (40 %)
|
0.44
|
|
DM
|
20 (33 %)
|
20 (40 %)
|
0.44
|
|
HF
|
10 (17 %)
|
10 (20 %)
|
0.68
|
|
COPD
|
10 (17 %)
|
0
|
0.002
|
HTN, hypertension, HLD, hyperlipidemia; diabetes mellitus; HF, heart failure; COPD,
chronic obstructive pulmonary disease.
Impact of BDL etiology
Cholecystectomy
Six hundred sixty patients with cholecystectomy developed BDL and 420 patients (63.64 %)
underwent ERCP. ERCP was performed emergently in 140 patients (33.3 %), urgently in
70 patients (16.67 %), and expectantly in 210 patients (50 %). The difference in the
rate of AEs in patients who underwent ERCP emergently or urgently compared to patients
who underwent the procedure expectantly (28.57 % vs 19.05 %, P = 0.09) was not statistically significant ([Fig. 2]). The difference in the rate of ERCP complications between patients who had the
procedure done emergently compared to expectantly (7.14 % vs 4.76 %, P = 0.44) was not statistically significant ([Fig. 2]).
Fig. 2 Comparison of adverse events and ERCP complication based on ERCP timing for post-cholecystectomy
BDL.
Trauma
Three hundred and twenty patients with trauma developed BDL and 150 patients (46.88 %)
underwent ERCP. ERCP was performed emergently in 50 patients (33.3 %), urgently in
20 patients (13.3 %), and expectantly in 80 patients (53.33 %). The rate of AEs in
patients who underwent ERCP emergently (80 % vs 62.5 %, P = 0.03) or urgently (100 % vs 62.5 %, P = 0.001) was higher compared to patients who underwent the procedure expectantly
([Fig. 3]).
Fig. 3 Rate of adverse events based on ERCP timing in trauma-related BDL.
Impact of ERCP technique
Three hundred and fifty patients underwent ERCP intervention. Of them, 200 (57.14 %)
had a biliary stent, 70 patients (20 %) had sphincterotomy, and 80 patients (22.86 %)
had combination therapy. Combination therapy had a lower rate of ERCP failure compared
to biliary stent (25 % vs 12.5 %, P = 0.02). There was no statistically significant difference in the rate of ERCPO failures
with biliary stent and sphincterotomy (25 % vs 14.29 %, P = 0.06) or sphincterotomy and combination therapy (14.29 % vs 12.5 %, P = 0.74).
Discussion
We present a retrospective cohort study of 600 patients who underwent ERCP after BDL.
We found that patients with BDL who had expectant ERCP had a lower risk of AEs, which
is consistent with prior studies [1]
[4]. This supports the notion that ERCP does not need to be performed emergently or
urgently. We also found that combination therapy had a lower incidence of ERCP failure
compared to biliary stent placement alone, but that there was no statistical significance
between combination therapy and sphincterotomy alone.
Four prior reports have investigated outcomes associated with the endoscopic technique
and timing of BDLs [1]
[4]
[5]
[6]. These reports included 518, 1,028, 100, and 58 patients, respectively. In the study
by Adler et al [1], there was no significant difference in post-ERCP AEs based on timing (21 % emergent,
22.9 % urgent, 24.6 % expectant), but the 90-day mortality rate was lowest in the
expectant group. The study by Abbas et al [4] also found a lower mortality rate and a lower rate of AEs among patients who underwent
expectant ERCP.
The findings of our study are consistent with the findings of Abbas et al [4], which is that expectant ERCP has a lower rate of AEs. Abbas et al [4] cite a concern for “severity bias,” which is that patients who are more ill at the
time of presentation are more likely to undergo emergent ERCP, and hence, are also
at higher risk of AEs. A similar pattern has been seen with outcomes regarding timing
of endoscopic intervention in patients with gastrointestinal bleeding, which have
been associated with higher rates of mortality in patients undergoing endoscopy on
an emergent basis [7]
[8]
[9]
[10]
[11]. Our study had a greater percentage of AEs in patients undergoing ERCP for BDL.
This could have been for several reasons, including that the Explorys database rounds
patient populations to the closest 10, which may have affected total population sizes.
In addition, it is possible that some AEs were a consequence of the surgery itself
and not the ERCP that was done afterward.
Prior studies assessing the technique of endoscopic intervention produced mixed results.
Haidar et al [5] found that interventions involving stent placement were more successful than sphincterotomy
alone. However, Chandra et al [6] found that sphincterotomy was as efficacious as stent placement, but sphincterotomy
was faster and more cost-effective.
Our study found that combination therapy had a lower incidence of AEs compared to
sphincterotomy and biliary stent placement alone; however, this did not reach statistical
significance. However, all three techniques had similar efficacy with regard to ERCP
failure. Emergent ERCP had a higher risk of post-ERCP pancreatitis (P = 0.004).
Unique findings of our study are that patients with COPD had a higher risk of ERCP
failure when the procedure was done emergently. This is suspected to be from decreased
functional reserve and increased risk of complications with anesthesia in patients
with chronic lung failure. We found that patients who underwent expectant ERCP were
also significantly less likely to be re-hospitalized with bile peritonitis, abdominal
abscess or persistent BDL within the first 3 months, which further emphasizes the
benefit of expectant ERCP. We also found no difference with regard to outcomes based
on patient demographic parameters. In addition, patients with a BDL from a traumatic
injury have better outcomes if ERCP is performed expectantly. No difference was seen
with regard to timing in patients who had a BDL after cholecystectomy.
Limitations
The study was based on an administrative database analysis. There was a lack of information
regarding grade of the biliary leaks (low vs high) and location of leaks because there
were no available codes for this information. Because of the structure of the Explorys
database, we were unable to determine the endpoint of leak resolution.
Because our study was database-driven using de-identified patient data, we were unable
to assess for additional outcomes, such as the effect of admission over a weekend
or need for biloma drainage or surgical intervention after endoscopy. We were also
unable to assess several types of surgery leading to BDLs (e. g. liver resection,
liver transplant, a Whipple procedure) or if there was any correlation between type
of surgery/trauma and type of intervention. This is likely because of the small size
of cohorts in the database, as a cohort of fewer than 10 patients is undetectable
within the database. Due to this limitation, we were also unable to report numbers
for each AE and complication. Due to a lack of ICD codes, we were unable to assess
bile duct diameter or the location of the BDL (i. e. duct of Luschka, cystic duct
stump, hepatic duct, biliary duct). Both duct diameter and location of BDL have been
reported as possible associations [1]
[4], but remain controversial.
The Explorys database [17] relies on the use of ICD diagnosis codes to identify patients in different cohorts.
An inherent limitation of such databases includes verifying the diagnosis and criteria
used to arrive at a diagnosis [18]. Further, the Explorys database is composed of population level data, so individual
patient-level information cannot be obtained. As a result, beyond the surgeries that
were included in our analysis, we were unable to ascertain the etiology of the BDL
for the remainder of the patients. We were also unable to determine the treatments
of patients who did not undergo ERCP or the number of patients who were managed conservatively.
Another consequence of lack of patient-level data is the inability to delineate whether
the AEs were an actual consequence of the ERCP procedure itself or a complication
of the surgery causing the BDL. It is possible that patients who underwent emergent
or urgent ERCP could have been more ill post-surgery and could be more prone to AEs
from ERCP. Lack of patient-level data also precluded further subgroup analysis in
the post-cholecystectomy group, where a common bile duct stone during cholecystectomy
could have influenced early ERCP. Finally, the database does not allow for assessment
of the type of bile duct stent that was used (plastic, metal, etc) so a comparison
based on type of stent could not be made.
One of the major strengths of our study is that it is the second largest cohort of
patients assessed with BDLs. Because we included patients from a national database,
it is expected to represent the general population. This study also adds to current
knowledge regarding the management of BDLs while also expanding on key aspects of
managing patients with this condition.
Conclusion
Standardized guidelines for effective management of BDLs are lacking [4]. Clinicians should be aware of the benefits of expectant timing of ERCP and that
combination therapy has a lower incidence of ERCP failure compared to monotherapy
with stenting alone.
Aakash Desai, Patrick Twohig, Sophie Trujillo et al. Clinical efficacy, timing, and
outcomes of ERCP for management of bile duct leaks: a nationwide cohort study Endoscopy International Open 2021; 09: E247–E252. DOI: 10.1055/a-1322-2425
In the above mentioned article a sentence in conclusion of abstract and article were
incorrect. Correct is: “Combination therapy is superior to stenting but not sphincterotomy.”
and “Clinicians should be aware of the benefits of expectant timing of ERCP and that
combination therapy has a lower incidence of ERCP failure compared to monotherapy
with stenting alone.”
