Endoscopic management of bile duct leaks: Current strategies and controversies

Table 1 Bile duct injury classification

Classification, year	Study objective	Type/grade	Practical implication
Bismuth[13], 1982	To classify post-cholecystectomy biliary strictures for surgical planning and prognosis	Type I: Injury > 2 cm below confluence; Type II: < 2 cm; Type III: Hilar with no confluence; Type IV: Complete separation of right and left ducts; Type V: Aberrant right sectoral duct ± CHD injury	Designed for strictures, not leaks. Offers limited guidance for endoscopic management of BDLs such as cystic duct or Luschka leaks
Strasberg[15], 1995	To classify bile duct injuries after cholecystectomy for treatment planning	Type A: Cystic duct/Luschka leak; B: Occluded right posterior duct; C: Leaking posterior duct; D: Lateral injury (< 50%); E1-E5: Strictures (Bismuth I-V).	Most widely adopted. Types A, C, D may be endoscopically managed; B and E often require surgery. Useful for guiding endoscopic decisions
Amsterdam[61], 1996	To guide endoscopic management of bile duct injuries	Type A: Cystic duct/peripheral leak; B: Major duct leak; C: Stricture; D: Complete transection	Types A and B can be managed endoscopically; C and D generally need surgical repair. Aids decision-making for endoscopic vs surgical management
Stewart-Way[22], 2004	To evaluate the mechanism and impact of RHAI in laparoscopic bile duct injury	Class I: CBD mistaken for cystic duct, recognized pre-transection; Class II: CHD injured by clip/cautery; Class III: CBD transected due to misidentification (most common); Class IV: RHD injured during dissection	Highlights the high RHAI incidence in severe injuries, especially Class III (35%) and IV (64%). Important for surgical planning; limited relevance for endoscopic strategies
Hannover[23], 2007	To guide surgical strategies for bile duct and vascular injuries	Type A: Peripheral leaks (A1: Cystic duct; A2: Gallbladder bed); Type B: Strictures without injury (B1-B2); Type C: Tangential injuries (C1-C4); Type D: Complete transections (D1-D4); Type E: Strictures (E1-E4); Vascular injury suffixes: D, s, p, com, c, pv	Provides comprehensive anatomical and vascular classification, aiding surgical decision-making. Limited utility for endoscopic management
McMahon[24], 1995	To classify bile duct injury severity and guide surgical repair	Minor: Laceration < 25% or cystic-CBD tear; Major: Laceration > 25%, CBD/CHD transection, postoperative stricture	Minor injuries often amenable to T-tube or suture repair; major injuries typically require hepaticojejunostomy. Endoscopy plays a limited role
Neuhaus[25], 2000	To guide surgical/endoscopic management of post-cholecystectomy injuries	Type A (Peripheral leaks): A1, cystic duct leak; A2, gallbladder bed leak. Type B (Occlusion): B1, incomplete (e.g., clip); B2, complete. Type C (Lateral CBD injury): C1, lesion < 5 mm; C2, > 5 mm. Type D (Transection): D1, without tissue defect; D2, with tissue defect. Type E (Stricture): E1, < 5 mm; E2, > 5 mm; E3, confluence; E4, right hepatic/segmental duct	Type A: Sphincterotomy ± stent; percutaneous drainage if needed. Type B1: Endoscopic dilation + stent; B2: Surgery (clip removal) + long-term stenting. Type C1: Sphincterotomy or stent; C2: Surgery + stent ≥ 12 months. Type D: Surgical reconstruction (e.g., hepaticojejunostomy). Type E1: Stenting ≥ 12 months; E2-E4: Surgical resection + hepaticojejunostomy; extended hepatectomy if ischemic cholangiopathy
Siewert[26], 1994	To stratify bile duct injuries for surgical planning	Type I: Immediate biliary fistula; Type II: Late stricture; Type IIIa/IIIb: Tangential lesion ± vascular injury; Type IVa/IVb: Duct disruption ± vascular injury	Type I may be endoscopically treated; Types II-IV typically require surgical reconstruction, especially with vascular involvement
Csencdes[27], 2001	To guide surgical/endoscopic treatment of bile duct injuries	Type I: Small tear of hepatic duct or right hepatic branch. Type II: Injury at cysticocholedochal junction (e.g., from traction, catheter, electrocautery, or close transection). Type III: Partial or complete CBD section. Type IV: Resection of > 10 mm of CBD	Type I/II: May be managed with endoscopic stenting; Type III/IV: Typically require surgical repair (e.g., hepaticojejunostomy)

CBD: Common bile duct; CHD: Common hepatic duct; RHD: Right hepatic duct; RHAI: Right hepatic artery injury; Com: Common hepatic artery involvement; c: Coeliac trunk injury; d: Right hepatic artery injury; p: Portal vein injury; pv: Portal vein branch injury; s: Left hepatic artery injury.

Table 2 Comparison of treatment strategies

Ref.	Study design (n)	Key findings	Conclusion	Quality1
EST vs stents
Dolay et al[62], 2010	Single-center, prospective (27)	Stenting led to faster leak resolution than EST (4.5 ± 2.0 days vs 6.5 ± 3.4 days); 2 failures in EST group	Stenting > EST	High
Abbas et al[33], 2019	Multicenter, retrospective (1028)	Stent alone (96%) and stent + EST (97%) had higher success than EST alone (89%)	Stenting ± EST > EST alone	Medium
Rainio et al[32], 2018	Single-center, retrospective (71)	Comparable leak closure time and healing rates between EST and EST + stent	EST and EST + stent offer similar efficacy in type A leaks	Medium
Kaffes et al[63], 2005	Single-center, retrospective (100)	Success: Stent and EST + stent (100%) vs EST alone (78%, P = 0.001)	Stenting ± EST > EST alone	Low
Haidar et al[29], 2020	Single-center, retrospective (100)	Stenting (± EST) had higher success than EST (95.3% vs 72.7%, P < 0.05)	Stenting ± EST > EST alone	Low
Sachdev et al[12], 2012	Single-center, retrospective (65)	EST + stent in 52 (80%), stent alone in 6 (9%), EST alone in 5 (8%), NBD in 2 (3%); all achieved clinical success	EST + stent may be optimal	Low
Sendino et al[64], 2018	Dual-center, retrospective (65)	Stent ± EST (n = 47) led to higher resolution than EST alone (94% vs 58%, P < 0.01). Fewer required percutaneous (4% vs 12%) or surgical intervention (6% vs 42%, P < 0.001)	Stenting ± EST > EST alone	Medium
Chandra et al[31], 2019	Single-center, retrospective (58)	Comparable initial success between EST and EST + stent (92% vs 90%, P = 0.85); stent group had slower resolution (P = 0.02) and more reinterventions (P < 0.01)	EST with or without stent is effective; stenting may delay resolution	Low
Flumignan et al[65], 2021	Single-center, retrospective (31)	EST + stent (n = 22) and EST alone (n = 9) both reduced drainage volume and time to cessation; 2 failures (group unspecified)	No significant difference between EST and EST + stent	Low
NBD vs stent
Raza et al[38], 2019	Systematic review	Stent efficacy: 82.4%; NBD efficacy: 87.2%	Comparable efficacy between NBD and stent	-

¹Quality was assessed using the Newcastle-Ottawa Scale[66] for non-randomized studies: High quality (score ≥ 7), medium quality (score 5-6), low quality (score ≤ 4). Randomized controlled trial was evaluated with Cochrane risk of bias[67].

EST: Endoscopic sphincterotomy; NBD: Nasobiliary drainage; FCSEMS: Fully covered self-expandable metal stent; MPS: Multiple plastic stents; ERCP: Endoscopic retrograde cholangiopancreatography.

Table 3 Factors of endoscopic success in bile duct leaks

Ref.	Study design (n)	Key findings	Conclusion	Quality1
Leak-Bridging vs short stent
Obata et al[37], 2025	Single-center, retrospective (122)	Bridging stents (P < 0.001), percutaneous drainage (P = 0.0025), and leak severity (P = 0.015) were independent predictors of endoscopic success	Bridging stents across the leak are key to clinical success	Medium
Schaible et al[36], 2017	Single-center, retrospective (35)	Bridging stents achieved 100% success (13/13) vs only 52.6% (10/19) for non-bridging stents	Bridging stents > non-bridging stents	Low
Quintini et al[42], 2024	Dual-center, retrospective (65)	Success rate higher with bridging vs. non-bridging stents (91% vs 53%, P = 0.005)	Bridging stents more effective	Low
Stent diameter
Katsinelos et al[40], 2008	RCT (63)	Success: 93.5% (7 Fr) vs 96.9% (10 Fr)	Stent diameter did not impact outcome	High
Vlaemynck et al[28], 2019	Meta (331)	Success: 95.4% (<10 Fr) vs 97.8% (≥10 Fr).	Stent size did not affect efficacy	High
Predictors
Yabe et al[17], 2017	Single-center, retrospective (58)	Success: 88% (low-grade) vs 59% (high-grade)	High-grade leak predicts failure	Medium
Quintini et al[42], 2024	Dual-center, retrospective (65)	Success: 67% (main duct) vs 90%-100% (others); bridging stents superior (91% vs 53%)	Leak location and bridging predict success	Low
Schaible et al[36], 2017	Single-center, retrospective (35)	Success: 64% (peripheral) vs 92% (central); not significant (P = 0.059); best with bridging at hepatic ducts	Peripheral leaks respond poorly	Low
Tewani et al[1], 2013	Single-center, retrospective (223)	ERCP is more effective for cystic/Luschka leaks (P = 0.028)	Leak site and stenting predict success	Medium
Chen et al[7], 2024	Multicenter, retrospective (106)	Positive: Bridging and cystic duct; Negative: SIRS, high-grade leaks	Location, severity, bridging stent, and systemic status are key predictors	Medium

¹Quality was assessed using the Newcastle-Ottawa Scale[66] for non-randomized studies: High quality (score ≥ 7), medium quality (score 5-6), low quality (score ≤ 4). Randomized controlled trial was evaluated with Cochrane risk of bias[67].

BDLs: Bile duct leaks; ERCP: Endoscopic retrograde cholangiopancreatography; RCT: Randomized controlled trial; SIRS: Systemic inflammatory response syndrome; Fr: French.