Endoscopic salvage therapy for refractory cystic duct type A bile leak after cholecystectomy with coil-assisted glue embolization: A case report

Abstract

BACKGROUND

An 83-year-old male with multiple comorbidities presented with high-output biliary leak following a subtotal cholecystectomy for acute cholecystitis. He was referred for advanced biliary intervention.

CASE SUMMARY

Despite repeated endoscopic retrograde cholangiopancreatography and the placement of up to three biliary plastic stents, the patient experienced an increase in bilious drainage reaching 200 mL/day, accompanied by significant weight loss. Magnetic resonance cholangiopancreatography revealed a fluid collection at the gallbladder bed connected to the biliary tree, confirming an active bile leak, likely originating from the cystic duct stump. At endoscopic retrograde cholangiopancreatography, the previously placed biliary stents were removed, and common bile duct (CBD) was selectively cannulated. Cholangiogram showed dilated CBD with a leak at the cystic duct. SpyGlass cholangioscope was used to cannulate the cystic duct, and a guidewire was passed through the leak site to the percutaneous drain. A biliary access cannula was inserted over the guidewire via the percutaneous route, and 3 coils (two of 4 mm and one of 6 mm) were deployed at the leak site, followed by cyanoacrylate glue injection. This achieved immediate and complete cessation of the leak, as confirmed by an occlusion cholangiogram. A 7-Fr 12-cm plastic biliary stent was placed into the CBD, and free flow of bile was noted, providing a minimally invasive solution for a refractory post-surgical complication.

CONCLUSION

This case highlights that for persistent, high-output stump leaks that fail conventional stenting, the combined use of cholangioscopy-guided coil and glue embolization offers an effective salvage therapy that avoids the morbidity of a second major surgery.

Key Words: Bile leak; Cholecystectomy; Choledocholithiasis; Embolization; Endoscopic retrograde cholangiopancreatography; Case report

Core Tip: Persistent high-output cystic duct stump leaks that fail conventional endoscopic stenting pose a significant therapeutic challenge, particularly in elderly patients with multiple comorbidities. For refractory biliary leaks, Spyglass cholangioscopy and percutaneous access enable precise targeting of the leak site. Utilizing a combination of coils and cyanoacrylate glue can achieve complete cessation of high-output drainage when multiple plastic stents have failed, offering a successful solution within the biliary tree and an alternative to high-risk revisional surgery.

INTRODUCTION

Bile duct injuries remain a significant complication of laparoscopic cholecystectomy[1,2]. Bile leakage from the cystic duct stump is the most common site[3]. The occurrence of bile duct injuries at laparoscopic cholecystectomy is 0.5%-0.7%, though rates range up to 1.5% and are usually higher than open surgery (0.3%)[4-6]. The acute inflammation from cholecystitis and advanced age creates a unique risk profile for bile duct injuries[7,8]. Endoscopic retrograde cholangiopancreatography (ERCP) with biliary stenting is the gold standard to resolve most of these leaks[9]. However, a subset of patients can present with persistent leaks necessitating alternative minimally invasive strategies to avoid the morbidity of open surgical repair. We present a detailed endoscopic coil-assisted glue embolization for persistent type A cystic duct stump leak, offering a safe, effective alternative.

CASE PRESENTATION

Chief complaints

This is an 83-year-old male with a history significant for diabetes mellitus, hypertension, and dyslipidemia who presented with low-grade fever.

History of present illness

He initially underwent an open cholecystectomy in 2025 for acute cholecystitis complicated by Mirizzi’s syndrome and choledocholithiasis. Laparoscopic cholecystectomy was converted to open due to extensive adhesions involving the colon, omentum, and liver, which obscured the gallbladder. Postoperative recovery was complicated by a persistent 30-40 mL/day bile leak from the gallbladder stump (day 7). Over several months, the patient underwent multiple ERCP procedures, including the placement of up to three plastic biliary stents to facilitate drainage. However, these standard measures failed to resolve the bile leak; instead, the drainage volume increased significantly from 80-90 mL to 200 mL/day. This chronic biliary loss led to a debilitating 14 kg weight loss and clinical deterioration, including a transition into cholangitis. He was referred for advanced biliary intervention, including evaluation for biliary metal stent placement.

History of past illness

No significant past history.

Personal and family history

The patient denied any relevant family history.

Physical examination

Physical examination was unremarkable except for right hypochondriac tenderness.

Laboratory examinations

Routine blood investigations were remarkable for leucocytosis, elevated alkaline phosphatase, and elevated total bilirubin. No significant abnormality was found in the urine analysis.

Imaging examinations

Magnetic resonance cholangiopancreatography showed three biliary stents with their distal ends in the duodenum, with the proximal end of one stent extending into the right intrahepatic duct and the other two stents at the level of the hepatic hilum. Notably, T2 hyperintense lesions with restricted diffusion on diffusion-weighted imaging in segment VIII of the liver along the course of the intrahepatic biliary radicals were highly suggestive of cholangitic abscess alongside existing pneumobilia. At the postoperative gallbladder bed adjacent to the surgical site, there was a well-defined T2 hyperintense fluid collection that showed continuity with the biliary tree, confirming an active bile leak (Strasberg type A - bile leak from cystic duct stump or small biliary ducts in gallbladder fossa), likely arising from the cystic duct stump.

FINAL DIAGNOSIS

Combined with the patient’s medical history, the final diagnosis was a bile leak from the cystic duct stump.

TREATMENT

Upon admission, diclofenac suppository (100 mg) was given perioperatively 30 minutes before ERCP. A duodenoscope (TJF-160R, Evis Exera Olympus, Japan) was used, and the procedure was performed under total intravenous anesthesia. Previously placed biliary stents were noted at the ampulla and were removed with a snare (Sensation, Boston Scientific, MA, United States). The common bile duct (CBD) was selectively cannulated using a sphincterotome (CleverCut, Olympus, Japan). After injecting saline-diluted contrast-diatrizoate meglumine (Trazograph 76%), the cholangiogram showed a dilated CBD with evidence of leak at the cystic duct. A biliary sphincterotomy was performed. SpyGlass cholangioscope (Boston Scientific, MA, United States) was used for cannulating the cystic duct, and a 0.035-inch guidewire (VisiGlide, Olympus, PA, United States) was advanced through the stump and exited externally through the percutaneous drain site. The VisiGlide guidewire was exchanged for Terumo. Under fluoroscopic guidance, a biliary access cannula (PR-104Q-1, Olympus, PA, United States) was inserted over the guidewire (Terumo, Japan) via percutaneous route and three pushable embolization coils [two of coiled embolus diameter 4 mm (MWCE-35-7-4-Nester) and one of 6 mm, (MWCE- MWCE-35-7-6-Nester, Cook Medical, IN, United States)] deployed at the leak site reinforced with an injection of undiluted cyanoacrylate glue (Endocryl, Samarth Life Sciences, Maharashtra, India) without Lipiodol admixture. The cannula was subsequently flushed with distilled water to avoid glue polymerization within the delivery system. Prior contrast injection had already delineated the leak anatomy fluoroscopically. The success of the embolization was confirmed via an occlusion cholangiogram, which demonstrated no further evidence of biliary extravasation (Figure 1A-J). The CBD was flushed with saline to clear residual sludge, and a prophylactic 7-Fr 12-cm plastic biliary stent was placed to ensure unobstructed bile flow into the duodenum. The percutaneous access utilized in this procedure was achieved exclusively through the pre-existing tract of the surgically placed drain within the gallbladder fossa.

Figure 1 Imaging results. A: Cystic duct leak with percutaneous drain in gallbladder fossa; B: Biliary cannulation with sphincterotome tip at cystic duct opening; C: SpyGlass cholangioscopy guided cannulation of the cystic duct stump; D: Guidewire placement into the cystic duct via the existing percutaneous drainage catheter; E: Cannula was advanced over the guidewire through the percutaneous drainage tube for selective cystic duct cannulation (panel inset endoscopy showing cannulation); F: Initial deployment of the first embolization coil within the cystic duct stump, viewed under fluoroscopic guidance; G: Fluoroscopic image confirming placement of three embolization coils in the cystic duct stump; H and I: Cholangiogram after coil placement and N-butyl cyanoacrylate glue embolization showing complete occlusion of the cystic duct stump with no residual leak (H: Panel inset- endoscopy showing sphincterotome in ampulla; I: Panel inset - Terumo wire outside ampulla); J: Biliary stent placement across the cystic duct origin following coil embolization; K and L: Follow-up endoscopic retrograde cholangiopancreatography (3 weeks post-procedure) demonstrating no contrast leak from the cystic duct stump.

OUTCOME AND FOLLOW-UP

The patient received peri-procedural antibiotic prophylaxis consisting of oral amoxycillin (875 mg) with clavulanic acid (125 mg), initiated with a pre-procedure dose and continued for 3 days after the procedure and analgesics (paracetamol) for pain. His previous medications, glimepiride 1 mg, telmisartan 40 mg, and atorvastatin 20 mg, were continued. The patient was stable and improving following the procedure, with the cessation of external drainage, and was discharged 24 hours after the procedure; consequently, the drain was removed after 72 hours. At follow-up 3 weeks later, a cholangiogram at ERCP showed a resolved biliary leak (Figure 1K and L), hence the stent was removed.

DISCUSSION

Bile duct injuries and subsequent leaks remain a significant complication of cholecystectomies, particularly in cases with dense adhesions and Mirizzi’s syndrome. In this patient, the conversion to an open procedure due to extensive inflammatory adhesions highlights the complexity of the procedure leading to iatrogenic injury[2]. While most type A leaks respond to ERCP with stenting, which reduces the pressure gradient by facilitating bile flow into the duodenum; persistent cases can lead to severe morbidity, including debilitating weight loss as seen in this patient. The failure of multiple plastic stents in this patient underscores the limitations of conventional drainage in high-output cases. The persistent high intrabiliary pressure prevented successful closure of the cystic duct leak. When standard measures fail, the transition from passive drainage to active occlusion becomes necessary.

The failure of conventional CBD stenting to divert bile flow necessitated a more definitive approach to the cystic duct stump. Given the patient’s age and financial constraints, the clinical goal shifted toward minimally invasive salvage techniques that avoid the high cost of a metal stent. Fully covered self-expanding metallic stent is useful for refractory bile leaks because they have a lower risk of tissue ingrowth than uncovered stents, which can lead to recurrent obstruction and often necessitate complex future re-interventions. Although the SpyGlass system is costly, our facility utilizes institutional reprocessing of the cholangioscope using ethylene oxide sterilization. Elderly patients have a fragile vasculature, which increases the risk of bleeding during percutaneous tract dilation, hence percutaneous transhepatic biliary drainage was avoided. The use of SpyGlass cholangioscopy enabled precise visualization and cannulation of the cystic duct stump, which was otherwise inaccessible with traditional fluoroscopy. Careful pre-procedural magnetic resonance cholangiopancreatography imaging is essential for anatomical delineation and successful planning of complex cholangioscopy-assisted rendezvous procedures. The cystic duct was selectively cannulated, thereby minimizing concern for inadvertent glue migration into the CBD. Because the guidewire and cannula were positioned within the cystic duct stump itself, reflux or inadvertent glue migration into the CBD was not encountered. Precautions against reflux included stable guidewire positioning, limited-volume injection, and rapid polymerization of undiluted N-butyl cyanoacrylate within the coil scaffold. On cholangiography, the bile leak appeared resolved following embolization; therefore, a prophylactic 7 Fr biliary stent was placed rather than a larger 10 Fr stent, as high-volume decompression was no longer considered necessary. Coils are considered an effective treatment option for cystic duct bile leaks. The coil is selected based on the length of the cystic duct stump and is slightly larger than the diameter of the target duct. Selective embolization with a combination of coils and cyanoacrylate glue provided definitive treatment of the leak site[10,11]. A combined coil-and-glue technique was chosen to provide a scaffold for the cyanoacrylate and reduce the risk of distal embolization or non-target spread compared with glue injection alone. This technique has emerged as a minimally invasive alternative to high-risk surgical revision, particularly in elderly patients with significant comorbidities[12,13]. Furthermore, the successful resolution of the 200 mL/day leak and the subsequent cessation of external drainage within 24 hours validate the role of trans-catheter embolization in managing persistent stump leaks[14]. The integration of percutaneous access with endoscopic guidance avoided the need for re-operation[15,16]. The non-surgical treatment of postoperative bile leaks has contributed to good success rate of around 90%[17-20]. The patient initially presented with double-pigtail stents, which are typically suboptimal for maximizing flow volume to bypass a leak. The ideal plastic stent for managing a bile leak during ERCP is a straight flanged polyethylene stent of 10-Fr (for better flow dynamics) and the appropriate length (typically 10 cm). If a custom-made stent, a flap should be created at the distal end to enhance anchoring and reduce distal migration, with multiple side holes.

The novelty of the present case lies in the combined cholangioscopy-guided and percutaneous rendezvous technique used to achieve selective cystic duct access after unsuccessful conventional endoscopic management with repeated multi-stenting of a persistent high-output leak. The short follow-up duration of 3 weeks represents a limitation. Although no recurrent bile leak, cholangitis, or coil migration was observed during this period, longer-term surveillance is required to assess procedural durability and delayed complications. Embolic material within or adjacent to the biliary system may serve as a nidus for future cholangitis; therefore, continued clinical follow-up with periodic liver function tests and imaging, or endoscopic evaluation in symptomatic patients, may be warranted.

CONCLUSION

This case highlights that high-output bile leaks may require advanced endoscopic interventions. The successful use of SpyGlass-guided cannulation, combined with coil embolization and cyanoacrylate glue, provides a definitive, minimally invasive solution that avoids the high morbidity of surgical re-exploration in elderly, comorbid patients. This hybrid endoscopic and percutaneous approach effectively treats the leak, allowing for rapid clinical recovery.