When can a biliary stent be removed after a bile leak?

When to Remove Biliary Stent After Bile Leak

Biliary stents should be removed at 4 to 8 weeks after placement, but only after retrograde cholangiography confirms complete resolution of the bile leak. 1

Timing of Stent Removal

Standard Duration

• Stents are typically left in place for approximately 4 to 8 weeks based on multiple studies examining post-cholecystectomy bile leaks and other biliary injuries. 1
• The specific duration within this range depends on the severity and location of the leak, with low-grade leaks often resolving faster than high-grade leaks. 1

Confirmation Before Removal

• Stent removal should only occur after performing repeat cholangiography that demonstrates complete resolution of the leakage. 1
• This confirmation step is critical—removing the stent without documented leak closure risks recurrent bile leak and its complications. 2

Clinical Context for Timing Decisions

Rapid Leak Closure

• Bile leaks typically close within 1 to 3 days after stent placement when the leak is from a cystic duct stump or duct of Luschka. 3
• Despite rapid clinical improvement, the stent should remain in place for the full 4-8 week period to ensure complete healing of the biliary tree injury. 1

Extended Duration Considerations

• For refractory bile leaks treated with fully covered self-expanding metal stents (FCSEMS), median stent duration may extend to approximately 92 days (range 48-251 days). 4
• Patients with bile leaks following hepatic resection had stents removed at 6 weeks with no persistent leaks detected and no late biliary complications at median 26-month follow-up. 2

Important Caveats and Pitfalls

Avoid Premature Removal

• Do not remove stents based solely on clinical improvement (cessation of drain output, normalization of labs), as the biliary injury requires adequate time to heal even after symptoms resolve. 1, 2
• Premature removal without cholangiographic confirmation increases risk of recurrent leak. 1

Stent Type Considerations

• Plastic stents are the recommended first-line option for bile duct leaks, with removal planned at 4-8 weeks. 1
• FCSEMS may require longer indwelling times but carry a high risk of post-removal biliary strictures (particularly with FCSEMS with fins), making them less ideal for routine bile leak management. 5

Follow-up After Removal

• Perform endoscopic stent removal with simultaneous cholangiography to confirm leak resolution at the time of removal. 1, 2
• Long-term follow-up is important, as benign biliary strictures can develop with recurrence rates as high as 30% within 2 years. 1

Alternative Drainage Methods

Nasobiliary Drainage

• When nasobiliary drains are used instead of plastic stents, leak closure can be documented as early as 2-11 days (mean 4.7 days), allowing non-endoscopic drain removal once closure is confirmed. 6
• This approach requires fewer ERCPs (1.0 vs 2.2 procedures) but has lower patient compliance. 1, 6