Successful ERCP guided rescue cystic duct embolization for the persistent bile leak after subtotal cholecystectomy: a case report.

Introduction and importance: Bile leakage is a recognized complication of subtotal cholecystectomy, particularly when using the fenestrating technique. Persistent leaks may not respond to standard endoscopic stenting. In refractory cases, non-surgical embolization using agents such as coils, glue, or gelatin sponge has emerged as a potential alternative to reoperation. Case presentation: We present a case of a 25-year-old male who developed persistent bile leakage following laparoscopic fenestrating STC for severe cholecystitis. The initial management with endoscopic retrograde cholangiopancreatography (ERCP) and plastic stent placement failed to resolve the leak. Subsequent ERCP with cholangioscopy revealed a wide cystic duct orifice. A mixture of contrast media, saline, and gelatin sponge was injected into the cystic duct using a cannulation catheter under fluoroscopic guidance, achieving complete occlusion. The bile leak resolved, and the patient remained asymptomatic during follow-up. Clinical discussion: Cystic duct stump leaks after subtotal cholecystectomy can be challenging to manage when they persist despite conventional endoscopic therapy. In this case, the use of a gelatin sponge-based embolic mixture under direct endoscopic and fluoroscopic control enabled successful, non-surgical closure of the leak. This highlights the potential utility of targeted ductal embolization in selective refractory cases. Conclusion: This case illustrates the successful use of gelatin sponge-based glue embolization under ERCP and cholangioscopic guidance to treat refractory cystic duct stump leakage. This minimally invasive approach may serve as a viable alternative where other advanced interventions such as fully covered metal stents are not feasible or available.