MANAGEMENT OF COMPLEX BILIARY LEAK BY ENDOSCOPIC DRAINAGE WITH TRANSMURAL OR TRANSPAPILLARY-TRANSFISTULARY ACCESS

Aims:

Biliary leak (BL) occurs often after hepatobiliary surgery. ERCP with biliary sphincterotomy and/or placement of a biliary stent or nasobiliary catheter represents the first therapeutic option. Some complex cases might resist to conventional treatment.

We report our experience of biloma drainage with transpapillary/transfistulary (TP/TF) or EUS assisted-transmural (TM) access.

Methods:

This is a retrospective analysis from January 2007 to December 2016. BL diagnosis was based on imaging or bile outflow from surgical drain. Patients who responded to conventional ERCP treatment were excluded. Baseline characteristics, radiologic, procedural and follow-up data were collected. TP/TF was performed by the placement of double pigtail stent during ERCP. For TM, plastic DPT stents were placed under EUS control.

Results:

We identified 30 patients (males 57%, median 55 years) with BL treated by TF/TP or TM drainage. BL resulted from hepatectomy (50%) and cholecystectomy (26,7%) in the majority of cases. Pain and sepsis were the common symptoms at presentation in 66% and 70% respectively. The drain, present in 90% of patients had a mean daily bile flow before endoscopy of 300 cc (40 – 1600). The median between the date of surgery and endoscopic treatment was 54 (10 – 1144) days. TM drainage was performed in 14 patients by transgastric (8) or transduodenal (6) route. 86% required a unique session with one stent (10) or 2 stents (4). TP/TF drainage was performed in 16 patients, needing one, two or more interventions in 75, 25 and 31%. Follow-up was available for 21 patients at three months. In those patients, collection regression occurred in 52% of cases (TM: 6; TF: 5) and 57%(TM: 6; TF: 6) were free of sepsis and weaned from percutaneous drain. Redo surgery was necessary for 2 patients. Two patients died due to early complications related to endoscopic treatment (vascular/pericardial erosion).

Conclusions:

Transfistular/transpapillary or transmural drainage is technically feasible in experienced centers and might avoid redo-biliary surgery.