Sphincterotomy alone appears sufficient for the treatment of bile leaks

Vlaemynck et al. recently reported a systematic review and meta-analysis to define the optimal endoscopic intervention for the management of biliary leaks [1]. Their analysis included 11 studies and compared sphincterotomy alone, stenting with leak-bridging stents, short stents alone, sphincterotomy with leak-bridging stenting, and sphincterotomy with short stenting. The bile leak healing rates were 91 %, 96 %, 91 %, 98 %, and 68 %, respectively. There were no statistically significant differences noted in healing rates between the interventions, with the 95 % confidence interval for the risk ratio including 1. This is likely the result of the high success rates of endoscopic intervention in biliary leaks and the small sample size. The authors did however report a non-statistically significant higher rate of pancreatitis with interventions that included biliary stenting compared with sphincterotomy alone. In addition, biliary stenting added to the procedural cost, the cost of a repeat procedure for stent removal, and carried risks of occlusion and infection.

Endoscopic interventions for biliary leaks are targeted at creating a low-pressure flow of bile away from the leak to allow healing of the leak. With biliary stenting, bile flows along the stent wall instead of through the lumen. Winged stents are equally as effective as conventional tubular plastic stents [2]. Therefore, leak bridging may not necessarily have an advantage.

In our own study [3], our data showed comparable success in terms of bile leak healing, with faster healing using sphincterotomy alone compared with sphincterotomy plus stenting. This is likely because the presence of a foreign body in the bile duct creates a persistent nidus for bacteria and increases contractions in the bile duct wall, which may delay the epithelialization.

In their meta-analysis, Vlaemynck et al. performed a rank probability analysis and reported the highest success rate for biliary leak healing using sphincterotomy with leak-bridging stenting. The merit of results from this modeling analysis is unclear. Unless the analysis has clear superiority, the routine use of biliary stents in addition to sphincterotomy for bile leaks should not be encouraged.

• References

• 1 Vlaemynck K, Lahousse L, Vanlander A. et al. Endoscopic management of biliary leaks: a systematic review with meta-analysis. Endoscopy 2019; DOI: 10.1055/a-0835-5940.
• 2 Ayres L, Cheriyan D, Scott R. et al. A randomized trial comparing winged versus conventional plastic stents for malignant bile duct strictures. Endosc Int Open 2017; 5: E635-E641
• 3 Chandra S, Murali AR, Mesadeh M. et al. Endoscopic biliary sphincterotomy alone versus with biliary stent in management of bile duct leak; a comparative study. Gastrointest Endosc 2017; 85 Suppl AB414