Endoscopic treatment of biliary fistulas after complex liver resection

The aim of this study was to evaluate the safety and efficacy of endoscopic treatment for biliary fistulas after complex liver resection.

The role of endoscopy in the treatment of fistulas of the common bile duct is well documented. On the contrary, results of endoscopic procedures for fistulas arising from peripheral bile ducts after liver resections are poorly studied, although more complex hepatectomies are increasingly performed. We analyzed retrospectively the results of these procedures in our experience.

Twenty-six patients aged 10 to 74 years were included. Fistulas arose after extended right hepatectomy, n = 14; extended left hepatectomy, n = 2; segmentectomy, n = 7; and split-liver transplantation, n = 3. All patients underwent radiologic or surgical external drainage before endoscopic retrograde cholangiopancreatography (ERCP). Mean bile outflow before endoscopy was 493.1 ± 386.1 mL/24 h (median, 400; range, 100-2000 mL). The mean time from surgery to diagnosis was 29.4 ± 45.5 days.

The ERCP was performed after a median of 13 days after the diagnosis of biliary fistula. A sphincterotomy was required in 96.1% of patients. A 5F to 10F polyethylene stent bypassing the leaking bile duct was implanted in 21 (80.7%) of 26 patients. Fistulas were dried up completely in 25 (96.1%) of 26 patients. The mean time from initial ERCP to running dry of the leaks was 17.5 ± 12.4 days. Procedure-related morbidity was 0%. There was no mortality.

Biliary fistulas arising from intrahepatic ducts after complex liver resections are more difficult to treat than distal fistulas arising from the common bile duct. However, despite a longer time for cure and the need for repeated ERCP, endoscopic therapy appears efficient and does not induce additional morbidity.