Efficacy of the Endoscopic Therapy of Biliary Fistulas Secondary to Complex Liver Resections

Abstract

The role and efficacy of endoscopy for the treatment of biliary fistulas of the common bile duct are 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, in case of oncologic surgery. We analyzed retrospectively the results of these procedures in order to identify their specific features. Seventeen patients (men: 9) aged from 10 to 74 years were included. Seven patients had a right hepatectomy, 1 a left hepatectomy, 1 a single segmentectomy, 6 had more than a single segmentectomy, and 2 had a bi partition liver transplantation (cystic fibrosis and hepato cell carcinoma post C viral hepatitis) . The liver diseases were primitive liver tumor in 7 patients, hepatic location of a metastatic cancer in 8 patients (colorectal carcinoma, n = 4, pharyngeal squamous cell carcinoma, n = 1, corticosurrenaloma, n = 2, breast cancer, n = 1), liver abscess in 1 patient, and cirrhosis in 1 patient. Bile outflow before endoscopy was measured at 300 to 2000ml/24h (median 400). A biloma was present on CT-scan in 15/17 patients (88%). Percutaneous drainage of the bilioma failed in all cases. Endoscopy Retrograde Cholangio Pancreatography was performed after a median time of 15 days after the diagnosis of fistula (range 10–488 days). A sphincterotomy was requiered in 94% of the patients. An 8.5 to 10F polyethylene stent bypassing the leaking bile duct was implanted in 13/17 patients (76%). 2 naso biliary drips, and 2 internal-external naso biliary drips were added to the procedure to access a good drainage. In one patient, application of histoacryl™ glue in the leaking ducts was needed.The treatment of fistulas required 1 to 3 ERCP (median 2 ERCP per patient). No procedure-related complications was observed. Fistulas were dried up completely in 13/17 patients (76%). Among the 4 failures, 3 were observed in patients with intra hepatic tumors. The time from initial ERCP to running dry of the leaks was 6 to 201 days (median 21 days, mean 48 days). Biliary fistulas arising from intra-hepatic ducts after complex liver resections are more difficult to treat than distal fistulas arising from the common bile duct, in part as a consequence of the associated sepsis. Failure of the drying up was mostly observed in patients with intra hepatic tumors.Therapeutics options are largers than before (NBD, IENBD, Prothesis, Embolization) However, despite a longer time for cure and the need for repeated ERCP, endoscopic therapy appears efficient and does not induce additional morbidity.