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Treatment of postoperative bile fistulas by internal endoscopic biliary drainage
GASTROENTEROLOGY 1986:90:1998-2003
Treatment of Postoperative Bile Fistulas by Internal Endoscopic Biliary Drainage TILMAN SAUERBRUCH, MARLENE WEINZIERL, JOSEPH HOLL, and EKKEHARD PRATSCHKE Department of Internal Medicine II and Department of Surgery, Klinikum University of Munich, Munich, Federal Republic of Germany
We report four consecutive cases in which postoperative cutaneous Mary fistulas were treated successfully by an endoscopically placed nasobiliary tube or an endoprosthesis. This simple and efiective method should be considered in selected patients as a viable alternative to established surgical procedures. Postoperative cutaneous bile duct fistulas may originate from delayed closure of the cystic stump or from direct leakage of the common bile duct. Although as a rule cystic duct stump leaks heal spontaneously, injury to the extrahepatic biliary tract may require operative repair (l-3). This paper reports successful treatment of cutaneous biliary fistulas by nonsurgical endoscopic biliary drainage in four consecutive cases. The method may accelerate closure of benign postoperative bile leaks and may even replace reoperation of patients with bile duct injury in selected cases.
Case Reports Case 1: Leak From the Cystic Duct Stump A 52-yr-old female patient was operated on because of a porcelain gallbladder. Intraoperative cholangiography revealed no common bile duct stones. When the gallbladder was removed from its bed, a small aberrant bile duct was damaged and ligated. From the second postoperative day onward, a daily secretion of 180-200 ml of bile, via the wound drainage, was observed over 5 wk. Retrograde cholangiography was performed in the sixth postoperative week. It revealed bile leakage in the area of the cystic duct stump (Figure la) but no stones or biliary obstruction. A 250-cm-long nasobiliary 5F polyethylene
Received August 5, 1985. Accepted November 22, 1985. Address requests for reprints to: Tilman Sauerbruch, M.D., Medizinische Klinik II, Klinikum Grosshadern, Marchioninistrasse 15, D-8000 Miinchen 70, Federal Republic of Germany. 0 1986 by the American Gastroenterological Association 0016-5085/86/$3.50
Grosshadern,
tube was inserted into the common bile duct (4,5) with the tip at the confluence of the hepatic ducts [Figure lb). Bile (250-300 ml/day) was aspirated using a motor pump. After this procedure, daily bile secretion from the wound decreased to 100 ml. A catheter cholangiogram 2 wk after placement of the nasobiliary tube showed nq more leakage (Figure lb). The catheter was removed and 6 days later bile secretion from the cutaneous fistula had ceased completely. The patient was asymptomatic during the follow-up period of 4 yr. Case
2: Leak From
the Choledochotomy
A 64-yr-old patient had his gallbladder removed and the common bile duct explored because of stones in the gallbladder and the common bile duct. From the second postoperative day onward, the patient had persistent loss of 100-200 ml of bile per day, via the Penrose drain, over a period of 2 wk. In addition, 100-300 ml of bile drained daily along the T tube. Bile duct leakage was probably due to an intermittent obstructiop of the T tube in the early postoperative period. Fourteen days after the operation, the patient inadvertently removed the T tube. Subsequent retrograde cholangiography showed a massive leakage from the choledochotomy [Figure 2a). A catheter could not be threaded into the T-tube tract because the channel was too small. Therefore, a nasobiliary tube was inserted into the bile duct (Figure 2b), and bile was aspirated continuously by a motor pump (loo-250 ml/ day). On the fifth day, bile flow from the wound drainage had ceased. The patient was asymptomatic during the follow-up period of 9 mo. Case
3: Leak
From
a Common
Bile
Duct
Lesion A 45-yr-old man was admitted to the hospital because of recurrent biliary colic. Oral cholecystogram revealed a solitary gallbladder stone. During insertion of a catheter into the cystic duct for intraoperative cholangiography, the common bile duct was injured and was repaired immediately by direct suture. Intraoperative cholangiography showed no bile duct stones or a stenosis. Therefore, no T tube was placed. From the fourth to the 17th postoper-
HILIAKY FWTI JL,A
June 1986
Figure
1999
1. Case 1. a. Retrograde cholangiography in a patient with persistent bile leakage from the cystic duct stump (arrow). b. Closure of the leakage after 2 wk of bile drainage via a nasobiliary catheter.
secretion (300-700 ml/day), via the ative day, biliary Penrose drain, was observed. The retrograde cholangiogram showed a stricture of the common bile duct in the area of the cystic drain junction and massive leakage of the contrast medium into the wound bed and into the wound drainage channel (Figure 31). Placement of a nasobiliary catheter through the common bile duct stenosis failed. In a second session 1 wk later we bridged the stenosis (Figure 3~) by endoscopically introducing a 7F prosthesis (56). Bile flow from the cutaneous biliary fistula ceased promptly and the patient was discharged. At the following examination z mo later, bilirubin, alkaline phosphatase, y-glutamyl transpeptidase, transaminases, and leukocytes were within the normal range. The patient was asymptomatic. The endoprosthesis was removed 6 mo after operation and bile duct injury. A retrograde cholangiogram 2 mo after removal of the prosthesis showed a beginning bile duct stenosis at the site of the former bile duct injury, but no evidence of fistula and no dilated bile ducts (Figure SC). Temperatures, white blood cells, bilirubin, y-glutamyl transpeptidase, alkaline phosphatase, and transaminases were within the normal range during regular follow-up examinations over a period of 18 mo after removal of the bile duct prosthesis.
Case
4: Leak From
a Common
Bile Duct
Lesion A 61-yr-old patient with liver cirrhosis was admitted to the hospital because of massive intestinal hemorrhage. Endoscopy revealed bleeding gastric varices. The patient was treated conservatively and had no recurrence of bleeding. Two weeks after the bleeding episode, an end-to-side portacaval shunt was performed. One week later, leukocytosis and septic temperatures were observed. Surgical drainage of a wound abscess was performed. On the 16th postoperative day, a sudden discharge of 700 ml of bile from the wound occurred. Retrograde cholangiography carried out on the same day revealed massive leakage of contrast medium from the bile duct (Figure ~a). Bile duct injury during preparation and mobilization of the portal vein with necrosis and subsequent leakage from the duct had to be assumed. A 7F endoprosthesis was inserted endoscopically into the bile duct. Two days later, discharge of bile dropped to 100 ml and ceased completely on the following day. During the next 2 wk the patient had slightly elevated temperatures. Computed tomography showed a subhepatic abscess, which was drained by an ultrasound-guided catheter. The abscess material was free
2000
SAUERBRUCH
of bile. One month later, the endoprosthesis was removed, as bile leakage had stopped for that entire month. Endoscopic retrograde cholangiography at that time confirmed healing of the leakage (Figure 4b). Two months later the patient died with the clinical and biochemical signs of hepatic failure. The temperature had been within the normal range after abscess drainage. Autopsy was not performed.
Discussion Diagnosis of bile duct injury is suspected when jaundice, biliary fistula, cholangitis, or subhepatic abscess occur in the early period after surgery of the biliary tract or within the vicinity of the hepatoduodenal ligament (l-3). Visualization of the biliary tree either by endoscopic retrograde cholangiography or by percutaneous transhepatic cholangiography should be obtained as soon as possible when bile duct injury is suspected (7~3). Direct cholangiography allows identification of the exact site of extravasation and permits planning of an operative repair if necessary.
Figure
GASTROENTEROLOGY
ET AL.
Vol. 90, No. 6
In all our cases, retrograde cholangiography enabled prompt diagnosis. Patient No. 1 had a bile duct fistula at the site of the cystic duct stump; patient No. 2 had a choledochotomy leak. Normaily, these patients are expected to close their fistulas spontaneously, especially if the Penrose drain is left in place. In case 1, permanent biliary secretion over a period of 6 wk without signs of improvement and, in case 2, inadvertent premature removal of the T tube led us to introduce a nasobiliary catheter. Although only 100-300 ml of bile, which is no more than one-third of the total bile flow, was diverted per day by active suction through the tube, cutaneous bile secretion ceased quickly after placement of the catheters. There are several explanations for this phenomenon. First, due to the relatively small caliber of the catheter, spontaneous bile flow via the common bile duct and the papilla of Vater was probably preserved. Additional suction of bile may have caused effective diminution of the bile duct pressure around the fistula so that it would seal. Second, the catheter could have acted additionally as a stimulus for
2. Case 2. Retrograde cholangiography of a patient with persistent immediately after (b) placement of a nasobiliary catheter.
bile leakage from the choledochotomy
(arrow] before (a) and
June 1986
Figure
BILIARY FISTULA
3. Case 3. Retrograde cholangiography of a patient with persistent bile leakage [arrow) after intraoperative which was bridged by an endoprosthesis (b), and healed, as proven by ERC, after 8 mo (c).
granulation at the site of leakage and thus promote closure. Very recently, nasobiliary tubes with larger diameters than 5F have become available. Introduction of these catheters might divert sufficient bile so that suction would not be needed. In summary, it is worthwhile in long-lasting benign postcholecystectomy leaks to try the very simple endoscopic introduction of a catheter to accelerate the healing process. In cases 3 and 4, the type of injury to the bile ducts makes spontaneous healing very unlikely. In patient No. 3, the bile duct injury was already recognized intraoperatively. No T tube was placed during repair of the damage, however. Thus, the patient had permanent postoperative discharge of bile from the wound drainage over several weeks. The common bile duct of the fourth patient was obviously damaged during exposure to the hepatoduodenal ligament. An internal bile fistula probably led to a subhepatic abscess, wound abscess, and cutaneous biliary fistula. For these patients, side-to-side Rouxen-Y hepaticojejunostomy or end-to-end anastomo-
bile duct
2001
injury
(a)
sis with a T-tube stent has been the method of reconstruction employed (l-3,9). Preliminary decompression of the bile ducts with percutaneous transhepatic catheter drainage has been advised by some authors (8,10,11), especially in cases of biliary obstruction. When fistulas predominate and when there are no signs of bile duct dilatation, however, endoscopic retrograde cholangiography with subsequent internal drainage either by a nasobiliary tube or by an endoprosthesis should prove to be an easier method without the morbidity and mortality associated with an operative repair. Nasobiliary catheters and percutaneous drainage have the advantage of being simple to flush if they get obstructed. On the other hand, an internal endoprosthesis is more comfortable for the patient and avoids bile loss. It is well known from the extensive experience with endoscopic introduction of transtumorous prostheses (5) that the whole daily bile secretion can pass through a 7F or 10F stent. In patient No. 3, stenosis of the common bile duct was demonstrated after withdrawal of the prosthesis
2002
SAUERBRUCH
ET AL.
8 mo after its placement (Figure 3~). Thus, the stent did not prevent scarring with subsequent stricture, which eventually may require additional surgery (12). The lumen of the bile duct, however, is still wide enough at this time to allow adequate bile flow. None of the liver function tests were abnormal during a close follow-up 18 mo after removal of the stent. Of course, the patient must be monitored closely in the future. As shown by the follow-up retrograde cholangiogram, patient No. 4 did not develop a bile duct stricture. In this patient, one might argue, endoscopic introduction of the stent was not able to prevent development of a subhepatic abscess. We believe, however, that this side effect had already been caused by the internal bile fistula, before its transcutaneous rupture, which led to performance of retrograde cholangiography. Possibly, earlier performance of computed tomography would have permitted a more timely diagnosis, The course of the patient demonstrates that abandonment of operative intervention in favor of nonsurgical biliary drainage
Figure
GASTROENTEROLOGY
Vol. 90, No. 6
in cases with bile duct injuries requires a very careful diagnostic workup so that the necessity of additional measures, e.g., direct percutaneous drainage of an abscess, is not overlooked. After drainage of the abscess, the patient had no more febrile episodes and died 3 mo later due to hepatic failure after placement of a portacaval shunt. In 1982 we described for the first time (13) endoscopic biliary drainage of the common bile duct in a patient with a persistent cystic stump fistula. Two years later, Rosch (14) pointed out the importance of a distal bile duct obstruction. Three postoperative bile fistulas healed spontaneously after endoscopic removal of common bile duct stones. In their series, three additional cases of bile leakage were successfully managed by nonsurgical endoscopic drainage. In a very recent paper, Kaufmann et al. (8) reported on the management of 12 patients with traumatic extravasation of bile using percutaneous biliary drainage. Their experience was similar to ours. They stressed the importance of direct cholangiography to define the anatomy of the bile ducts and to delineate
4. Case 4. Bile leakage from a large defect in the common bile duct (arrow) immediately after bridging by an endoprosthesis (a) and 1 mo later after withdrawal of the prosthesis (b), showing healing of the leak [single arrow) and drainage of a subhepatic abscess (arrows).
June 1986
the site of leakage. In 6 of these patients, biliary leakage closed with only percutaneous biliary drainage. These observations underscore the importance of nonsurgical biliary drainage in patients supposed to have bile leaks or fistulas. Especially in the absence of dilated bile ducts, endoscopic access via the papilla of Vater may have the advantage of a higher success rate with fewer complications (15). In summary, endoscopic retrograde cholangiography is an important adjunct to the management of patients with persistent or massive postoperative biliary cutaneous fistulas. As our case reports show, insertion of an endoprosthesis or nasobiliary tube with the side viewing endoscope at the time of the diagnostic procedure may allow rapid healing of the leakage and replace surgical intervention in carefully selected patients. Note added in proof. Since submission of this manuscript we have seen an additional 2 patients with persistent leaks from the bile ducts: 1 patient is a 46-yr-old man in whom cholecystectomy and exploration of the common bile duct were performed and another is a 57-yr-old man who underwent resection of a hepatic metastasis. Both patients showed rapid healing of the leaks after endoscopic insertion of a 7F biliary endoprosthesis.
References 1. Hillis ThM, Westbrook KC, Caldwell FT, Read RC. Surgical injury of the common bile duct. Am J Surg 1977;134:712-6. 2. Longmire WP. Early management of injury to the extrahepatic biliary tract. JAMA 1966;195:623-5.
BILIARY FISTULA
2003
3. Saber K, El-Manialawi M. Repair of bile duct injuries. World J Surg 1984;8:82-9. 4. Wurbs D, Classen M. Transpapillary longstanding tube for hepatobiliary drainage. Endoscopy 1977;9:192-3. 5. Hagenmiiller F, Soehendra N. Non-surgical biliary drainage. Clin Gastroenterol 1983;12:297-316. 6. Soehendra N, Reynders-Frederix V. Palliative Gallengangdrainage. Eine neue Methode zur endoskopischen Einfiihrung eines inneren Drains. Dtsch Med Wochenschr 1979;104: 206-7. 7. Nelson AM. Cystic duct fistula: a complication of cholecystectomy. Am J Gastroenterol 1984;79:479-81. 8. Kaufmann SL, Kadir S, Mitchell SE, et al. Percutaneous transhepatic biliary drainage for bile leaks and fistulas. AJR 1985;144:1055-8, 9. Pellegrini CA, Thomas MJ, Way LW. Recurrent biliary stricture. Am J Surg 1984;147:175-80. 10. Nakayama T, Ikeda A, Okuda K. Percutaneous transhepatic drainage of the biliary tract. Gastroenterology 1978;74:554-9. 11. Pollock ThW, Ring ER, Oleaga JA, Freiman DB, Mullen JL, Rosato EF. Percutaneous decompression of benign and malignant biliary obstruction. Arch Surg 1979;114:148-51, 12. Blumgart LH, Kelley CJ, Benjamin JS. Benign bile duct stricture following cholecystectomy: critical factors in management. Br J Surg 1964;71:836-43. 13. Sauerbruch T, Hopp H, Weinzierl M. Nasobiliare Verweilsonde zur Behandlung der Zysticusstumpffistel. Tips f d gastroenterologische Praxis 1982;9:5-6. 14. Rosch W. Innere Schienung zur Behandlung postoperativer Gallefisteln. Fortschr Gastroenterol Endoskopie 1984;13: 167-71. 15. Elias E, Hamlyn AN, Jain S, et al. A randomized trial of percutaneous transhepatic cholangiography with the Chiba needle versus endoscopic retrograde cholangiography for bile duct visualization in jaundice. Gastroenterology 1976;71: 439-43.
Treatment of Postoperative Bile Fistulas by Internal Endoscopic Biliary Drainage TILMAN SAUERBRUCH, MARLENE WEINZIERL, JOSEPH HOLL, and EKKEHARD PRATSCHKE Department of Internal Medicine II and Department of Surgery, Klinikum University of Munich, Munich, Federal Republic of Germany
We report four consecutive cases in which postoperative cutaneous Mary fistulas were treated successfully by an endoscopically placed nasobiliary tube or an endoprosthesis. This simple and efiective method should be considered in selected patients as a viable alternative to established surgical procedures. Postoperative cutaneous bile duct fistulas may originate from delayed closure of the cystic stump or from direct leakage of the common bile duct. Although as a rule cystic duct stump leaks heal spontaneously, injury to the extrahepatic biliary tract may require operative repair (l-3). This paper reports successful treatment of cutaneous biliary fistulas by nonsurgical endoscopic biliary drainage in four consecutive cases. The method may accelerate closure of benign postoperative bile leaks and may even replace reoperation of patients with bile duct injury in selected cases.
Case Reports Case 1: Leak From the Cystic Duct Stump A 52-yr-old female patient was operated on because of a porcelain gallbladder. Intraoperative cholangiography revealed no common bile duct stones. When the gallbladder was removed from its bed, a small aberrant bile duct was damaged and ligated. From the second postoperative day onward, a daily secretion of 180-200 ml of bile, via the wound drainage, was observed over 5 wk. Retrograde cholangiography was performed in the sixth postoperative week. It revealed bile leakage in the area of the cystic duct stump (Figure la) but no stones or biliary obstruction. A 250-cm-long nasobiliary 5F polyethylene
Received August 5, 1985. Accepted November 22, 1985. Address requests for reprints to: Tilman Sauerbruch, M.D., Medizinische Klinik II, Klinikum Grosshadern, Marchioninistrasse 15, D-8000 Miinchen 70, Federal Republic of Germany. 0 1986 by the American Gastroenterological Association 0016-5085/86/$3.50
Grosshadern,
tube was inserted into the common bile duct (4,5) with the tip at the confluence of the hepatic ducts [Figure lb). Bile (250-300 ml/day) was aspirated using a motor pump. After this procedure, daily bile secretion from the wound decreased to 100 ml. A catheter cholangiogram 2 wk after placement of the nasobiliary tube showed nq more leakage (Figure lb). The catheter was removed and 6 days later bile secretion from the cutaneous fistula had ceased completely. The patient was asymptomatic during the follow-up period of 4 yr. Case
2: Leak From
the Choledochotomy
A 64-yr-old patient had his gallbladder removed and the common bile duct explored because of stones in the gallbladder and the common bile duct. From the second postoperative day onward, the patient had persistent loss of 100-200 ml of bile per day, via the Penrose drain, over a period of 2 wk. In addition, 100-300 ml of bile drained daily along the T tube. Bile duct leakage was probably due to an intermittent obstructiop of the T tube in the early postoperative period. Fourteen days after the operation, the patient inadvertently removed the T tube. Subsequent retrograde cholangiography showed a massive leakage from the choledochotomy [Figure 2a). A catheter could not be threaded into the T-tube tract because the channel was too small. Therefore, a nasobiliary tube was inserted into the bile duct (Figure 2b), and bile was aspirated continuously by a motor pump (loo-250 ml/ day). On the fifth day, bile flow from the wound drainage had ceased. The patient was asymptomatic during the follow-up period of 9 mo. Case
3: Leak
From
a Common
Bile
Duct
Lesion A 45-yr-old man was admitted to the hospital because of recurrent biliary colic. Oral cholecystogram revealed a solitary gallbladder stone. During insertion of a catheter into the cystic duct for intraoperative cholangiography, the common bile duct was injured and was repaired immediately by direct suture. Intraoperative cholangiography showed no bile duct stones or a stenosis. Therefore, no T tube was placed. From the fourth to the 17th postoper-
HILIAKY FWTI JL,A
June 1986
Figure
1999
1. Case 1. a. Retrograde cholangiography in a patient with persistent bile leakage from the cystic duct stump (arrow). b. Closure of the leakage after 2 wk of bile drainage via a nasobiliary catheter.
secretion (300-700 ml/day), via the ative day, biliary Penrose drain, was observed. The retrograde cholangiogram showed a stricture of the common bile duct in the area of the cystic drain junction and massive leakage of the contrast medium into the wound bed and into the wound drainage channel (Figure 31). Placement of a nasobiliary catheter through the common bile duct stenosis failed. In a second session 1 wk later we bridged the stenosis (Figure 3~) by endoscopically introducing a 7F prosthesis (56). Bile flow from the cutaneous biliary fistula ceased promptly and the patient was discharged. At the following examination z mo later, bilirubin, alkaline phosphatase, y-glutamyl transpeptidase, transaminases, and leukocytes were within the normal range. The patient was asymptomatic. The endoprosthesis was removed 6 mo after operation and bile duct injury. A retrograde cholangiogram 2 mo after removal of the prosthesis showed a beginning bile duct stenosis at the site of the former bile duct injury, but no evidence of fistula and no dilated bile ducts (Figure SC). Temperatures, white blood cells, bilirubin, y-glutamyl transpeptidase, alkaline phosphatase, and transaminases were within the normal range during regular follow-up examinations over a period of 18 mo after removal of the bile duct prosthesis.
Case
4: Leak From
a Common
Bile Duct
Lesion A 61-yr-old patient with liver cirrhosis was admitted to the hospital because of massive intestinal hemorrhage. Endoscopy revealed bleeding gastric varices. The patient was treated conservatively and had no recurrence of bleeding. Two weeks after the bleeding episode, an end-to-side portacaval shunt was performed. One week later, leukocytosis and septic temperatures were observed. Surgical drainage of a wound abscess was performed. On the 16th postoperative day, a sudden discharge of 700 ml of bile from the wound occurred. Retrograde cholangiography carried out on the same day revealed massive leakage of contrast medium from the bile duct (Figure ~a). Bile duct injury during preparation and mobilization of the portal vein with necrosis and subsequent leakage from the duct had to be assumed. A 7F endoprosthesis was inserted endoscopically into the bile duct. Two days later, discharge of bile dropped to 100 ml and ceased completely on the following day. During the next 2 wk the patient had slightly elevated temperatures. Computed tomography showed a subhepatic abscess, which was drained by an ultrasound-guided catheter. The abscess material was free
2000
SAUERBRUCH
of bile. One month later, the endoprosthesis was removed, as bile leakage had stopped for that entire month. Endoscopic retrograde cholangiography at that time confirmed healing of the leakage (Figure 4b). Two months later the patient died with the clinical and biochemical signs of hepatic failure. The temperature had been within the normal range after abscess drainage. Autopsy was not performed.
Discussion Diagnosis of bile duct injury is suspected when jaundice, biliary fistula, cholangitis, or subhepatic abscess occur in the early period after surgery of the biliary tract or within the vicinity of the hepatoduodenal ligament (l-3). Visualization of the biliary tree either by endoscopic retrograde cholangiography or by percutaneous transhepatic cholangiography should be obtained as soon as possible when bile duct injury is suspected (7~3). Direct cholangiography allows identification of the exact site of extravasation and permits planning of an operative repair if necessary.
Figure
GASTROENTEROLOGY
ET AL.
Vol. 90, No. 6
In all our cases, retrograde cholangiography enabled prompt diagnosis. Patient No. 1 had a bile duct fistula at the site of the cystic duct stump; patient No. 2 had a choledochotomy leak. Normaily, these patients are expected to close their fistulas spontaneously, especially if the Penrose drain is left in place. In case 1, permanent biliary secretion over a period of 6 wk without signs of improvement and, in case 2, inadvertent premature removal of the T tube led us to introduce a nasobiliary catheter. Although only 100-300 ml of bile, which is no more than one-third of the total bile flow, was diverted per day by active suction through the tube, cutaneous bile secretion ceased quickly after placement of the catheters. There are several explanations for this phenomenon. First, due to the relatively small caliber of the catheter, spontaneous bile flow via the common bile duct and the papilla of Vater was probably preserved. Additional suction of bile may have caused effective diminution of the bile duct pressure around the fistula so that it would seal. Second, the catheter could have acted additionally as a stimulus for
2. Case 2. Retrograde cholangiography of a patient with persistent immediately after (b) placement of a nasobiliary catheter.
bile leakage from the choledochotomy
(arrow] before (a) and
June 1986
Figure
BILIARY FISTULA
3. Case 3. Retrograde cholangiography of a patient with persistent bile leakage [arrow) after intraoperative which was bridged by an endoprosthesis (b), and healed, as proven by ERC, after 8 mo (c).
granulation at the site of leakage and thus promote closure. Very recently, nasobiliary tubes with larger diameters than 5F have become available. Introduction of these catheters might divert sufficient bile so that suction would not be needed. In summary, it is worthwhile in long-lasting benign postcholecystectomy leaks to try the very simple endoscopic introduction of a catheter to accelerate the healing process. In cases 3 and 4, the type of injury to the bile ducts makes spontaneous healing very unlikely. In patient No. 3, the bile duct injury was already recognized intraoperatively. No T tube was placed during repair of the damage, however. Thus, the patient had permanent postoperative discharge of bile from the wound drainage over several weeks. The common bile duct of the fourth patient was obviously damaged during exposure to the hepatoduodenal ligament. An internal bile fistula probably led to a subhepatic abscess, wound abscess, and cutaneous biliary fistula. For these patients, side-to-side Rouxen-Y hepaticojejunostomy or end-to-end anastomo-
bile duct
2001
injury
(a)
sis with a T-tube stent has been the method of reconstruction employed (l-3,9). Preliminary decompression of the bile ducts with percutaneous transhepatic catheter drainage has been advised by some authors (8,10,11), especially in cases of biliary obstruction. When fistulas predominate and when there are no signs of bile duct dilatation, however, endoscopic retrograde cholangiography with subsequent internal drainage either by a nasobiliary tube or by an endoprosthesis should prove to be an easier method without the morbidity and mortality associated with an operative repair. Nasobiliary catheters and percutaneous drainage have the advantage of being simple to flush if they get obstructed. On the other hand, an internal endoprosthesis is more comfortable for the patient and avoids bile loss. It is well known from the extensive experience with endoscopic introduction of transtumorous prostheses (5) that the whole daily bile secretion can pass through a 7F or 10F stent. In patient No. 3, stenosis of the common bile duct was demonstrated after withdrawal of the prosthesis
2002
SAUERBRUCH
ET AL.
8 mo after its placement (Figure 3~). Thus, the stent did not prevent scarring with subsequent stricture, which eventually may require additional surgery (12). The lumen of the bile duct, however, is still wide enough at this time to allow adequate bile flow. None of the liver function tests were abnormal during a close follow-up 18 mo after removal of the stent. Of course, the patient must be monitored closely in the future. As shown by the follow-up retrograde cholangiogram, patient No. 4 did not develop a bile duct stricture. In this patient, one might argue, endoscopic introduction of the stent was not able to prevent development of a subhepatic abscess. We believe, however, that this side effect had already been caused by the internal bile fistula, before its transcutaneous rupture, which led to performance of retrograde cholangiography. Possibly, earlier performance of computed tomography would have permitted a more timely diagnosis, The course of the patient demonstrates that abandonment of operative intervention in favor of nonsurgical biliary drainage
Figure
GASTROENTEROLOGY
Vol. 90, No. 6
in cases with bile duct injuries requires a very careful diagnostic workup so that the necessity of additional measures, e.g., direct percutaneous drainage of an abscess, is not overlooked. After drainage of the abscess, the patient had no more febrile episodes and died 3 mo later due to hepatic failure after placement of a portacaval shunt. In 1982 we described for the first time (13) endoscopic biliary drainage of the common bile duct in a patient with a persistent cystic stump fistula. Two years later, Rosch (14) pointed out the importance of a distal bile duct obstruction. Three postoperative bile fistulas healed spontaneously after endoscopic removal of common bile duct stones. In their series, three additional cases of bile leakage were successfully managed by nonsurgical endoscopic drainage. In a very recent paper, Kaufmann et al. (8) reported on the management of 12 patients with traumatic extravasation of bile using percutaneous biliary drainage. Their experience was similar to ours. They stressed the importance of direct cholangiography to define the anatomy of the bile ducts and to delineate
4. Case 4. Bile leakage from a large defect in the common bile duct (arrow) immediately after bridging by an endoprosthesis (a) and 1 mo later after withdrawal of the prosthesis (b), showing healing of the leak [single arrow) and drainage of a subhepatic abscess (arrows).
June 1986
the site of leakage. In 6 of these patients, biliary leakage closed with only percutaneous biliary drainage. These observations underscore the importance of nonsurgical biliary drainage in patients supposed to have bile leaks or fistulas. Especially in the absence of dilated bile ducts, endoscopic access via the papilla of Vater may have the advantage of a higher success rate with fewer complications (15). In summary, endoscopic retrograde cholangiography is an important adjunct to the management of patients with persistent or massive postoperative biliary cutaneous fistulas. As our case reports show, insertion of an endoprosthesis or nasobiliary tube with the side viewing endoscope at the time of the diagnostic procedure may allow rapid healing of the leakage and replace surgical intervention in carefully selected patients. Note added in proof. Since submission of this manuscript we have seen an additional 2 patients with persistent leaks from the bile ducts: 1 patient is a 46-yr-old man in whom cholecystectomy and exploration of the common bile duct were performed and another is a 57-yr-old man who underwent resection of a hepatic metastasis. Both patients showed rapid healing of the leaks after endoscopic insertion of a 7F biliary endoprosthesis.
References 1. Hillis ThM, Westbrook KC, Caldwell FT, Read RC. Surgical injury of the common bile duct. Am J Surg 1977;134:712-6. 2. Longmire WP. Early management of injury to the extrahepatic biliary tract. JAMA 1966;195:623-5.
BILIARY FISTULA
2003
3. Saber K, El-Manialawi M. Repair of bile duct injuries. World J Surg 1984;8:82-9. 4. Wurbs D, Classen M. Transpapillary longstanding tube for hepatobiliary drainage. Endoscopy 1977;9:192-3. 5. Hagenmiiller F, Soehendra N. Non-surgical biliary drainage. Clin Gastroenterol 1983;12:297-316. 6. Soehendra N, Reynders-Frederix V. Palliative Gallengangdrainage. Eine neue Methode zur endoskopischen Einfiihrung eines inneren Drains. Dtsch Med Wochenschr 1979;104: 206-7. 7. Nelson AM. Cystic duct fistula: a complication of cholecystectomy. Am J Gastroenterol 1984;79:479-81. 8. Kaufmann SL, Kadir S, Mitchell SE, et al. Percutaneous transhepatic biliary drainage for bile leaks and fistulas. AJR 1985;144:1055-8, 9. Pellegrini CA, Thomas MJ, Way LW. Recurrent biliary stricture. Am J Surg 1984;147:175-80. 10. Nakayama T, Ikeda A, Okuda K. Percutaneous transhepatic drainage of the biliary tract. Gastroenterology 1978;74:554-9. 11. Pollock ThW, Ring ER, Oleaga JA, Freiman DB, Mullen JL, Rosato EF. Percutaneous decompression of benign and malignant biliary obstruction. Arch Surg 1979;114:148-51, 12. Blumgart LH, Kelley CJ, Benjamin JS. Benign bile duct stricture following cholecystectomy: critical factors in management. Br J Surg 1964;71:836-43. 13. Sauerbruch T, Hopp H, Weinzierl M. Nasobiliare Verweilsonde zur Behandlung der Zysticusstumpffistel. Tips f d gastroenterologische Praxis 1982;9:5-6. 14. Rosch W. Innere Schienung zur Behandlung postoperativer Gallefisteln. Fortschr Gastroenterol Endoskopie 1984;13: 167-71. 15. Elias E, Hamlyn AN, Jain S, et al. A randomized trial of percutaneous transhepatic cholangiography with the Chiba needle versus endoscopic retrograde cholangiography for bile duct visualization in jaundice. Gastroenterology 1976;71: 439-43.