Jm. Marks et al., BILIARY STENTING IS MORE EFFECTIVE THAN SPHINCTEROTOMY IN THE RESOLUTION OF BILIARY LEAKS, Surgical endoscopy, 12(4), 1998, pp. 327-330
Background: Biliary fistulae may occur following surgical injury, abdo
minal trauma, or inadequate closure of a cystic duct stump. These leak
s are most often managed by drainage of the associate biloma and eithe
r endoscopic sphincterotomy or placement of a biliary endoprosthesis t
o decrease the pressure gradient between the bile duct and the duodenu
m created by the muscular contraction of the ampullary sphincter. In a
previous study, we demonstrated a statistically significant reduction
in ductal pressures following stent placement as compared to sphincte
rotomy. The goal of this present study was to determine if reduction i
n ductal pressures correlates clinically with the resolution of biliar
y leaks in an animal model. Methods: Fourteen mongrel dogs underwent l
aparotomy, cholecystectomy without closure of the cystic stump, and a
lateral duodenotomy to identify the major papilla. The; dogs were then
randomized into three groups. Group I (n = 5) was a control group und
ergoing closure of the duodenotomy only. Group II (n = 4) underwent sp
hincterotomy. Group LII (n = 5) underwent placement of a 7 Fr x 5 cm b
iliary endoprosthesis prior to duodenotomy closure. A drain was placed
adjacent to the cystic duct stump in all groups. Drain output was rec
orded daily. The biliary leak was considered resolved when the output
was <10 cc/day. Regardless of suspected fistula closure, the drains we
re not removed until 2 weeks postprocedure. Necropsy was performed to
identify undrained intraperitoneal bile, Statistical analysis was perf
ormed using Student's paired t test. Results: All dogs had bile leaks
identified on postoperative day 1. The number of days required for res
olution of bile leak in group I (mean +/- SEM) was 7.60 +/- 0.87 days,
as compared to 6.75 +/- 0.80 days for group II and 2.60 +/- 0.24 days
for group III. There was no significant difference in the duration of
bile leak between groups I and II (p = 0.445). Group III, however, ha
d a significant reduction in the duration of biliary fistulae as compa
red to both groups I and II (p < 0.005). At autopsy, persistent biloma
s were identified in 80% of group I, 25% of group II, and 0% of group
III. None of the dogs showed evidence of dehisence of the duodenotomy
closure site as a source of bile leak. Conclusions: Biliary stenting s
ignificantly reduces the time to resolution of cystic duct leaks as co
mpared to sphincterotomy in a canine model. The results obtained in th
is study support the use of biliary endoprostheses in the management o
f biliary leaks and fistulae.