BILIARY STENTING IS MORE EFFECTIVE THAN SPHINCTEROTOMY IN THE RESOLUTION OF BILIARY LEAKS

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.