Postcholecystectomy refractory biliary leaks

Jorge Canena, MD, PhD, from the Center of Gastroenterology, Hospital Cuf Infante Santo, in Lisbon, Portugal discusses this Original Article “A non-randomized study in consecutive patients with postcholecystectomy refractory biliary leaks who were managed endoscopically with the use of multiple plastic stents or fully covered self-expandable metal stents (with videos).”

We compared the clinical effectiveness of the use of a fully covered self-expandable metal stent (FCSEMS) with the placement of multiple plastic stents (MPSs) for the treatment of postcholecystectomy refractory biliary leaks.

Endoscopic retrograde cholangiopancreatography (ERCP) is the treatment of choice for the primary treatment for bile leaks. Despite the high success rate and safety of endotherapy for bile leaks, there are reports of difficult to treat refractory bile leaks. In recent years, the temporary placement of a FCSEMS has emerged as an effective rescue therapy for refractory biliary leaks. However, in patients with persistent biliary leaks, instead of using an FCSEMS, the endoscopist could place more than 1 plastic stent (multiple plastic stents [MPSs]) at a lower cost to further decrease the transpapillary pressure gradient and to seal the leak. Until now, there have been no comparative studies between these 2 types of endoscopic treatment and the decisions regarding the treatment of a refractory biliary leak must be made on an individual basis.

This is the first study to compare the 2 types of rescue endoscopic management available for the treatment of postcholecystectomy refractory biliary leaks. Closure of the leak was accomplished in 13 patients (65%) who received MPSs, and in 20 patients (100%), who received an FCSEMS. Use of fewer than 3 plastic stents, a plastic stent diameter below 20Fr, and a high-grade biliary leak were shown to be significant predictors of treatment failure with MPSs. The 7 patients in whom the placement of MPSs failed were retreated with an FCSEMS, resulting in closure of the leak in all cases. In conclusion, in our series and in our centers the results of using a FCSEMS as a rescue endotherapy for postcholecystectomy refractory biliary leaks were superior to the use of MPSs. We suggest that a randomized clinical trial is needed before the temporary placement of a FCSEMS should be recommended as the treatment of choice.

Read the abstract of this article online.

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