Endoscopic internal drainage of complex bilomas and biliary leaks by transmural or transpapillary/transfistulary access

Abstract

Background and Aims: Bilomas most frequently result from postoperative bile leaks. The endoscopic conventional treatment is sphincterotomy AE stent placement. In complex cases, such as altered anatomy or failure of conventional treatment, transpapillary/transfistulary (TP/TF) drainage or EUS-guided transmural drainage (EUS-TD) may obviate additional biliary surgery. This study reports our experience with treating biloma secondary to refractory biliary leak with TP/TF drainage or EUS-TD and evaluates the safety and outcomes associated with this approach.Methods: This observational study focused on consecutive patients managed for biliary leakage (diagnosis based on imaging and/or bile outflow from a surgical drain) at a tertiary care hospital (2007)(2008)(2009)(2010)(2011)(2012)(2013)(2014)(2015)(2016)(2017). TP/TF drainage was performed by double-pigtail stent(s) placement to drain the biloma through the leak during ERCP. For EUS-TD, plastic stent(s) were placed under EUS control. Primary outcomes were a composite of clinical success (patient free of sepsis after percutaneous drain removal and, in patients with benign disease, removal of all endoscopically placed stents, without need for reintervention) and biloma regression (<3 cm) at last follow-up.Results: Thirty patients (men, 57%; median age, 55 years) were included. Most biliary leaks resulted from cholecystectomy (27%) and hepatectomy (50%). Initial EUS-TD and TP/TF drainage were performed in 14 (47%) and 16 (53%) patients, respectively. At last follow-up (median, 33.2 months), clinical success and primary outcome were achieved in 70.4% of patients (EUS-TD, 75%; TP/TF, 67%). Additional surgery was necessary in 1 patient. Rate of serious adverse events was 23% (7/30), of which 13% (4/30) were procedure related. There were 4 deaths during the course of treatment, 2 of which were related to endoscopic interventions (hemorrhage and fibrillation).Conclusions: TP/TF drainage or EUS-TD is technically feasible with high clinical success and may avoid the need for additional surgery in complex cases or in patients with altered anatomy. (Gastrointest Endosc 2021;-:1-9.

Liver cyst with biliary communication treated with endoscopic ultrasound-guided drainage

“…In conclusion, EUS-guided cyst drainage is an effective, minimally invasive treatment for liver cysts with biliary communication that were unresponsive to conventional treatments, such as percutaneous drainage, sclerotherapy, and endoscopic transpapillary drainage. [17] 39/M Abscess Naso-biliary stent 110 mm Transgastric No Yes 2008 Shami et al [18] 44/M Biloma Plastic 37 mm Transgastric No Yes 2008 Shami et al [18] 22/F Biloma Plastic 80 mm Transgastric No Yes 2008 Shami et al [18] 67/M Biloma Plastic 40 mm Transduodenal No Yes 2008 Shami et al [18] 39/F Biloma Plastic 40 mm Transgastric No Yes 2008 Shami et al [18] 43/M Biloma Plastic 85 mm Transgastric No Yes 2009 Ang et al [19] 58/M Abscess Plastic 107 mm Transgastric No Yes 2010 Noh et al [20] 60/M Abscess Plastic 51 mm Transgastric No Yes 2010 Noh et al [20] 50/M Abscess Plastic 60 mm Transgastric No Yes 2010 Noh et al [20] 69/M Abscess Plastic + naso-biliary tube 55 mm Transduodenal No Yes 2011 Itoi et al [21] 78/M Abscess Plastic + naso-biliary tube 70 mm Transgastric No Yes 2013 Medrado et al [22] 73/F Abscess Metalic 97 mm Transgastric Stent migration during the procedure Yes 2014 Taguchi et al [4] 77/M Incfected cyst Plastic N/A Transgastric No Yes 2015 Tonozuka et al [23] 71 (53-94)/M: [24] 37/M Abscess Naso-biliary tube N/A Transgastric No Yes 2016 Ulla-Rocha et al [25] 76/M Perihepatic biloma Plastic 120 mm Transgastric No Yes 2016 Ogura et al [26] 66.5 (31-84)/M:4, F:3 Abscess Metalic 74.6 mm (61.9-99.3)…”

Evaluation of exclusive internal endoscopic drainage for complex biloma with transluminal and transpapillary stenting

“…Secondary outcomes were the evaluated clinical success rate and the rate of adverse events associated with these procedures. The final clinical success rate was defined as a complete or partial decrease in biloma size (>50% reduction in diameter and size <3 cm in maximum diameter of the biloma on cross-sectional computed tomography) without adding external drainage; and disappearance of symptoms such as abdominal pain and fever, with resolution of inflammation on blood examination during clinical follow-up [16,17]. Adverse events associated with the procedures were evaluated using the severity grading system of the American Society for Gastrointestinal Endoscopy lexicon [18].…”

“…More recently, various interventions have emerged that are performed under EUS guidance. Several reports regarding EUS-TBD have been published to date [10][11][12][13][14][15][16][17]. In the first published case series, Shami et al described EUS-guided drainage in five patients complicated with symptomatic biloma [12].…”

Bilioma espontáneo: reporte de un caso y revisión de la literatura

“…Héctor Adolfo Polanía Liscano: conceptualización, validación, redacción (revisión y edición), supervisión, administración del proyecto. con este manejo inicial, se han propuesto como intervenciones el drenaje transmural guiado por ecografía, o el acceso transpapilar/transfistular (10) . En un caso revisado se realizó el drenaje con un tubo en T y colecistectomía luego del fracaso de la CPRE con esfinterotomía.…”