TWO ROLES FOR ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY IN BILIARY INJURY AND BENIGN STRICTURES: DEFINITIVE TREATMENT AND BRIDGING TO SURGERY. PERSONAL EXPERIENCE IN 111 CASES

Abstract

Aim: To define the role of endoscopic retrograde cholangioponcreatography (ERCP) in the treatment of biliary injury and benign strictures.

Background: Biliary injury continues to be one of the most challenging complications to treat for the general surgeon. Its management, in most patients, reguires a multidisciplinary approach. In this context, the therapeutic role of ERCP needs to be better defined.

Methods: A retrospective analysis on patients subjected to ERCP in a hepatopancreatobiliary reference center with the diagnosis of biliary injury or benign stricture. Files of 111 patients were reviewed and the operations as the cause of biliary injury, symptoms and duration, endoscopic findings and therapy, complications, results and follow-up records were evaluated.

Results: Canulation of the bile duct was successful in 108 patients (97%). Simple bile leak was detected in 33 patients (30%), major biliary injury in 42 (38%), billary stricture in 25 (22%) and narrowing of the choledochoduodenostomy in three. In five patients, no leak could be demonstrated despite the existence of an external biliary fistula. Endoscopic sphincterotomy (ES) was performed in all patients with a simple bile leak, a 10 Fr stent was added in five and the fistula closed in all except one. A 10Fr stent could be inserted to bridge the defect in eight patients with major injury, closing their external fistulas and preparing them for surgical repair. Of the 25 patients with a bile duct stricture, three were not fit for surgery; two were stented and one received baloon dilatation endoscopically. One patient was operated upon due to bleeding from the sphicterotomy site despite efforts at endoscopic hemostasis (0.9%). There was no procedure related mortality.

Conclusion: ERCP/ES was found to be effective in the definitive treatment of simple bile leaks. In major injury without complete transsection, ERCP may bridge the patient to surgical repair without further intervention, by stent closure of the fistula.