Successful treatment of postoperative external biliary fistulas by endoscopic sphincterotomy

0016·5107/88/3404-0307$02.00 GASTROINTESTINAL ENDOSCOPY Copyright © 1988 by the American Society for Gastrointestinal Endoscopy

Successful treatment of postoperative external biliary fistulas by endoscopic sphincterotomy L. Del Olmo, MD, E. Merono, MD V. F. Moreira, MD, T. Garcia, MD A. Garcia-Plaza, MD Madrid, Spain

External biliary fistulas occur as a complication of biliary tract surgery. Until recently, excision of the fistula was the primary therapeutic modality. We describe seven cases of postoperative external biliary fistula successfully treated by endoscopic papillotomy. Fistulation occurred in four patients after operations for hydatid cysts of the liver, in one patient after cholecystectomy for acute cholecystitis, in one patient with carcinoma of the periampullary region after a decompression procedure, and in the remaining patient after an intraoperative biopsy of a carcinoma of the gallbladder. Endoscopic sphincterotomy is a reliable and effective therapeutic alternative in patients with external biliary fistulas. (Gastrointest Endosc 1988;34:307-309)

External biliary fistulas are one of the most serious immediate complications after biliary tract surgery, usually requiring laparotomy for their resolution. 1- 3 Overlooked gallstones are the main cause. Their removal and the restoration of normal biliary outflow via the papilla is the treatment of choice. 4 Occasionally, fistula formation develops after surgical drainage of liver abscesses and cysts. 3 A case of external biliary fistula following esophagogastrectomy has also been reported. 5 External biliary fistulas in the absence of outflow obstruction in the distal bile duct are rare. 6 The causes of bile flow obstruction and leakage from the common bile duct can be identified using ERCP. An indication for ERCP in the immediate postoperative period occurs in obstructive jaundice, biliary fistula formation, and upper gastrointestinal hemorrhage,7,S In cases of biliary fistula the ERCP can be followed by endoscopic sphincterotomy, thereby obviating re-Iaparotomy.4 We describe seven cases of postoperative external biliary fistula successfully treated by endoscopic sphincterotomy. Received January 27, 1987. For revision April 1, 1987. Accepted June 29,1987.

From the Department of Gastroenterology, Hospital Ramon y Cajal, Madrid, Spain. Reprint requests: Ernesto Meroiio, MD, Servicio de Gastroenterologia, Hospital RamOn y Cajal, Carretera de Colmenar Viejo km. 9.2, 28034 Madrid, Spain. VOLUME 34, NO.4, 1988

MATERIALS AND METHODS

From September 1977 to February 1986, we performed a total of 2200 ERCPs following a previously reported technique. 9 Endoscopic sphincterotomy was associated with this procedure on 240 occasions. In seven (2.9%) patients, two men and five women, endoscopic sphincterotomy was performed as a therapy for external biliary fistula. Ages of these seven patients ranged from 34 to 48 years (mean, 52.6 years). Fistulation occurred in four patients after operations for hydatid cysts of the liver, in one patient after cholecystectomy for acute cholecystitis, in one patient with carcinoma of the periampullary region after a decompression procedure,1O and in the remaining patient after an intraoperative biopsy of a carcinoma of the gallbladder. The time elapsing between surgical operation and the indication for endoscopic sphincterotomy varied from 12 days to 3 months, the precise day being in accord with the surgeon's agreement for the procedure. Clinical data of the patients are outlined in Table 1. At the time of ERCP five patients were asymptomatic, except for the presence of external biliary fistulas which drained 50 to 200 ml/day. Jaundice persisted in one patient. The remaining patient had fever and pain in the right upper quadrant; Proteus mirabilis and Streptococcus faecalis were isolated in the bile culture.

RESULTS

Selective cannulation of the bile ducts was achieved in all cases, but in only three (43%) patients were external biliary fistulas radiologically visualized. In no 307

Table 1. Clinical data of seven patients with external biliary fistula

Case

Age (yr)

Sex

1 2

34 69

M F

3

77

4

Previous pathologic condition

Type of operation

Fistula ERCP

Interval between surgery-ESa (days)

Fistulous drainage (ml/day)

Fistulous drainage after ES (days)

None None

+ +

60 90

50 65

5 4

Fever, RVQ Pain None

+

120

75

3

35

60

4

Symptoms before ERCP

M

Calcified hydatid cyst Calcified hydatid cyst Pyloric stenosis Cholelithiasis Calcified hydatid cyst

Cysto-pericystectomy Drainage of the cyst Gastrojejunostomy Cholecystectomy Capitonnage of the remaining cavity

41

F

Infected hydatid cyst

5 6

46 49

F F

Jaundice None

12 15

200 150

5 3

7

83

F

Ampulloma Acute cholecystitis Cholelithiasis Carcinoma of the gallbladder

Resection of the cystic cupule Cholecystectomy Cholecystectomy Intraoperative biopsy

Jaundice

26

180

3

a ES, endoscopic sphincterotomy.

case could the presence of calculi, hydatid membranes, or other causes of obstruction be demonstrated, with the exception of case 5 showing an intraampullary tumor and case 7 where the common hepatic duct was stenosed as a result of tumor invasion, leaving free the cystic duct. Endoscopic sphincterotomy was successfully performed in all patients. Biliary fistulas healed within 3 to 5 days. DISCUSSION

External biliary fistulas have been reported following surgical drainage of liver abscesses and hydatid cysts, probably because it is easier for bile to fill the residual hepatic cavity than flow through the papilla of Vater. In cases of calcified or infected hydatid cysts a re-Iaparotomy may be indicated when the external bile flow does not spontaneously cease. 3 Three of our four patients with hydatid disease had calcified cysts and one had an infected cyst at the time of operation. Barrosl l reported a series of cystic hydatid disease surgically treated, with an incidence of postoperative external biliary fistula of 3.8% Fistula formation in the absence of outflow obstruction in the distal bile duct is extremely rare. Smith et al. 6 recently reported five cases of external biliary fistula but only one of them occurred following cholecystectomy. In our case 6, external biliary fistula developed after cholecystectomy for acute cholecystitis although ERCP failed to show overlooked stones. Fistula formation may result from benign papillary stenosis or dysfunction. 12 The accuracy of echography, CT scan, and isotope scanning using iminodiacetic acid derivatives in the detection of biliary fistulas remains to be substanti308

ated. 13- 15 Direct cholangiography using the percutaneous transhepatic method is contraindicated in patients with a presumptive diagnosis of residual hydatid cyst. 16 Injecting a radiopaque medium into the fistulous tract is a simple and reliable diagnostic method in cases of external biliary fistula. However, ERCP is another method to be considered, since it also permits simultaneous treatment. 7 In five of our seven patients, ERCP was not helpful for visualization of the fistulous tract. Until recently, excision of the fistula was the treatment of choice. 3 Smith et al. 6 reported successful treatment of nonhealing biliary-cutaneous fistulas with biliary stents, and Sauerbruch et aU 7 described successful nasobiliary catheter intubation in two of four cases. In our experience these techniques are not as dependable as endoscopic sphincterotomy which provides a nonsurgical therapeutic alternative in the management of external biliary fistulas. 4 , 5,16,18 With endoscopic sphincterotomy biliary decompression and the reestablishment of drainage to the duodenum allows fistula closure in a few days. This rapid response makes endoscopic sphincterotomy the preferred method of fistula management. A re-Iaparotomy is indicated when endoscopic measures have been unsuccessful. ACKNOWLEDGMENT

The authors are grateful to Dr. Marta Pulido for the English translation and copy editing of this manuscript.

REFERENCES 1. Glenn F. Other biliary tract disorders: torsion, trauma, perforation, fistulas bile peritonitis. In: Bockus HL, ed. Gastroenterology. 3rd ed. Philadelphia: WB Saunders, 1976:886-93.

GASTROINTESTINAL ENDOSCOPY

2. Thorbjarnarson B. Complications of biliary tract surgery. In: Thorbjarnarson B, ed. Surgery of the biliary tract. Major problems in clinical surgery. Philadelphia: WB Saunders, 1982:23652. 3. Jordan G. Choledocholithiasis. Curr Probl Surg 1982;19:774. 4. Deltenre M, Hermans A, De Renck M, Van Gossum M, Rajan A. La sphinterotomie endoscopique chez Ie patient cholecystectomise. Rev Med Brux 1982;3:263-8. 5. O'Rahilly S, Duignan JP, Lennon JR, O'Malley E. Successful treatment of a post-operative external biliary fistula by endoscopic papillotomy. Endoscopy 1983;15:68-9. 6. Smith AC, Schapiro RM, Kelsey PB, Warshaw AL. Successful treatment of nonhealing biliary-cutaneous fistulas with biliary stents. Gastroenterology 1986;90:764-9. 7. Moreira VF, Merono E, Simon MA, et al. La colangiopancreatografia retrograda endoscopica (CPRE) en el sindrome postcolecistectomia. Med Clin (Bare) 1984;82:664-8. 8. Soehendra N, Kempeneers I, Eichfuss HP, Raynders-Frederix V. Early post-operative endoscopy after biliary tract surgery. Endoscopy 1981;13:113-7. 9. Moreira VF, Merono E. Nuestra experiencia con la colangiopancreatografia retrograda endoscopica (CPRE): 1977-1980. Rev Esp Enf Ap Dig 1982;61:202-17. 10. Moreira VF, Del Olmo L, Merono E, Seara J. Ampulomas intraampulares en la colangiopancreatografia retrograda endoscopica. Rev Clin Esp 1986;178:37-8.

VOLUME 34, NO.4, 1988

11. Barros JL. Hydatid diseases of the liver. Am J Surg 1978;135:597-600. 12. Silvis SE. What is the postcholecystectomy pain syndrome? Gastrointest Endosc 1985;31:401-2. 13. O'Connor HJ, Bartlett RJ, Hamilton I, et al. Bile duct caliber: the discrepancy between ultrasonic and retrograde cholangiographic measurement in the post-cholecystectomy patient. Clin RadioI1985;36:507-10. 14. Weiner SN, Das K, Gold M, Stollman Y, Bernstein RG. Demonstration of an internal pancreatic fistula by computed tomography. Gastrointest RadioI1984;9:123-5. 15. Alarcon A, Meneses M, Gomez MA, Carrillo A, Soriano A, Gonzillez F. Diagnostico no invasivo de fistulas biliares espontimeas y accidentales. A proposito de cinco casos. Rev Esp Enf Ap Dig 1985;68:117-20. 16. Classen M, Ossemberg FW, Hagenmuller F. Endoscopic-radiological examination and therapy in biliary tract disease. In: Wright R, Millward-Sadler GM, Alberti KG, Karran S, eds. Liver and biliary disease. 2nd ed. Philadelphia: WB Saunders, 1985:589-616. 17. Sauerbruch T , Weinzierl M, Holl J, Pratschke E. Treatment of postoperative bile fistulas by internal endoscopic biliary drainage. Gastroenterology 1986;90:1998-2003. 18. Bannister P, Bennett C, Denyer ME. Spontaneous choledochalcolonic fistula treated by duodenoscopic sphincterotomy. Br Med J 1984;289:1114.

309