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 ± stent placement. In complex cases, such as altered anatomy or failure of conventional treatment, transpapillary/transfistulary (TP/TF) drainage or EUS-guided transmural (EUS-TD) drainage may obviate additional biliary surgery. This study reports our experience with treating biloma secondary to refractory biliary leak with TP/TF or EUS-TD, and evaluates the safety and outcomes associated with this approach. Method This observational study focuses on consecutive patients managed for biliary leakage (diagnosis based on imaging and/or bile outflow from a surgical drain) at a tertiary care hospital (2007-2017). TP/TF drainage was performed by double-pigtail stent(s) placement to drain the biloma through the leak during endoscopic retrograde cholangiopancreatography. For EUS-TD, plastic stent(s) were placed under EUS control. Primary outcome was 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 re-intervention) and biloma regression ( Results Thirty patients (males 57%, median age 55 years) were included. Most biliary leaks resulted from cholecystectomy (27%) and hepatectomy (50%). Initial EUS-TD and TP/TF 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 case. 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, fibrillation). Conclusions TP/TF or EUS-TD is technically feasible with high clinical success and may avoid the need for additional surgery in complex cases or patients with altered anatomy.