Pancreas and biliary tract

Endoscopic treatment of post-surgical bile duct injuries: long term outcome and predictors of success

Philip R de Reuver¹, Erik A Rauws², Mattijs Vermeulen¹, Marcel G W Dijkgraaf³, Dirk J Gouma¹, Marco J Bruno²

¹ Departments of Surgery, Academic Medical Center – University of Amsterdam, Amsterdam, the Netherlands
² Departments of Gastroenterology, Academic Medical Center – University of Amsterdam, Amsterdam, the Netherlands
³ Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Academic Medical Center – University of Amsterdam, Amsterdam, the Netherlands

Marco Bruno, Department of Gastroenterology, Amsterdam Medical Centre, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands; m.j.bruno{at}amc.uva.nl

Objective: To analyse the short and long term outcome of endoscopic stent treatment after bile duct injury (BDI), and to determine the effect of multiple stent treatment.

Design, setting and patients: A retrospective cohort study was performed in a tertiary referral centre to analyse the outcome of endoscopic stenting in 67 patients with cystic duct leakage, 26 patients with common bile duct leakage and 110 patients with a bile duct stricture.

Main outcome measures: Long term outcome and independent predictors for successful stent treatment.

Results: Overall success in patients with cystic duct leakage was 97%. In patients with common bile duct leakage, stent related complications occurred in 3.8% (n = 1). The overall success rate was 89% (n = 23). In patients with a bile duct stricture, stent related complications occurred in 33% (n = 36) and the overall success rate was 74% (n = 81). After a mean follow up of 4.5 years, liver function tests did not identify "occult" bile duct strictures. Independent predictors for outcome were the number of stents inserted during the first procedure (OR 3.2 per stent; 95% CI 1.3 to 8.4), injuries classified as Bismuth III (OR 0.12; 95% CI 0.02 to 0.91) and IV (OR 0.04; CI 0.003 to 0.52) and endoscopic stenting before referral (OR 0.24; CI 0.06 to 0.88). Introduction of sequential insertion of multiple stents did not improve outcome (before 77% vs after 66%, p = 0.25), but more patients reported stent related pain (before 11% vs after 28%, p = 0.02).

Conclusions: In patients with a postoperative bile duct leakage and/or strictures, endoscopic stent treatment should be regarded as the choice of primary treatment because of safety and favourable long term outcome. Apart from the early insertion of more than one stent, the benefit from sequential insertion of multiple stents did not become readily apparent from this series.

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