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Biliary leakage after cholecystectomy is not uncommon'. It is accepted teaching that in an adequately nourished patient with no active disease and no distal obstruction, fistulae will close spontaneously. We report a case of a postcholecystectomy fistula which resolved when distal obstruction due to presumed sphincter spasm was relieved by the use of glyceryl trinitrate. Case reportAn obese 46-year-old man gave a 12-year history of abdominal pain due to proven gallstones. Cholecystectomy proved difficult because the gallbladder was firmly adherent to surrounding structures. A fundus first dissection was performed and during dissection in Calot's triangle the cystic duct was avulsed from the common bile duct. This was repaired primarily without narrowing and a tube drain was placed in the hepatorenal pouch.In the 2 days after operation there was no drainage and the patient was well. When the drain was removed on the second day 300ml of bile-stained fluid escaped from the drain site. Two days later the patient complained of right hypochondria1 pain and ultrasonography demonstrated a small intraperitoneal collection. This was treated conservatively and the patient appeared to settle. He was well enough to return home at 10 days but returned a week later complaining of abdominal pain and distension. Ultrasonography revealed an increased amount of intraperitoneal fluid and a 99Tc-Sn-2,6-diethylacetanilidoiminodiacetate (HIDA) scan showed continued leakage of bile from the common bile duct. A second laparotomy was performed and 3 litres of bile-stained fluid was aspirated. Drainage was re-established but the common bile duct was not disturbed.Over the next 6 days drainage was between 700 and 800 ml per day (Figure 1 ). Endoscopic retrograde cholangiopancreatography (ERCP) showed continuing leakage but no stricturing or retained stone. Contrast failed to drain from the bile duct during the examination and spasm of the sphincter of Oddi was diagnosed. Drainage from the intra-abdominal drain was unchanged by ERCP. Before offering endoscopic sphincterotomy, glyceryl trinitrate was administered in the form ofa trinitrin patch in a dose of 5 mg per day (Transiderm-NitroN, DiscussionIn the present case it is probable that spasm of the sphincter o f O d d i prevented fistula closure. In such a situation endoscopic sphincterotomy may be used to good effect but in our patient this was not needed following the use of glyceryl trinitrate. T h e delay in response after ERCP suggests that the eventual fall in fistula output is a genuine result of pharmacological relaxation of the sphincter. This medication is eaily administered in a slow-release form and is known t o induce sphincter relaxation*. It may prove t o be a practical alternative t o endoscopic sphincterotomy with its attendant morbidity a n d mortality rates.