Endoscopic management of biliary leaks: a systematic review with meta-analysis

Abstract

Background The first-line approach to the treatment of biliary leaks is endoscopic retrograde cholangiopancreatography. A variety of techniques can be used, including sphincterotomy, stenting, a combination of both techniques, or nasobiliary drainage. We performed a systematic review with meta-analysis to define the optimal strategy. Methods We searched MEDLINE/PubMed, EMBASE, CENTRAL, Scopus, Google Scholar, and Web of Science until January 2018 for randomized clinical trials, case-control studies, and prospective cohort studies. Data on procedure, success, and complication rate were extracted. Risk of bias was assessed. A network meta-analysis was performed to compare sphincterotomy alone vs. stenting alone vs. combination treatment. Stenting was further stratified into leak-bridging and short stenting. Results 11 studies out of 5085 references were included. Compared with sphincterotomy alone, the combination of sphincterotomy with leak-bridging stenting had the highest success rate (risk ratio [RR] 1.15, 95 % confidence interval [CI] 0.97 – 1.50), followed by leak-bridging stenting alone (RR 1.10, 95 %CI 0.84 – 1.44). For nonbridgeable leaks, stenting alone had a higher success rate than sphincterotomy alone (RR 1.07, 95 %CI 0.72 – 1.40). The combination of short stents with sphincterotomy had no added benefit (RR 0.94, 95 %CI 0.49 – 1.29). Overall quality of the included studies was considered to be moderate. Conclusions We recommend sphincterotomy with stenting if the biliary leak can be bridged. If not, stenting alone with a short stent may be preferred in order to avoid sphincterotomy-related complications. More and larger studies are needed to confirm these findings.

Clinical efficacy, timing, and outcomes of ERCP for management of bile duct leaks: a nationwide cohort study

“…Techniques that are commonly used include bile duct sphincterotomy, bile duct stenting, or a combination of both [2,3]. Recent studies have evaluated the clinical efficacy and outcomes of these techniques, but the results have been varied and controversial [4][5][6].…”

“…Explorys is a Health Insurance Portability and Accountability Act (HIPAA)-and Health Information Technology for Economic and Clinical Health Act (HITECH)-compliant platform, and institutional review board approval for its use is not required. This study was reported according to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines for observational cohort studies [2].…”

Sphincterotomy Alone Versus Sphincterotomy and Biliary Stent Placement in the Treatment of Bile Leaks: 10 Year Experience at a Quaternary Hospital

“…The goal of the endoscopic treatment is to eliminate the transpapillary pressure by performing a sphincterotomy, placing a biliary stent or the combination of both, lowering the pressure on the bile duct which allows healing the leak (1,3) . Large and refractory bile leaks are often treated with multiple plastic stents or self-expandable metal stents (SEMS), and usually stents are removed after 4 to 8 weeks (2) . The aims of this study are to determine efficacy of endoscopic treatment of bile leaks secondary to cholecystectomy, hepatectomies, and hepatic trauma and to compare the currently employed ERCP approaches to biliary leaks: endoscopic sphincterotomy alone and sphincterotomy plus biliary stenting, regarding the number of days needed to remove the abdominal surgical drain or cessation of drainage after each technique.…”

“…Bile leaks are a potentially serious complication that can occur after cholecystectomy, liver transplantation, partial hepatectomy, and hepatic damage secondary to abdominal trauma (1,2) . Although post cholecystectomy surgery is responsible for most of biliary injuries, it occurs with an incidence of only 1% (3,4) .…”

The Need for a Better-Designed Study of the Outcomes of Endoscopic Management of Bile Leak

“…5 A systematic review has reported the success rate of endoscopic therapy for bile leak to be 68% to 98.3%. 6 The current proposed treatment algorithm for bile leak is shown in Fig. 1.…”