Endoscopic techniques in management of biliary tract injuries.

What can be said with certainty regarding endotherapy for biliary injuries associated with laparoscopic or conventional cholecystectomy? On the one hand, ongoing cystic duct and most bile duct leaks close rapidly after sphincterotomy or placement of a stent or both. Such therapy does not preclude the need for drainage of sizable bilomas. On the other hand, acute and ultimate success of endotherapy appears to be contingent on the degree and perhaps the cause of injury. Although ERCP is useful in diagnosing transection or an inadvertently stapled right hepatic duct, treatment of these conditions remains in the surgical realm. Nor is it likely, in my opinion, that a duct that has been stapled across 75% of its diameter or one with an extremely long stenosis, suggesting devascularization and ischemic injury, will respond to either a radiologic or endoscopic approach. In this setting, ERCP may be used diagnostically, or therapy may be undertaken in an attempt to convert an urgent surgical intervention into an elective and controlled one. Endotherapy appears to be useful, however, for a considerable subset of patients with inadvertent thermal or incisional injury, although need for periodic dilation therapy and exchange of the stent remain limiting factors. Moreover, even in patients with apparent short-term or intermediate-term success, caution is urged to continue periodic clinical and liver function test surveillance because recurrent stenosis may occasionally be subtle and present not as jaundice or cholangitis but as secondary biliary cirrhosis with its attendant consequences.