Serial Studies On Microinvasive Treatment Of Bile Leak

Background and Aims of the StudyBile leak is a disorder in which bile leaks into the abdominal cavities from the biliary system due to various causes. It is one of the direct causes of mortality after trauma or surgery. Conventional therapy such as open surgery and choledochojejunostomy entails large wound, high expense and prolonged hospital stay. Endoscopic biliary drainage for the treatment of bile leak was reported anecdotically, lack of systematic study. In these serial studies, bile leak from various locations and of various modality was studied extensively, and microinvasive treatment was tested in an originally designed bile leak simulation system to reveal the mechanism of the therapy. MethodsThis study consists of four parts:Part one: Design and adjustment of in vitro Bile Secretion and Excretion Simulation System. An in vitro Bile Secretion and Excretion Simulation System was designed originally, including simulation of intrahepatic bile duct, extrahepatic bile duct, bile flow and extrahepatic bile duct pressure. A test system for the efficacy of microinvasive treatment to bile leak of different locations of the biliary system was established to provide intuitive evidence for clinical management.Part Two: Endoscopic treatment of patients in whom T-tube could not be closed timely after T-tube drainage. The study showed that patency of the distal end of the bile duct was essential for the closure of the breach in the biliary system.Part Three: Study on the microinvasive treatment of intrahepatic bile leak. Efficacy of microinvasive treatment by internal drainage in the treatment and prevention of intrahepatic bile leak in patients who had undergone percutaneous transhepatic cholangiography (PTC) was studied. Simulation system was used to analyse the mechanism of intrahepatic bile leak. Mechanisms of the occurrence and treatment of intrahepatic bile leak were explored .Part Four: Study on the treatment of extrahepatic bile leak. Both simple and complex extrahepatic bile leak were studied clinically. Simulation system was used to analyse the whole process. Mechanism of extrahepatic bile leak and the efficacy with microinvasive procedure were explored .ResultsPart One: The in vitro Bile Secretion and Excretion Simulation System, which was designed originally, could simulate the bile excretion in postcholecystectomy patient almost perfectly, and could be used to analyze the leakage of various locations of the biliary system.Part Two: EST and stone removal, or internal biliary drainage to relieve the obstruction of the end of the common bile duct were performed in 9 cases of patients in whom common bile duct exploration was done and T-tube could not be closed. T-tube could be closed and removed in all of these patients after the treatment.Part Three: In 30 cases of patients who had undergone percutaneous transhepatic biliary puncture plus internal biliary drainage, no bile leak (0%) occurred; while in the control group without internal drainage, 3 cases suffered from bile leak out of 50 cases (6%), with significant difference between the groups(p < 0.05). In 5 cases of intrahepatic bile leak patients, internal drainage was performed by stenting with 100% success rate, and drainage of the bile from the abdominal cavity decreased significantly (p < 0.01) after the procedure, and drainage tubes were able to be removed afterwards. Simulation tests showed that in the case of bile leak due to breach in the left or right hepatic duct, comparing with the no internal drainage group, the leakage decreased significantly (p < 0.01) after internal drainage; in the case of complete cut-off of the left or right hepatic duct, if the bile duct pressure was 10 cm H₂O, no difference could be detected of the leakage between the two groups; if the bile duct pressure was 20 cm H₂O, leakage of the internal drainage group decreased significantly (p < 0.05) comparing with the no drainage group, and the leakage of the no drainage group was greater than the secretion of the mimic ipsilateral lobe of the liver.Part Four: In 7 cases of patients with simple extrahepatic bile leak who had undergone internal biliary drainage, bile drainage of the abdominal cavity decreased significantly (p < 0.01). Five of these seven cases were drained by stent placed distal to the breach. In vitro simulation showed that leakage of the group with stent placed distal to the breach was significantly less than that of the group with stent placed proximal to the breach (p < 0.01), but the leakage of both groups was less than that of the no drainage group (p < 0.01).In 5 cases of patients who had undergone liver transplantation and suffered from stenosis of the biliary anastomosis accompanied with bile leak, success rate of endoscopic treatment was 60% (3/5); leakage decreased after PTCD in 2 case of patients; in 3 cases, the efficacy was not satisfactory when drainage with stent distal to the stenosis was initiated, while the efficacy improved markedly when stent through the stenosis was used for the drainage. In another 2 cases, drainage was initiated with stent passing through the stenosis and significant efficacy was achieved. In vitro simulation showed that the leakage in the group with the stent distal to the stenosis was more severe than that in the group with stent passing through the stenosis (p < 0.01).Conclusions1. The in vitro Bile Secretion and Excretion Simulation System could be used to analyze the mechanism of different types of bile leak and test the efficacy of the treatment to bile leakage.2. The key factor to influence the healing of bile leak is the pressure of the oddi's sphincter of the terminal bile duct. Stenting passing through the oddi's sphincter could cure bile leak in patients without stenosis of the bililary system. 3. The stenosis or obstruction distal to the leak is the principal factor to interfere the cure of bile leakage. Stenting passing through the proximal end of stenosis and distal to the leak could cure bile leak patients with stenosis distal to the leak.4. Stent drainage could prevent the bile leakage caused by PTC.5. There was no difference in the efficacy of drainage between the stent of different calibers (8.5Fr, 10Fr and 12Fr).6. The phenomenon of "billiary steal flow" is a new discovery observed in the in vitro Bile Secretion and Excretion Simulation System when intrahepatic bile duct was cut off completely. Internal biliary drainage could prevent the phenomenon of biliary steal, but it was not able to completely drain the fluid after the mimic cut-off of the liver lobe.