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Background and study aims Endoscopic therapy for postoperative Bergmann type A bile leaks is based on biliary sphincterotomy ±â€Šstent insertion. However, recurrent or refractory bile leaks can occur. Patients and methods This was retrospective study including all consecutive patients who were referred to our center with a Bergmann type A bile leak refractory to previous conventional endoscopic treatments. Results Seventeen patients with post-cholecystectomy-refractory Bergmann type A bile leak were included. All had received prior endoscopic biliary sphincterotomy with biliary stent or nasobiliary catheter placement and all had a percutaneous or surgical abdominal drainage. Repeat endoscopic retrograde cholangiopancreatography (ERCP) confirmed a Bergmann type A bile leak and in all patients we observed that the abdominal drainage was placed adjacent to the origin of the fistula. Our treatment consisted of pulling the drain away from the fistulous site, with extension of the previous sphincterotomy when needed. The treatment was successful in all cases. Mild complications occurred in three patients. Conclusions Our retrospective study shows that refractory Bergmann type A bile leak may be a consequence of an unfavorable position of the abdominal drainage tube, which can be corrected by pulling the drain away from the origin of the fistula. This establishes a favorable pressure gradient that leads the bile flowing from the bile duct into the duodenum.

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BACKGROUND: Pancreatic leaks occur as a complication of upper gastrointestinal surgery, acute pancreatitis, or abdominal trauma. Pancreatic fistulas and leaks are primarily managed conservatively. Overall, conservative measures are successful in more than half of cases. Whenever conservative treatment is not efficient, surgery is usually considered the treatment of choice. Nowadays however, endoscopic treatment is being increasingly considered and employed in many cases, as a surgery sparing intervention. AIM: To introduce a classification of pancreatic fistulas according to the location of the leak and ductal anatomy and finally propose the best suited endoscopic method to treat the leak according to current literature. METHODS: We performed an extensive review of the literature on pancreatic fistulae and leaks. RESULTS: In this paper, we review the various types of leaks and propose a novel endoscopic classification of pancreatic fistulas in order to standardize and improve endoscopic treatment. CONCLUSIONS: A proper and precise diagnosis should be made before embarking on endoscopic treatment for pancreatic leaks in order to obtain prime therapeutic results. A multidisciplinary team of interventional endoscopists, pancreatic surgeons, and interventional radiologists is best suited to care for these patients.

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BACKGROUND: Bile leakage is a common complication after hepatic resection [1-4] (Donadon et al., 2016; Dechene et al., 2014; Zimmitti et al., 2013; Yabe et al., 2016). Endotherapy is the treatment of choice for this complication except for bile leaks originating from isolated ducts; a condition resembling the post laparoscopic cholecystectomy Strasberg type C lesions [5-9] (Lillemo et al., 2000; Gupta and Chandra, 2011; Park et al., 2005; Colovic, 2009; Mutignani et al., 2002). In such cases, surgical repair is complex, often of uncertain result and with a high morbidity and mortality [1] (Donadon et al., 2016). On the other hand, percutaneous interventions (i.e. plugging the isolated duct with glue) are technically difficult and risky [7,8] (Park et al., 2005; Colovic, 2009). Endoscopy, thus far, was not considered amongst treatment options. That is because the isolated duct cannot be opacified during cholangiography and is not accessible with the usual endoscopic methods [5,6] (Lillemo et al., 2000; Gupta and Chandra, 2011). METHODS: Considering the pathophysiology of this type of bile leaks, it is possible to change the pressure gradient endoscopically in order to direct bile flow from the isolated duct towards the duodenal lumen, thus creating an internal biliary fistula to restore bile flow. In order to achieve this goal, we have to perforate the biliary tree into the abdomen. The key element of endoscopic treatment is to create a direct connection between the abdominal cavity and the duodenal lumen by-passing the residual biliary tree with a new technique fully explained in the paper. Our case series (from 2011 to 2016) consists of 13 patients (eight male, five female, mean age 58 years) with fistulas from isolated ducts after various types of hepatic resection. RESULTS: We performed sphincterotomy and placed a biliary stent with the proximal edge inside the intra-abdominal bile collection in 11 patients (eight biliary fully-covered self-expandable metal stents; three plastic stents). In the remaining two patients we successfully cannulated the involved isolated biliary duct and we placed a bridging stent (one fully covered self-expandable metal stent; one plastic stent). Technical and clinical success (considered as fistula healing) was achieved in all 13 patients (mean fistula healing time was four days). Biliary stents were removed three to six months after atrophy of the involved duct in nine cases. In two patients the stent is still in situ. Two patients died with stent in situ due to advanced cancer at 8 and 42 months respectively. Mean follow up was 18 months (range: 8-42 months). CONCLUSIONS: The described endoscopic treatment is innovative, safe and effective. It is applicable in tertiary level endoscopic centers and requires considerable expertise. This minimally invasive procedure can increase the rate of fistula healing and will eventually reduce the need for more aggressive and risky surgical procedures.

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BACKGROUND: Endoscopic stenting is widely used to manage benign and malignant strictures, postoperative stenoses, or anastomotic leaks and fistulas. MATERIALS AND METHODS: However, Over the Wire delivery systems are generally short and quite stiff, and therefore, cannot reach distal parts of the gastrointestinal tract or cross severely angulated strictures. In such cases, we used the Over-the-Scope stenting (OTSS) technique to deliver and deploy endoscopically large-bore fully covered stents. We present herein a series of 11 patients treated with the OTSS technique for a variety of indications. To our knowledge, this is the largest series of OTSS cases published. RESULTS: The stents were correctly deployed in 10 cases. In one case, the stent was dislocated during scope withdrawal and Through the Scope stenting was performed with a smaller diameter uncovered stent instead. Predilation of the stricture was necessary in 5 patients. Clinical success was achieved in all patients. CONCLUSIONS: Our results encourage the use of the OTSS technique in cases where standard Over the Wire delivery systems of large-bore stents cannot reach or cross distal or tortuous strictures. The technique can also be used to reinsert migrated stents or misplaced braided-suture release mechanism (Ultraflex) stents.

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Between April 2013 and October 2015, 6 patients developed periampullary duodenal or jejunal/biliary leaks after major abdominal surgery. In all patients, percutaneous drainage of the collection or re-operation with primary surgical repair was attempted at first but failed. A fully covered enteral metal stent was placed in all patients to seal the leak. Subsequently, we cannulated the common bile duct and, in some cases, and the main pancreatic duct inserting hydrophilic guidewires through the stent after dilating the stent mesh with a dilatation balloon or breaking the meshes with Argon Plasma Beam. Finally, we inserted a fully covered biliary metal stent to drain the bile into the lumen of the enteral stent. In cases of normal proximal upper gastrointestinal anatomy, a pancreatic plastic stent was also inserted. Oral food intake was initiated when the abdominal drain outflow stopped completely. Stent removal was scheduled four to eight weeks later after a CT scan to confirm the complete healing of the fistula and the absence of any perilesional residual fluid collection. The leak resolved in five patients. One patient died two days after the procedure due to severe, pre-existing, sepsis. The stents were removed endoscopically in four weeks in four patients. In one patient we experienced stent migration causing small bowel obstruction. In this case, the stents were removed surgically. Four patients are still alive today. They are still under follow-up and doing well. Bilio-enteral fully covered metal stenting with or without pancreatic stenting was feasible, safe and effective in treating postoperative enteral leaks near the biliopancreatic orifice in our small series. This minimally invasive procedure can be implemented in selected patients as a rescue procedure to repair these challenging leaks.

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