Efficacy of Fibrin-collagen Sealant for Reducing the Incidence of Biliary Fistulae After Laparoscopic Exploration of the Bile Duct

Dear Editor,

We appreciate the comments about our study by Dr. Martínez-Isla et al.¹ We share his interest in the transcystic approach, which has indeed demonstrated a reduction in the incidence of biliary fistulae.² Our transcystic exploration cases are not included in the article we published, since our objective was to try to establish the reduction in biliary leaks after choledochorraphy using sealants. However, we feel that transcystic exploration is more complex, often technically impossible, and does not guarantee complete exploration of the bile duct. There is a 10%–25% variation in the implantation of the cystic duct, running parallel to the bile duct or inserting into the left side of the common bile duct.^3,4 This makes access difficult, so that complete dissection of the cystic duct can lead to injury to common bile duct vascularization. As a result, the risk/benefit balance does not clearly lean toward the transcystic approach.

Under these conditions, exploration of the bile duct proximal to the cystic implantation is not always possible, so the removal of stones in this area can be hindered. Furthermore, in our setting there is a significant amount of choledocholithiases that are much larger than the cystic duct, preventing extraction by this route. Fragmentation is difficult, as most hospitals do not have lasers. In addition, we do not share the indication of its use, as it increases the number of extraction maneuvers necessary and the risk of residual lithiasis. The size of the cystic duct or calculi and the number of stones and their location have been shown to be predictors of failed transcystic exploration.⁵ On occasion, we have used pneumatic dilatation of the cystic duct to facilitate the insertion of the choledochoscope and extraction of the calculus, but this maneuver can cause cystic ischemia, delayed necrosis and the appearance of biliary peritonitis. Lastly, excessive manipulation of 3-mm fiber optic choledochoscopes, given the weakness of their protective covering, often results in the loss of this seal, which requires more frequent repairs and must be added to the costs of the surgery.

We have not had any cases of pancreatitis due to transpapillary stents, as the authors of the comments to our study have mentioned. We believe that the fistula rate may be related to the fact that we strictly apply the ISGLS classification, which was not really created for this purpose,⁶ although it is all we have available to date.

In short, we share the enthusiasm for the transcystic pathway that we use, like most groups,⁷ when it comes to extracting solitary stones measuring less than one centimeter in patients with normally inserted cystic ducts. Nonetheless, we believe that, at least in our setting, use of the transcholedochal approach continues to be more frequent and completely necessary.