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Ann Thorac Surg 2004;78:1513
© 2004 The Society of Thoracic Surgeons

Correspondence

Reply

Bhugwan Singh, FCS (SA), Jaynathan Moodley, FCS(SA)

Department of Surgery, Faculty of Health Sciences, Nelson K. Mandela School of Medicine, University of Natal, Private Bag 7, Congella 4013, South Africa.

moodleyj6{at}nu.ac.za

To the Editor:

The persistence of a thoracobiliary fistula (TBF) is widely attributed to the differential pressure gradient between the common bile duct and the sphincter of Oddi [1, 2]. When this pressure gradient is effectively eliminated (as after an endoscopic sphincterotomy), the output of the biliary fistula is dramatically reduced, thus facilitating rapid closure of the fistula. The consistent and enduring success of endoscopic sphincterotomy in the management of TBF lends credence to the role of differential biliary pressures in the persistence of this type of fistula. Although there is little doubt that other factors can be implicated in the continuance of a TBF, the most notable of which appears to be sepsis, the importance of these factors cannot be conclusively established.

A role for octreotide in the management of TBF has been adopted from studies that have demonstrated its beneficial effect in the management of enterocutaneous and pancreatic fistulas [3]. Octreotide as an adjunct to standard treatment (support and drainage of sepsis) has been associated with diminution of fistulous output, but its effectiveness remains to be proven by well-designed comparative studies [4]. Indeed, persistent use of octreotide has been associated with a higher incidence of thrombotic and septic complications [5].

Like others [3, 4], we recommend the use of octreotide as adjunctive therapy rather than as definitive treatment of TBF. Biliary decompression by sphincterotomy should be the mainstay of therapy when there is persistence of the fistula despite standard medical therapy.

References

  1. Hoffman BJ, Cunningham JT, Marsh WH. Endoscopic management of biliary fistulas with small caliber stents. Am J Gastroenterol. 1990;85:705–707[Medline]
  2. Geenen JE, Toouli L, Hogan WJ, et al. Endoscopic sphincterotomy: follow-up evaluation of effects on the sphincter of Oddi. Gastroenterology. 1984;87:54–58
  3. Kocak S, Bumin C, Karayalcin K, Alacayir I, Aribal D. Treatment of external biliary, pancreatic and intestinal fistulas with a somatostatin analog. Dig Dis. 1994;12:62–68[Medline]
  4. Martineau P, Shwed JA, Denis R. Is octreotide a new hope for enterocutaneous and external pancreatic fistulas closure? Am J Surg. 1996;172:386–395[Medline]
  5. Avarez C, McFadden DW, Reber HA. Complicated enterocutaneous fistulas: failure of octreotide to improve healing. World J Surg. 2000;24:533–537[Medline]

Related Article

Octreotide in Bronchobiliary Fistula Management
Michael Ong, Kouros Moozar, and Lawrence B. Cohen
Ann. Thorac. Surg. 2004 78: 1512-1513. [Extract] [Full Text] [PDF]



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