Reply to Chandra et al.

We performed our systematic review with meta-analysis as an attempt to define the optimal strategy for endoscopic management of biliary leaks in daily clinical practice. We agree that, in the study of Chandra et al., a faster healing of bile leak was observed with sphincterotomy alone compared with sphincterotomy with stenting [2]. However, we have carefully reviewed all of the literature and have assessed the quality of the studies, taking into account the potential biases to which particularly retrospective non-randomized studies in selected patient groups are prone. Although the hypothesis that slower healing could be attributed to the presence of a foreign body in the bile duct that may delay epithelialization is plausible, other studies suggest the opposite, with sphincterotomy being inferior to stenting, as mentioned in our article. These conflicting results were the main reason to perform our systematic review with meta-analysis. We are confident that our results summarize the best available evidence at this moment and we adopted these to guide clinical practice.

The plot of treatment rank probabilities supports clinical decision-making by showing that the combination of sphincterotomy with leak-bridging stenting had the highest probability of being the best treatment. However, the plot also nicely illustrates the remaining uncertainty of this not being the best option in 3 out of 10 cases. In addition, as we mentioned in the discussion section of our article, our recommendations must be interpreted with caution because of the moderate quality of evidence with possible biases, possible type II error due to small sample sizes, and the important heterogeneity in the included studies with the presence of only a few randomized clinical trials. Therefore, we believe that large-scale randomized clinical trials are needed to further define the optimal approach.

• References

• 1 Vlaemynck K, Lahousse L, Vanlander A. et al. Endoscopic management of biliary leaks: a systematic review with meta-analysis. Endoscopy 2019; DOI: 10.1055/a-0835-5940.
• 2 Chandra S, Murali AR, Mesadeh M. et al. Endoscopic biliary sphincterotomy alone versus with biliary stent in management of bile duct leak; a comparative study. Gastrointest Endosc 2017; 85: AB414-AB414