A few thoughts on "Interventional radiology in the management of benign biliary stenoses, biliary leaks and fistulas: a pictorial review".

Dear Editor,

We read with great interest the article by Krokidis and colleagues [1] recently published in Insights into Imaging. In this well-presented pictorial review, the authors point out the crucial role of interventional radiology as a minimally invasive approach to treat benign strictures, to divert the bile away from the site of the fistula, and to seal the leaking tract.

Balloon dilation was reported as the strategy of choice in the percutaneous treatment of benign biliary strictures (although burdened by 29–58 % re-stenosis), while the role of stent placement was reported to still be controversial. A different approach can be the use of novel bioabsorbable biliary stents [2], which may limit the number of balloon dilations in bilioplasty, also overcoming the problem of stent withdrawal.

Regarding bile leaks, the authors discuss—inter alia—the role of percutaneous drainage of biliary collections, of coil/gelfoam embolisation of bilio-vascular fistulas, and of covered stents. However, we underline that the most commonly used technique for treating postsurgical biliary leak is percutaneous transhepatic biliary drainage, which allow for bile diversion from the site of the fistula [3]. Moreover, an occlusion balloon placed above the site of the fistula has been demonstrated to allow for complete external drainage of the bile, thus representing a valuable option to treat post-surgical biliary leaks [3, 4].

In case of direct communication between a collection and the biliary system, it may happen that percutaneous drainage is not enough to allow for full healing and surgery may be required, as the authors show in Figure 3 [1]. We note that, in this particular setting, percutaneous cyanoacrilyc glue embolisation has been reported as a feasible technique, which may lead to fistula sealing, avoiding the morbidity related to surgical re-intervention [5].