A 68-year-old man who had a Whipple procedure for pancreatic head adenocarcinoma 4 years ago now presents with a bilious draining wound over the upper abdomen. CT shows a fistula tract from the hepaticojejunostomy to the skin. Output is 200 mL/day. Which factor determines whether this will close with conservative management?
- A Volume of output >500 mL/day
- B Duration since surgery > 6 months
- C Presence of distal obstruction in the biliary limb ✓
- D Elevated serum bilirubin
Correct answer: C. Presence of distal obstruction in the biliary limb
Explanation
Biliary fistulas close spontaneously provided there is no distal obstruction (FRIENDS mnemonic: Foreign body, Radiation, Inflammation/Infection, Epithelialization, Neoplasia, Distal obstruction, Short fistula tract). Distal biliary obstruction prevents the natural flow of bile and maintains fistula output. Low-output fistulas (<200 mL/day) have better spontaneous closure rates, but the presence of distal obstruction is the dominant factor preventing conservative closure regardless of output.
Reference: Bailey & Love's Short Practice of Surgery, 27th ed.
High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP
Written and medically reviewed by the StethoPrep medical team.