68 M. DE MONTI et al. a nasobiliary tube or endoprosthesis. Successful endo- scopic therapy has been reported after endoscopic sphincterotomy [8,9] or drainage by use of nasobiliary catheters [10] or after positioning plastic or metal stents [11-13]. The authors report a case of external biliary fistula subsequent to an operation for hepatic injury in a patient with blunt abdominal trauma. Endoscopic positioning of a nasobiliary drainage tube permitted complete healing of the fistula within a few days. CASE REPORT A 17-year-old male patient was involved in a motor- cycle accident and was admitted to the emergency department exhibiting a right humerus fracture and abdominal blunt trauma. His arterial blood pressure could not be obtained; an abdominal ultrasound scan demonstrated a massive hemoperitoneum. As a result, laparatomy was immediately performed. The discov- ery of multiple dilacerations of the Vlth, VIIth, and VIIIth liver segments suggested the extension of the laparotomy to a thoracolaparotomy. Intraperitoneal blood losses were evaluated as 4.5 liters; however, 2.2 liters were reinfused by an automatic blood intraoper- ative transfusion machine. Multiple hemostatic sutures were placed to avoid extensive hepatectomy. The patient was subsequently admitted to the critical care unit. On the 3rd postoperative day, biliary leakage from the abdominal drainage tube became evident. The leakage averaged approximately 800 ml in a 24-hr period. On the 16th postoperative day, surgical osteosynthesis of the humerus was performed. At the same time, an ERCP was performed, which demon- strated contrast leakage on the VIIIth segment intra- hepatic biliary duct. Biliary tracts appeared extremely narrow due both to the young age of the patient and the fact that they were empty. Cholelithiasis was not found (Fig. 1). A papillosphincterotomy was per- formed, and a nasobiliary tube was placed directly in the injured biliary duct. One day later, only 40 ml of biliary leakage was registered, and 600 ml had been drained from the nasobiliary tube. Afterward no more bile leaked from the abdominal drainage tubes. A trans-nasobilary tube cholangiography, performed 5 days later, demonstrated the persistence of leakage of contrast material (Fig. 2). Another cholangiography, performed 12 days after ERCP, demonstrated com- plete healing of the fistula (Fig. 3). After 40 days of hospital stay, the patient was com- pletely recovered and was discharged. DISCUSSION The possibility of spontaneous resolution of biliocuta- neous fistulas directly depends on the drainage capa- bility of the main biliary tract. Fistulas will be sustained until the obstacle is removed. Persistence of biliary leakage around biliary ducts generally causes definitive stenosis. Prompt choledochal drainage pre- vents biliary leakage complications, which may occur early on or at a later stage 14]. Decompression of the biliary tract causes a significant reduction of fistula output (up to 90 to 95%) [5], facilitating internal drainage and fistula closure in a shorter time. It is reported that untreated bile leakage spontaneously resolves in an average of 33 days (ranging from 3 to 110 days), with a high incidence of complications such as infections, sepsis, and respiratory failure 15]. Healing of nasobiliary drained fistulas is reported to occur between 2 and 3 weeks without any complica- tions [2,5]. First, the procedure requires a correct diag- nosis using ERCP to identify the precise location of the fistula. The next step involves the wedging of the nasobiliary catheter as distally as possible in the bil- iary tract, which is directly responsible for nourishing the fistula. The nasobiliary catheter must be main- tained in continuous aspiration. Additionally, in our patient, we preferred to perform a papillosphinctero- tomy to decrease the pressure in the biliar-y tree and also to allow the bile to drain from the left side of the biliary tree, which had not been drained by the catheter. In 1979, Agrawal et al. [16] described the first endoscopic diagnosis of biliary fistulas. In 1983, O’Raihilly et al. [17] successfully cured a fistula by endoscopic sphincterotomy. The first endoscopic treatment of post-traumatic biliocutaneous fistula was