Abstract
Background
The diagnosis and management of bile leaks after hepatectomy are heterogeneous because there is no agreement on the definition of post-hepatectomy biliary fistula. The aim of this study was to validate our definition and management of biliary fistulas after hepatic resection and to compare our results with those proposed by other authors.
Methods
A prospective series of patients who underwent hepatic resection from 2004 to 2012 were established. Drains were maintained for 7 days, and bilirubin was measured on postoperative days (PODs) 3, 5, and 7. Drains were removed if the bilirubin on POD 7 was less than that on POD 5 and less than 171 µmol/l (10 mg/dl). A statistical analysis of prognostic factors for biliary fistula was performed.
Results
Among 475 consecutive patients, 39 (8 %) had biliary fistulas. Only 8 (1.7 %) patients required postoperative interventions. In comparison with other studies, we observed a higher rate of bile leaks, but at the same time, we observed a lower rate of interventional procedures. The area under the receiver operating characteristic curve on POD 7 had the highest predictive value (0.81; P < 0.001). Pringle maneuvers lasting ≥90 min (OR = 3.4; P < 0.001), extended resections (OR = 6.4; P = 0.007), blood transfusions (OR = 2.4; P = 0.035), and resections including segment I (OR = 1.9; P = 0.033) or segment V (OR = 1.8; P = 0.024) were independently associated with an increased risk of bile leak.
Conclusions
The proposed definition of biliary fistula provides effective recognition of those that are clinically relevant with a reduction of the risk of unrecognized collections and minimal postoperative morbidity. Registration Number: NCT02056028 (http://www.clinicaltrials.gov).
Similar content being viewed by others
References
Poon RT, Fan ST, Lo CM et al (2004) Improving perioperative outcome expands the role of hepatectomy in management of benign and malignant hepatobiliary diseases: analysis of 1222 consecutive patients from a prospective database. Ann Surg 240(4):698–710
Lo CM, Fan ST, Liu CL et al (1998) Biliary complications after hepatic resection: risk factors, management, and outcome. Arch Surg 133(2):156–161
Belghiti J, Kabbej M, Sauvanet A et al (1993) Drainage after elective hepatic resection. A randomized trial. Ann Surg 218(6):748–753
Fong Y, Brennan MF, Brown K et al (1996) Drainage is unnecessary after elective liver resection. Am J Surg 171(1):158–162
Liu CL, Fan ST, Lo CM et al (2004) Abdominal drainage after hepatic resection is contraindicated in patients with chronic liver diseases. Ann Surg 239(2):194–201
Torzilli G, Olivari N, Del Fabbro D et al (2005) Bilirubin level fluctuation in drain discharge after hepatectomies justifies long-term drain maintenance. Hepatogastroenterology 52(64):1206–1210
Sun HC, Qin LX, Lu L et al (2006) Randomized clinical trial of the effects of abdominal drainage after elective hepatectomy using the crushing clamp method. Br J Surg 93(4):422–426
Kyoden Y, Imamura H, Sano K et al (2010) Value of prophylactic abdominal drainage in 1269 consecutive cases of elective liver resection. J Hepatobiliary Pancreat Sci 17(2):186–192
Yamazaki S, Takayama T, Moriguchi M et al (2012) Criteria for drain removal following liver resection. Br J Surg 99(11):1584–1590
Koch M, Garden OJ, Padbury R et al (2011) Bile leakage after hepatobiliary and pancreatic surgery: a definition and grading of severity by the International Study Group of Liver Surgery. Surgery 149(5):680–688
Brooke-Smith M, Figueras J, Ullah S et al (2015) Prospective evaluation of the International Study Group for Liver Surgery definition of bile leak after a liver resection and the role of routine operative drainage: an international multicentre study. HPB (Oxford) 17:46–51
Capussotti L, Ferrero A, Vigano L et al (2006) Bile leakage and liver resection: where is the risk? Arch Surg 141(7):690–694
Cescon M, Vetrone G, Grazi GL et al (2009) Trends in perioperative outcome after hepatic resection: analysis of 1500 consecutive unselected cases over 20 years. Ann Surg 249(6):995–1002
Guillaud A, Pery C, Campillo B et al (2013) Incidence and predictive factors of clinically relevant bile leakage in the modern era of liver resections. HPB (Oxford) 15(3):224–229
Imamura H, Seyama Y, Kokudo N et al (2003) One thousand fifty-six hepatectomies without mortality in 8 years. Arch Surg 138(11):1198–1206
Jarnagin WR, Gonen M, Fong Y et al (2002) Improvement in perioperative outcome after hepatic resection: analysis of 1803 consecutive cases over the past decade. Ann Surg 236(4):397–407
Rahbari NN, Elbers H, Koch M et al (2012) Bilirubin level in the drainage fluid is an early and independent predictor of clinically relevant bile leakage after hepatic resection. Surgery 152(5):821–831
Reissfelder C, Rahbari NN, Koch M et al (2011) Postoperative course and clinical significance of biochemical blood tests following hepatic resection. Br J Surg 98(6):836–844
Taguchi Y, Ebata T, Yokoyama Y et al (2014) The determination of bile leakage in complex hepatectomy based on the guidelines of the International Study Group of Liver Surgery. World J Surg 38(1):168–176. doi:10.1007/s00268-013-2252-x
Vauthey JN, Pawlik TM, Abdalla EK et al (2004) Is extended hepatectomy for hepatobiliary malignancy justified? Ann Surg 239(5):722–732
Yamashita Y, Hamatsu T, Rikimaru T et al (2001) Bile leakage after hepatic resection. Ann Surg 233(1):45–50
Belghiti J, Clavien P, Gadzijev E et al (2000) The Brisbane 2000 terminology of liver anatomy and resections. HPB (Oxford) 2(3):333–339
Dindo D, Demartines N, Clavien PA (2004) Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 240(2):205–213
Imamura H, Sano K, Sugawara Y et al (2005) Assessment of hepatic reserve for indication of hepatic resection: decision tree incorporating indocyanine green test. J Hepatobiliary Pancreat Surg 12(1):16–22
Donadon M, Cimino M, Procopio F et al (2013) Potential role of cholinesterases to predict short-term outcome after hepatic resection for hepatocellular carcinoma. Updates Surg 65(1):11–18
Torzilli G, Montorsi M, Donadon M et al (2005) “Radical but conservative” is the main goal for ultrasonography-guided liver resection: prospective validation of this approach. J Am Coll Surg 201(4):517–528
Torzilli G, Donadon M, Marconi M et al (2008) Systematic extended right posterior sectionectomy: a safe and effective alternative to right hepatectomy. Ann Surg 247(4):603–611
Torzilli G, Donadon M, Palmisano A et al (2009) Ultrasound guided liver resection: does this approach limit the need for portal vein embolization? Hepatogastroenterology 56(94–95):1483–1490
Torzilli G, Palmisano A, Procopio F et al (2010) A new systematic small for size resection for liver tumors invading the middle hepatic vein at its caval confluence: mini-mesohepatectomy. Ann Surg 251(1):33–39
Torzilli G, Garancini M, Donadon M et al (2010) Intraoperative ultrasonographic detection of communicating veins between adjacent hepatic veins during hepatectomy for tumours at the hepatocaval confluence. Br J Surg 97(12):1867–1873
Ijichi M, Takayama T, Toyoda H et al (2000) Randomized trial of the usefulness of a bile leakage test during hepatic resection. Arch Surg 135(12):1395–1400
Torzilli G, Makuuchi M, Inoue K et al (1999) No-mortality liver resection for hepatocellular carcinoma in cirrhotic and noncirrhotic patients: is there a way? A prospective analysis of our approach. Arch Surg 134(9):984–992
Takayama T, Makuuchi M, Kubota K et al (2001) Randomized comparison of ultrasonic vs clamp transection of the liver. Arch Surg 136(8):922–928
Lesurtel M, Selzner M, Petrowsky H et al (2005) How should transection of the liver be performed?: a prospective randomized study in 100 consecutive patients: comparing four different transection strategies. Ann Surg 242(6):814–823
Gurusamy KS, Pamecha V, Sharma D et al (2009) Techniques for liver parenchymal transection in liver resection. Cochrane Database Syst Rev (1):Cd006880
Vigano L, Ferrero A, Sgotto E et al (2008) Bile leak after hepatectomy: predictive factors of spontaneous healing. Am J Surg 196(2):195–200
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Donadon, M., Costa, G., Cimino, M. et al. Diagnosis and Management of Bile Leaks After Hepatectomy: Results of a Prospective Analysis of 475 Hepatectomies. World J Surg 40, 172–181 (2016). https://doi.org/10.1007/s00268-015-3143-0
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00268-015-3143-0