Diagnosis and Management of Bile Leaks After Hepatectomy: Results of a Prospective Analysis of 475 Hepatectomies

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