Risk Factors and Management of Bile Leakage after Hepatic Resection

Abstract

The aim of this study was to identify the perioperative risk factors for postoperative bile leakage after hepatic resection and to propose a treatment strategy for such leakage when it does occur. Between 1992 and 2000 a total of 313 hepatic resections without choledocojejunal anastomosis were performed at our institute. Risk factors related to bile leakage were identified with univariate analysis, and strategies were evaluated in relation to the findings of postoperative fistulography. Postoperative bile leakage developed in 17 patients (5.4%). Univariate analysis identified high risk factors as advanced age, a wide surface area of the incision (bile leakage group versus no bile leakage group: 102.1 vs. 66.4 cm(2), p < 0.05), and exposure of Glisson's sheath at the cut surface (e.g., central bisegmentectomy, S4, S8 subsegmentectomy). Groupings of patients by their postoperative fistulography results showed that patients with involvement of the proximal bile duct were slower to heal than those with no demonstrable bile duct involvement. The one patient whose fistulogram demonstrated peripheral bile duct involvement had uncontrollable leakage and required reoperation. Hepatectomies with a wide surface area and those that expose the major Glisson's sheath present serious risk factors for bile leakage. When the fistulogram shows proximal bile duct involvement, endoscopic nasobiliary tube drainage is necessary; when the fistulogram shows peripheral bile duct involvement, reoperation is needed.

Prevention of Biliary Leakage after Partial Liver Resection Using Topical Hemostatic Agents

“…In the study of Yamashita et al [3], biliary leakage had occurred in 4% of patients. Nagano et al [11] reported biliary leakage in 5.4%. Other studies showed biliary leakage in 5.8% [12], 7.2% [13] and 8.1% [14] of patients.…”

Estimation of a Predictor’s Importance by Random Forests When There Is Missing Data: RISK Prediction in Liver Surgery using Laboratory Data

“…Due to improvements in liver surgery, postoperative mortality and morbidity decreased dramatically over the last decades [1][2][3]. However, operations are still not hazard-free [1].…”

Use of Topical Hemostatic Agents during Liver Resection

“…The incidence of bile fistula after liver surgery at the resection site has been reported to be 5–21% [32,33,34], while the definition of a bile fistula may differ from ‘a continuous drainage for more than 2 days with a bilirubin level over 20 mg/dl or 1,500 mg/day’ to ‘drainage of bile from abdominal wound or drain with a bilirubin level of more than 5 mg/dl’. Risk factors for leakage after liver surgery include resection surface area >60 cm 2 , exposure of major Glisson’s sheath, S4 resection, intraoperative blood loss and preoperative chemoembolization [32, 34]. In preventing this bile leakage, peroperative treatment of the remnant liver is extremely important and infrared coagulation, argon beamer, fibrin glue or hemostatic collagen fleeces might be helpful, but meticulous preparation during resection remains the most important factor with adequate placement of clips and sutures.…”