Incidence, Predictive Factors and Management of Biliary Leakage After Hepaticojejunostomy
S.M.M. de Castro, K.F.D. Kuhlmann, O.M. van Delden, O.R.C. Busch, J.S. Laméris, Academic Medical Center, Amsterdam, Noord Holland, Netherlands; T.M. van Gulik, Academic Medical Center, Amsterdam, Noord Holland; H. Obertop, D.J. Gouma, Academica Medical Center, Amsterdam, Noord Holland, Netherlands
Postoperative biliary leakage after hepaticojejunostomy is an infrequent but clinically important complication. The aim of this study was to analyze incidence, predictive factors and management of biliary leakage after a hepaticojejunostomy, specifically if less invasive techniques have been used more frequently.
Between January1993 and December 2003, all patients (n=1033) who underwent a hepaticojejunostomy (hepatectomy excluded) were included. Procedures consisted of a pancreatoduodenectomy (n=486), proximal bile duct resection (n=35) and biliodigestive bypass for malignant (n=301) and benign (n=211) disease. Biliary leakage was defined as the presence of bile in the abdominal drain, more then 24 hours after surgery, or leakage proven radiologically or found at relaparotomy.
Overall, 29 out of 1033 patients (2.8%) had biliary leakage after a hepaticojejunostomy. Leakage occurred in 14 patients (2.9%) after pancreatoduodenectomy, in 5 patients (14.3%) after a proximal bile duct resection, in 10 patients (2.0%) after a biliodigestive bypass. Three prognostic factors associated with increased biliary leakage rate (p<0.05) were identified in Univariate analysis: severe obesity according to the NIH classification (OR = 13.00, 95%CI 1.32-129.15, p=0.03), estimated blood loss ˇÝ1500 ml (4th quartile) (OR = 3.97, 95%CI:1.08-14.67, p=0.04) and segmental hepatic anastomosis (OR = 8.89, 95%CI:3.69-21.43, p<0.01). In Multivarite analysis, a segmental hepatic anastomosis (OR = 9.74, 95%CI: 1.30-73.11,p=0.03) was the only factor associated with leakage. This was still the case after adjusting for procedure type. Management in the first half (1993-1997) compared with the second half (1998-2003) of the study period consisted of re-laparotomy (67% vs. 25%, respectively, p=0.05), percutaneous drainage (22% vs. 0, respectively, p=0.09) stent placement via PTC (0 vs. 60%, respectively, p<0.01) and conservative therapy (11% vs. 15% respectively, p=0.34). No mortality occurred in the 29 patients with biliary leakage. The overall mortalilty (n=-1033) was 1.5%.
An anastomosis on the common hepatic duct leads to less leakage then on hepatic branches and is preferred when possible. Relaparotomy is scarcely necessary in recent years and management of leakage can be successfully performed by stent placement via PTC.
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