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Incidence and Risk Factors Associated With Bile Leak and Liver Failure following Hepatic Resection Among a Cohort of 3,064 Patients in the United State
Neda Amini*1, Faiz Gani1, Georgios A. Margonis1, Yuhree Kim1, Ana Wilson1, Henry Pitt2, Timothy M. Pawlik1
1Surgery, Johns Hopkins Hospital, Baltimore, MD; 2Surgery, Temple University Health System, Philadelphia, PA
Background: Postoperative bile leak and liver failure are major potential sources of morbidity and mortality among patients undergoing liver resection. We sought to define the incidence and identify risk factors for bile leak and liver failure using a cohort of 3,604 patients undergoing liver surgery in the United States.
Methods: The NSQIP Hepatectomy targeted database was queried to identify patients who underwent a liver resection between January 01, 2014 and December 31, 2014. Multivariable logistic regression analysis was performed to identify risk factors associated with bile leak and liver failure.
Results: The median age of the cohort was 60 years (IQR:50-68); 52.4% of patients were female and 67.1% were white. A majority of patients underwent surgery for a malignant indication (78.9%) while 21.1% underwent surgery for a benign lesion. 872 (28.8%) patients received preoperative treatment including either neo-adjuvant chemotherapy (26.1%) or portal vein embolization (PVE)(4.2%). At the time of surgery, most patients underwent an open liver resection (80.0%), while 18.5% and 1.5% underwent a laparoscopic or robotic procedure, respectively. An operative drain was placed in 46.1% (n=1,407) of patients (open 50.7% vs. laparoscopic 27.4% vs. robotic 29.8%, P<0.001). Post-operatively, 250 (8.5%) patients experienced a bile leak. Among 37 patients without an operative drain who experienced a bile leak, a percutaneous drain was placed in 70.3% (n=26) of patients, 27.0% (n=10) required a reoperation, and 1 patient was managed conservatively with no additional interventions. On multivariable analysis, PVE (odds ratio [OR] 1.90, 95% confidence interval [CI] 1.13-3.18), major hepatectomy (OR 1.79, 95%CI 1.29-2.47), biliary reconstruction (OR 2.96,95%CI 1.81-4.86), and operation time >300 minutes (OR 1.61,95%CI 1.61-2.24) were independently associated with a higher risk of bile leak (Figure). In contrast, patients who underwent a minimally invasive approach (laparoscopic or robotic) had a decreased odds of bile leak (OR 0.36,95% CI 0.20-0.65)(P=0.001). A total of 4.9% (n=149) patients developed liver failure, which resulted in a deviation in the regular hospital course in over one-third (36.2%) of patients. Factors associated with risk of liver failure on multivariable analysis included male sex (OR 2.11,95%CI 1.37-3.25), ASA scoreā„3 (OR 1.98,95%CI 1.13-3.48), cirrhosis (OR 1.81,95%CI 1.07-3.05), major hepatectomy (OR 3.12,95%CI 1.97-4.94), and operation time >300 minutes (OR 1.63,95%CI 1.05-2.52).
Conclusion: Bile leak and liver failure were relatively common postoperative complications following liver surgery occurring in 1 in 12 patients and 1 in 20 patients, respectively. Identification of risk factors associated with bile leak and liver failure may help target strategies to reduce the risk of these complications following hepatic resection.
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