Author Affiliations: General, Visceral, and Transplantation Surgery, Charité-Universitaetsmedizin Berlin, Campus Virchow Clinic, Berlin 13353, Germany (Struecker B, Andreou A, Sauer IM, Pratschke J and Seehofer D)

Corresponding Author: Benjamin Struecker, MD, General, Visceral, and Transplantation Surgery, Charité-Universitaetsmedizin Berlin, Augustenburger Platz 1, Berlin 13353, Germany (Tel: +004930652004; Fax: +004930552900; Email: Benjamin.struecker@charite.de)

 

© 2016, Hepatobiliary Pancreat Dis Int. All rights reserved.

doi: 10.1016/S1499-3872(15)60041-8

Published online December 31, 2015.

 

 

Contributors: SB wrote the first draft. All authors contributed to the design and interpretation of the study and to further drafts. PJ is the guarantor.

Funding: None.

Ethical approval: Not needed.

Competing interest: No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article.

 

 

In the current issue, Panaro et al^[1] presented a retrospective single-center study on 411 hepatectomies for benign and malignant liver tumors. After exclusion of hilar cholangiocarcinomas and hepatectomies with simultaneous biliary or pancreatic resection, risk factors for postoperative bile leakage were analyzed. Progress in preoperative assessment (e.g. modern imaging studies, liver function tests), liver preconditioning (e.g. portal vein embolization), improving perioperative care, and advances in surgical techniques (e.g. two stage hepatectomies, liver partition with portal vein ligation for staged hepatectomy) enable curative resections even for advanced hepatic malignancies with reasonable mortality rates and constantly improving oncological outcomes.^[2] In accordance with the existing literature, they reported that 10.2% of their patients suffered from a postoperative bile leakage and concluded that bile leakage remains a major issue after hepatic resection, causing extended length of hospital stay (median 9 vs 16 days, P=0.001), higher costs, and higher postoperative mortality resulting from liver failure due to decompensation of preexisting cirrhosis. The authors reported that four senior hepatobiliary surgeons performed liver resections using different techniques of liver parenchymal transection and concluded that bile leakage was associated with non-anatomical resections and total vascular exclusion (TVE).

 

As for the risk factors for postoperative bile leakage, some other studies showed a benefit for the intraoperative use of biological agents to seal the resected parenchyma (i.e. human thrombin, fibrinogen patch agents, glue etc.)^[3] or intraoperative leakage tests (i.e. methylene blue or cholangiography).^[4] Zimmitti et al^[4] showed in a large study cohort that the systematic use of an intraoperative air leak test at the time of major liver resection reduces the rate of postoperative biliary complications. Furthermore, some studies tried to find a correlation between postoperative bile leakage and the quality of the liver parenchyma. Available data regarding this issue remains unclear. The study of Pawlik et al^[5] showed no association between preoperative chemotherapy for colorectal liver metastases with the expected chemotherapy-related liver injury and the rate of bile leakage after curative resection, while Guillaud et al^[6] showed the contrary.

 

Nearly 90% of the current study patients received a passive drainage near to the resection surface and the authors concluded that the drainage allowed for an early diagnosis of postoperative bile leakage. However, according to recent “Enhanced Recovery After Surgery (ERAS)” protocols, the standardized placement of intra-abdominal drainages should be obsolete, at least for uncomplicated liver resections.^{[7, 8]} Applying the latest classification of the International Study Group of Liver Surgery (ISGLS),^[9] 21.4%, 64.3% and 14.3% of patients with bile leakage were classified with grade A, grade B and grade C bile leakage and required a medical, interventional (endoscopic or radiologic), or surgical treatment, respectively. Interestingly, Table 4 in the study of Panaro et al^[1] shows that bile leakage resulting from TVE appears to be more severe than that resulting from non-anatomical resections: it seems reasonable that simple parenchyma sparing wedge resections may cause grade A or B bile leakage that can be treated medically or interventionally and thus have minor impact on patients’ postoperative courses, whereas bile leakage resulting from TVE may more often require surgical re-intervention (e.g. placement of intraductal bile drainages). In our opinion, strategies to prevent bile leakage in cases of planned complex resections (e.g. by primary placement of intraductal biliary drainages^[10]) should be subjected to further randomized studies.

 

To sum up, bile leakage remains a major issue after liver resection, and major progress in reduction of bile leakage after liver resection is still lacking and should be addressed in further clinical studies.

 

 

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2 Seehofer D, Neuhaus P. Current status of multimodal therapy for colorectal liver metastases. Zentralbl Chir 2011;136:343-351. PMID: 21863512

3 Capussotti L, Ferrero A, Viganò L, Sgotto E, Muratore A, Polastri R. Bile leakage and liver resection: Where is the risk? Arch Surg 2006;141:690-695. PMID: 16847242

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7 Ishizawa T, Zuker NB, Conrad C, Lei HJ, Ciacio O, Kokudo N, et al. Using a ‘no drain’ policy in 342 laparoscopic hepatectomies: which factors predict failure? HPB (Oxford) 2014;16:494- 499. PMID: 23991910

8 Hughes MJ, McNally S, Wigmore SJ. Enhanced recovery following liver surgery: a systematic review and meta-analysis. HPB (Oxford) 2014;16:699-706. PMID: 24661306

9 Koch M, Garden OJ, Padbury R, Rahbari NN, Adam R, Capussotti L, et al. Bile leakage after hepatobiliary and pancreatic surgery: a definition and grading of severity by the International Study Group of Liver Surgery. Surgery 2011;149:680-688. PMID: 21316725

10 Strücker B, Stockmann M, Denecke T, Neuhaus P, Seehofer D. Intraoperative placement of external biliary drains for prevention and treatment of bile leaks after extended liver resection without bilioenteric anastomosis. World J Surg 2013;37: 2629-2634. PMID: 23892726