A novel algorithm for the diagnosis and treatment of different types of bile leakage following hepatectomy with bilioenteric anastomosis

Introduction: After liver resection with bilioenteric anastomosis (BEA), post-hepatectomy bile leakage (PHBL) may originate from two main sources: the BEA or the transection surface of the liver. Leaks from the transection surface can result from either isolated bile ducts not connected to the central biliary tree or from small intrahepatic ducts inadequately closed during parenchymal dissection. Accurate localization remains challenging, as current diagnostic methods are complex and often inconclusive. Consequently, standardized guidelines for PHBL diagnosis and management are still lacking.

Objectives: This study aims to distinguish between different types of PHBL, evaluate diagnostic parameters, and analyze outcomes of different management strategies to develop a structured treatment algorithm.

Methods: All patients undergoing liver resection with concomitant BEA between 2008 and 2023 were included. Perioperative data, drain bilirubin concentration, and treatment strategies – including conservative management, interventional procedures, and reoperation – were collected and analyzed by leak type.

Results: Of 2936 patients undergoing liver resection, 229 had concomitant BEA. BEA leaks were associated with significantly higher morbidity and mortality than transection surface leaks. Patients with BEA leaks showed significantly higher peak bilirubin concentration in drain fluid compared to transection surface leaks (38.3 mg/dl vs. 18.6 mg/dl, P<0.001), with a cut-off value of 20.85 mg/dl in receiver operating characteristic (ROC) curve analysis. Leaks from isolated bile ducts responded best to reoperation (success rate of 100% (5/5), P=0.008), while transection surface leaks were more effectively managed non-operatively (68% (44/65) success, P<0.001). In BEA leaks treatment success varied by timing: in early leaks reoperation was more effective, whereas in late leaks percutaneous transhepatic cholangio-drainage (PTCD) was more successful.

Conclusion: Classification of PHBL according to its anatomical origin is essential for choosing the optimal treatment. A drain bilirubin concentration greater than 20.85 mg/dl is highly suggestive for BEA leakage. Early BEA leaks and leaks from isolated bile ducts respond best to reoperation, while late BEA leakage and transection surface leaks are better treated non-operatively. Based on these findings, we propose a treatment algorithm integrating leak type and timing to support clinical decision-making.

Publication History

Article published online:
04 September 2025