Incidence and predictive factors of clinically relevant bile leakage in the modern era of liver resections

Abstract Objective To evaluate the incidence, the impact on survival and the predictive factors of bile leakage (BL) in a recent large monocentric series of liver resections performed in a referral tertiary care centre. Background Previous reports dealing with bile leakage (BL) after liver resection are rare and have displayed conflicting results regarding incidence, impact on follow‐up and predictive factors. Methods A retrospective review of the records of 912 patients who underwent a total of 1001 consecutive liver resections without biliary reconstruction, performed between January 2005 and May 2011. BL was defined by the presence of bile in the abdominal drains, a radiologically or surgically drained bilioma or biliary peritonitis. BL severity was established according to the Clavien–Dindo classification. Fifty‐eight pre‐, per‐ and post‐resection variables were analysed and the independent BL predictive factors were identified using logistic regression. Results The incidence of BL was 8%. Clavien–Dindo I‐II, IIIa, IIIb or IV rates were 29%, 35%, 32.5% and 2.5%, respectively. BL did not increase in‐hospital mortality (2.5% versus 2.9%, P = 1.0), but doubled the median duration of hospital stay (16 versus 9 days, P < 0.001) and increased 1‐year mortality (11% versus 5%, P = 0.03). Multivariate analysis identified that pre‐operative bevacizumab [odds ratio (OR) = 2.9, confidence interval (CI) 95% = 1.58–5.41] P = 0.001], a major hepatectomy [OR = 2.6 (CI 95% = 1.48–4.76) P = 0.001], a two‐stage hepatectomy [OR = 2.5 (CI 95% = 1.17–5.52) P = 0.018], the selective clamping technique [OR = 2.6 (CI 95% = 1.03–6.78) P = 0.042], R1 or R2 resection [OR = 2.6 (CI 95% = 1.52–4.64) P = 0.001] and the absence of a methylene blue test [OR = 2.6 (IC 95% = 1.43–4.65) P = 0.002] were independent risk factors of BL. Conclusion BL remains frequent after liver resection. It has a dramatic impact on patient survival and care costs. Its incidence could be reduced by avoiding the pre‐operative use of bevacizumab, avoiding selective clamping and performing a blue dye test in all resections.