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

International audience; 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.