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Invited Critique
July 1, 2006

Bile Leakage and Liver Resection: Where Is the Risk?—Invited Critique

Arch Surg. 2006;141(7):695. doi:10.1001/archsurg.141.7.695

Capussotti et al review the incidence of bile leakage complicating liver surgery in 610 patients who underwent a variety of hepatic resections for various indications. They observed a low incidence of this complication (22 [3.6%] of 610 patients), although it was associated with more than doubling the length of hospitalization but was not associated with increased secondary morbidity or mortality. The authors examined a variety of patient, disease, and technical factors associated with the development of this operative complication; resection of segment 4 and the diagnosis of peripheral cholangiocarcinoma were associated with an increased risk of bile leakage, whereas treatment of the cut hepatic surface with fibrin glue was associated with a decreased risk. The authors conducted the study to identify risk factors that could be modified and therefore reduce the incidence of this complication. Unfortunately, 2 of the 3 risk factors (namely, the diagnosis of peripheral cholangiocarcinoma and resection of segment 4) cannot be altered by the surgeon to reduce the risk of bile leakage. Interestingly, fibrin glue was applied to the cut hepatic surface as a hemostatic agent, without intent to address bile leakage, although its use apparently facilitated the closure of bile ducts that may have been responsible for postoperative bile leakage. Are these data sufficient to warrant the routine use of fibrin glue as a biliary sealant? The answer is clearly no. Even with the use of fibrin sealant, bile leakage still developed in 2.2% of patients compared with 6.2% in patients who were not treated with fibrin glue. Furthermore, it is not reported whether this reduced incidence was associated with altering the sequelae of this complication—the added length of hospitalization. Perhaps fibrin glue should be considered in the patients at highest risk for bile leakage (resection for peripheral cholangiocarcinoma or involving segment 4), although the clinical effect remains unknown.

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