Biliary Leakage After Hepatobiliary and Pancreatic Surgery: A Classification System to Guide the Proper Percutaneous Treatment

Purpose To investigate the effectiveness of percutaneous approaches to treat bile leak and to propose an anatomical classification of biliary fistula to guide the most appropriate percutaneous approach. Materials and Methods Fifty-six patients with bile leakage after hepatobiliary surgery were included. Based on preoperative images and postoperative fistulogram images, three categories of bile leakage were defined. Every category was treated with non-surgical approaches (internal–external percutaneous drainage, percutaneous/endoscopic biliodigestive anastomosis with rendez - vous technique and biliodigestive percutaneous anastomosis with totally radiologic rendez-vous). Results In 44/56 (78%) patients, anatomical conformation was “direct communication” (bile ducts upstream from the leak present a direct communication with downstream ducts) and their treatment was conventional percutaneous drainage. In 5/56 (9%), anatomical conformation was “indirect communication” (bile ducts upstream from the leak communicate with downstream ducts through a bile collection) and treatment was percutaneous/endoscopic rendez-vous technique. In 7/56 (12%), anatomical conformation was “no communication” (ducts upstream from the leak are completely excluded from ducts downstream) and treatment was totally radiologic rendez-vous. In 54/56 (96%) during the follow-up, cholangiography revealed complete resolution of the leak without residual stenosis and drains were removed. Complications occurred in 12/56 (21%). Procedure-related mortality was 0%. Ten patients, after > 6 months from resolution of their fistula and drain removal, died due to cancer recurrence. Currently, 44/56 patients (77%) at long-term follow-up (> 12 months) are alive, without bile leak. Conclusion Our classification helps to choose the most proper percutaneous approach in all kinds of bile leakage, even in severe cases; these are safe techniques with a high success rate.