A critical appraisal of the ISGLS definition for biliary leakage following hepatic resection

Abstract

Aims: The International Study Group for liver surgery defined post hepatectomy biliary leakage as drainage bilirubin to serum bilirubin ratio >3 at day 3 after resection or later or the interventional/surgical revision due to biliary peritonitis. Methods: Retrospective evaluation of consecutive liver resections in 2012 and 2013. Biliary leakage was classified in accordance with the ISGLS definition. ROC-analysis were performed for drainage/serum bilirubin ratios on day 1, 2, 3 and 4 including grade A to C leakages (analysis I) and consecutively for grade B and C biliary leakages (analysis II) to define statistically meaningful cut-off values and their potential relevance for the occurrence of biliary leakages after hepatic resection. Results: A total of 251 consecutive patients undergoing liver resection were included in the analysis. Data are given as median with interquartile range. Age was 64 years (51; 71). A total of 62 bile leakages occurred post-operatively (25%, grade A: 16, grade B: 39, grade C: 7). Areas under the curve for analysis I were 1.00 (day 1), 0.93 (day 2), 0.81 (day 3) and 0.86 (day 4). The highest sensitivity (77%) and specifity (90%) were obtained for a drainage/serum bilirubin ratio of 2.4 on day 4 after hepatic resection. Areas under the curve for analysis II were similar than for analysis I: 0.95, 0.91, 0.82 and 0.79. The highest sensitivity (89%) and specifity (87%) was detected for a drainage/serum bilirubin ratio of 2.6 on post-operative day 2 with positive likelihood-ratio of 6.7 and a negative likelihood ratio of 0.13. Conclusions: Based on our statistical investigations we carefully suggest amending the current definition of biliary leakages as defined by the ISGLS. Biliary leakages should be defined in case the drainage/serum bilirubin ratio >2.6 on postoperative day 2.