Bile Leakage after Laparoscopic and Open Liver Resection; Incidence and Clinical Impact: An International Multicenter Propensity Score-matched Study of 13,379 Patients

Abstract

Purpose: Despite many developments, postoperative bile leakage (POBL) remains a relatively common postoperative complication after laparoscopic liver resection (LLR) and open liver resection (OLR). Previous studies regarding the incidence and clinical impact of POBL have mainly focused on patients undergoing OLR. The aim of this study is to compare the incidence and clinical impact of POBL between patients undergoing LLR and OLR in a large international multicenter cohort using a propensity score matched analysis. Methods: Patients undergoing LLR or OLR for all indications between January 2000 and October 2019 were analyzed using a large, international multicenter liver database including data from 15 tertiary referral centers. Primary outcome was clinically relevant POBL (CR-POBL), defined as Grade B/C POBL. Patients were matched based on propensity scores in a 1 : 1 ratio. The incidence and clinical impact of POBL were compared between LLR and OLR after propensity score matching (PSM). Results: Overall, 13,379 patients met the inclusion criteria and were included in the analysis (6,369 LLR and 7,010 OLR), with 6.0% POBL. After PSM, a total of 3,563 LLR patients were matched to 3,563 OLR patients. POBL occurred in 405 patients (5.6%), including 121 patients after LLR (3.4%) and 284 patients after OLR (8.8%) (P<0.001). The incidence of CR-POBL was significantly lower in patients after LLR as compared to patients after OLR (2.6% vs. 6.4%; P<0.001). Among the subgroup of patients with CR-POBL, patients after LLR experienced less severe (non-POBL) postoperative complications (10.1% vs. 20.9%; P=0.028), less surgical site infections (4.4% vs. 17.9%; P=0.002), a shorter hospital stay (12.5 vs. 17 days; P=0.001), and a lower 90-day/in-hospital mortality (0% vs. 5.4%; P=0.027) as compared to patients after OLR with CR-POBL. Conclusions: This international multicenter study shows that LLR is associated with a lower rate of CR-POBL as compared to the open approach. Our findings demonstrate that in patients with CR-POBL, those after LLR experience a less impactful postoperative course as compared to patients after OLR. A further stepwise implementation of LLR into daily clinical practice may be encouraged to improve outcomes of liver surgery.