Pure vs Pancreatic Fistula-Associated Biliary Leak after Pancreaticoduodenectomy: Different Twins

Abstract

Introduction: Biliary leak (BL) after pancreatoduodenectomy (PD) is a rare complication, with variable severity. We sought to evaluate the range of possible treatment strategies and outcomes for BL, according to the presence of an associated postoperative pancreatic fistula (POPF). Methods: Postoperative data of patients undergoing PD at the Verona and the Karolinska University Hospitals between 2011 and 2020 were retrospectively reviewed, including: BL incidence, grading and outcomes; BL time of onset and resolution; the presence of associated postoperative pancreatic fistula (POPF); BL-specific treatments and their timing. Results: A BL occurred in 153 out of 2715 patients undergoing PD (6%). Ten patients with BL were excluded due to missing postoperative data. Of the remaining 143, 67 (47%) had an associated POPF (POPF-BL) while 76 (53%) had a pure BL. Pancreas-specific morbidity and in-hospital mortality (19% vs 4%; P< 0.01) were higher in the POPF-BL group. Time of BL onset was similar between the groups, while BL closure occurred earlier in pure BL (12 vs 23 days; P< 0.01). Conservative treatment was more frequent in the pure BL group (55 vs 15%; P< 0.01), while the rate of percutaneous and/or trans-hepatic drain placement was similar. Relaparotomy was more common in the POPF-BL group (42% VS 17%; P< 0.01) but occurred earlier in case of pure BL (2 vs 10 days; P= 0.02). Conclusions: The association with POPF is a negative prognostic factor for BL after PD. Pure BL represents a more benign entity, which is managed conservatively in half of the cases.