title: Defining treatment and outcomes of hepaticojejunostomy failure following pancreaticoduodenectomy.
abstract: BACKGROUND
  The overall complication rate after pancreaticoduodenectomy (PD) approaches 50 %, with anastomotic failure being the most frequent cause of serious postoperative morbidity. Hepaticojejunostomy leaks (also called bile leaks) are the second most common type of leak, behind pancreaticojejunostomy leaks, yet have been the focus of only a single study as reported by Suzuki et al. (Hepatogastroenterology 50:254-257, 12).
  
  
  METHODS
  We reviewed the recent experience with bile leaks at a single, high-volume pancreatic surgery center over a six-year time period.
  
  
  RESULTS
  Bile leaks were identified in 16 out of 715 patients (2.2 %). Low preoperative albumin was associated with an increased risk. Bile leaks typically manifested within the first week after surgery as bilious drainage in a surgically placed drain. Associated warning signs included fever and leukocytosis. Patients with a bile leak frequently developed other complications, including a pancreatic fistula, wound infection, delayed gastric emptying, and sepsis. The impact on perioperative outcomes was comparable to patients with a pancreatic leak. A grading system is proposed based on the International Study Group on Pancreatic Fistula model. Grade A bile leaks were classified as those managed with prolonged drainage by operatively placed drains, grade B bile leaks with percutaneous abdominal drainage, and grade C bile leaks with insertion of a percutaneous transhepatic biliary drainage.
  
  
  CONCLUSIONS
  Hepaticojejunostomy leaks are rare after PD. The complication severity ranges from trivial to life threatening and is comparable overall to pancreaticojejunostomy leaks. Surgical intervention is rarely, if ever, required. With prompt and aggressive management, a full recovery can be expected.
authors.affiliation: Department of Surgery, Jefferson Pancreas, Biliary and Related Cancer Center, Thomas Jefferson University, Philadelphia, PA 19107, USA.
authors.forename: Richard A
authors.initials: RA
authors.lastname: Burkhart
authors.forename: Daniel
authors.initials: D
authors.lastname: Relles
authors.forename: Danielle M
authors.initials: DM
authors.lastname: Pineda
authors.forename: Salil
authors.initials: S
authors.lastname: Gabale
authors.forename: Patricia K
authors.initials: PK
authors.lastname: Sauter
authors.forename: Ernest L
authors.initials: EL
authors.lastname: Rosato
authors.forename: Leonidas G
authors.initials: LG
authors.lastname: Koniaris
authors.forename: Harish
authors.initials: H
authors.lastname: Lavu
authors.forename: Eugene P
authors.initials: EP
authors.lastname: Kennedy
authors.forename: Charles J
authors.initials: CJ
authors.lastname: Yeo
authors.forename: Jordan M
authors.initials: JM
authors.lastname: Winter
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000714:Anastomosis, Surgical / Q000009:adverse effects; D057868:Anastomotic Leak / Q000145:classification* / Q000209:etiology / Q000628:therapy*; D003138:Common Bile Duct Neoplasms / Q000601:surgery*; D004322:Drainage; D005260:Female; D005746:Gastric Emptying; D006500:Hepatic Duct, Common / Q000601:surgery*; D006801:Humans; D007583:Jejunum / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D010185:Pancreatic Fistula / Q000209:etiology; D010190:Pancreatic Neoplasms / Q000601:surgery*; D016577:Pancreaticoduodenectomy / Q000009:adverse effects*; D018805:Sepsis / Q000209:etiology; D012709:Serum Albumin; D018709:Statistics, Nonparametric; D013530:Surgical Wound Infection / Q000209:etiology; D016896:Treatment Outcome; D055815:Young Adult
chemical_list: D012709:Serum Albumin