title: The determination of bile leakage in complex hepatectomy based on the guidelines of the International Study Group of Liver Surgery.
abstract: BACKGROUND
  The International Study Group of Liver Surgery (ISGLS) has defined bile leakage as a drain fluid-to-serum total bilirubin concentration (TBC) ratio (the bilirubin ratio) ≥ 3.0. The aim of the present study was to determine the clinical significance of this definition, and to outline characteristics of bile leakage in complex hepatectomy.
  
  
  METHODS
  The TBCs of the serum and drain fluid were measured on postoperative days (POD) 1, 3, and 7 in 241 patients who had undergone hepatobiliary resection. The validation of the bilirubin ratio and predictors of bile leakage were retrospectively assessed.
  
  
  RESULTS
  Grade A, B, or C bile leakage was found in 23 (9.5 %), 66 (27.4 %), and 0 patients, respectively. The median duration of drainage was 27 days in grade B bile leakage. The sensitivity and specificity of the bilirubin ratio for detecting grade B bile leakage were 59 and 87 %, respectively. The area under the receiver operating characteristics curve of the drain fluid TBC on POD 3 had the highest predictive value: 68 % sensitivity and 76 % specificity for a drain fluid TBC of 3.7 mg/dL. The multivariate analysis demonstrated that operative time, left trisectionectomy, bilirubin ratio, and TBC of the drain fluid on POD 3 were independent predictors of grade B bile leakage.
  
  
  CONCLUSIONS
  In complex hepatectomy, bile leakage develops most frequently after left trisectionectomy and often results in a refractory clinical course. The ISGLS biochemical definition is valid, and a combination of bilirubin ratio and drain fluid TBC may enhance risk prediction for grade B bile leakage.
authors.affiliation: Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan, yoshirotaguchi@hotmail.com.
authors.forename: Yoshiro
authors.initials: Y
authors.lastname: Taguchi
authors.forename: Tomoki
authors.initials: T
authors.lastname: Ebata
authors.forename: Yukihiro
authors.initials: Y
authors.lastname: Yokoyama
authors.forename: Tsuyoshi
authors.initials: T
authors.lastname: Igami
authors.forename: Gen
authors.initials: G
authors.lastname: Sugawara
authors.forename: Toshio
authors.initials: T
authors.lastname: Kokuryo
authors.forename: Kenji
authors.initials: K
authors.lastname: Wakai
authors.forename: Masato
authors.initials: M
authors.lastname: Nagino
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001646:Bile; D001663:Bilirubin / Q000032:analysis; D001826:Body Fluids / Q000737:chemistry; D004322:Drainage; D005260:Female; D006498:Hepatectomy / Q000009:adverse effects*; D006801:Humans; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000453:epidemiology / Q000378:metabolism; D017410:Practice Guidelines as Topic; D012189:Retrospective Studies; D055815:Young Adult
chemical_list: D001663:Bilirubin