Original Communication| Volume 149, ISSUE 5, P680-688, May 2011

Bile leakage after hepatobiliary and pancreatic surgery: A definition and grading of severity by the International Study Group of Liver Surgery

Published:February 14, 2011DOI:


      Despite the potentially severe impact of bile leakage on patients’ perioperative and long-term outcome, a commonly used definition of this complication after hepatobiliary and pancreatic operations has not yet been established. The aim of the present article is to propose a uniform definition and severity grading of bile leakage after hepatobiliary and pancreatic operative therapy.


      An international study group of hepatobiliary and pancreatic surgeons was convened. A consensus definition of bile leakage after hepatobiliary and pancreatic operative therapy was developed based on the postoperative course of bilirubin concentrations in patients’ serum and drain fluid.


      After evaluation of the postoperative course of bilirubin levels in the drain fluid of patients who underwent hepatobiliary and pancreatic operations, bile leakage was defined as bilirubin concentration in the drain fluid at least 3 times the serum bilirubin concentration on or after postoperative day 3 or as the need for radiologic or operative intervention resulting from biliary collections or bile peritonitis. Using this criterion severity of bile leakage was classified according to its impact on patients’ clinical management. Grade A bile leakage causes no change in patients’ clinical management. A Grade B bile leakage requires active therapeutic intervention but is manageable without relaparotomy, whereas in Grade C, bile leakage relaparotomy is required.


      We propose a simple definition and severity grading of bile leakage after hepatobiliary and pancreatic operative therapy. The application of the present proposal will enable a standardized comparison of the results of different clinical trials and may facilitate an objective evaluation of diagnostic and therapeutic modalities in the field of hepatobiliary and pancreatic operative therapy.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Surgery
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Poon R.T.
        • Fan S.T.
        • Lo C.M.
        • Liu C.L.
        • Lam C.M.
        • Yuen W.K.
        • et al.
        Improving perioperative outcome expands the role of hepatectomy in management of benign and malignant hepatobiliary diseases: analysis of 1222 consecutive patients from a prospective database.
        Ann Surg. 2004; 240: 698-708
        • Buchler M.W.
        • Wagner M.
        • Schmied B.M.
        • Uhl W.
        • Friess H.
        • Z’graggen K.
        Changes in morbidity after pancreatic resection: toward the end of completion pancreatectomy.
        Arch Surg. 2003; 138: 1310-1314
        • Rahbari N.N.
        • Wente M.N.
        • Schemmer P.
        • Diener M.K.
        • Hoffmann K.
        • Motschall E.
        • et al.
        Systematic review and meta-analysis of the effect of portal triad clamping on outcome after hepatic resection.
        Br J Surg. 2008; 95: 424-432
        • Reed Jr., D.N.
        • Vitale G.C.
        • Wrightson W.R.
        • Edwards M.
        • McMasters K.
        Decreasing mortality of bile leaks after elective hepatic surgery.
        Am J Surg. 2003; 185: 316-318
        • Schiesser M.
        • Chen J.W.
        • Maddern G.J.
        • Padbury R.T.
        Perioperative morbidity affects long-term survival in patients following liver resection for colorectal metastases.
        J Gastrointest Surg. 2008; 12: 1054-1060
        • Chok K.S.
        • Ng K.K.
        • Poon R.T.
        • Lo C.M.
        • Fan S.T.
        Impact of postoperative complications on long-term outcome of curative resection for hepatocellular carcinoma.
        Br J Surg. 2009; 96: 81-87
        • Farid S.G.
        • Aldouri A.
        • Morris-Stiff G.
        • Khan A.Z.
        • Toogood G.J.
        • Lodge J.P.
        • et al.
        Correlation between postoperative infective complications and long-term outcomes after hepatic resection for colorectal liver metastasis.
        Ann Surg. 2010; 251: 91-100
        • Ito H.
        • Are C.
        • Gonen M.
        • D’Angelica M.
        • DeMatteo R.P.
        • Kemeny N.E.
        • et al.
        Effect of postoperative morbidity on long-term survival after hepatic resection for metastatic colorectal cancer.
        Ann Surg. 2008; 247: 994-1002
        • Erdogan D.
        • Busch O.R.
        • van Delden O.M.
        • Rauws E.A.
        • Gouma D.J.
        • van Gulik T.M.
        Incidence and management of bile leakage after partial liver resection.
        Dig Surg. 2008; 25: 60-66
        • de Castro S.M.
        • Kuhlmann K.F.
        • Busch O.R.
        • van Delden O.M.
        • Lameris J.S.
        • van Gulik T.M.
        • et al.
        Incidence and management of biliary leakage after hepaticojejunostomy.
        J Gastrointest Surg. 2005; 9: 1163-1171
        • Bassi C.
        • Dervenis C.
        • Butturini G.
        • Fingerhut A.
        • Yeo C.
        • Izbicki J.
        • et al.
        Postoperative pancreatic fistula: an international study group (ISGPF) definition.
        Surgery. 2005; 138: 8-13
        • Wente M.N.
        • Veit J.A.
        • Bassi C.
        • Dervenis C.
        • Fingerhut A.
        • Gouma D.J.
        • et al.
        Postpancreatectomy hemorrhage (PPH): an International Study Group of Pancreatic Surgery (ISGPS) definition.
        Surgery. 2007; 142: 20-25
        • Wente M.N.
        • Bassi C.
        • Dervenis C.
        • Fingerhut A.
        • Gouma D.J.
        • Izbicki J.R.
        • et al.
        Delayed gastric emptying (DGE) after pancreatic surgery: a suggested definition by the International Study Group of Pancreatic Surgery (ISGPS).
        Surgery. 2007; 142: 761-768
        • Rahbari N.N.
        • Weitz J.
        • Hohenberger W.
        • Heald R.J.
        • Moran B.
        • Ulrich A.
        • et al.
        Definition and grading of anastomotic leakage following anterior resection of the rectum: a proposal by the International Study Group of Rectal Cancer.
        Surgery. 2010; 147: 339-351
        • Rahbari N.N.
        • Zimmermann J.B.
        • Koch M.
        • Bruckner T.
        • Schmidt T.
        • Elbers H.
        • et al.
        IVC CLAMP: infrahepatic inferior vena cava clamping during hepatectomy—a randomised controlled trial in an interdisciplinary setting.
        Trials. 2009; 10: 94
      1. Reissfelder C, Rahbari NN, Koch M, Kofler B, Sutedja N, Elbers H, et al. Postoperative course and clinical significance of biochemical blood tests following hepatic resection. Br J Surg. In press.

        • Weitz J.
        • Rahbari N.
        • Koch M.
        • Buchler M.W.
        The “artery first” approach for resection of pancreatic head cancer.
        J Am Coll Surg. 2010; 210: e1-e4
        • Ferrero A.
        • Russolillo N.
        • Vigano L.
        • Sgotto E.
        • Lo T.R.
        • Amisano M.
        • et al.
        Safety of conservative management of bile leakage after hepatectomy with biliary reconstruction.
        J Gastrointest Surg. 2008; 12: 2204-2211
        • Capussotti L.
        • Ferrero A.
        • Vigano L.
        • Sgotto E.
        • Muratore A.
        • Polastri R.
        Bile leakage and liver resection: Where is the risk?.
        Arch Surg. 2006; 141: 690-694
        • Vigano L.
        • Ferrero A.
        • Sgotto E.
        • Tesoriere R.L.
        • Calgaro M.
        • Capussotti L.
        Bile leak after hepatectomy: predictive factors of spontaneous healing.
        Am J Surg. 2008; 196: 195-200
        • Arita J.
        • Hasegawa K.
        • Kokudo N.
        • Sano K.
        • Sugawara Y.
        • Makuuchi M.
        Randomized clinical trial of the effect of a saline-linked radiofrequency coagulator on blood loss during hepatic resection.
        Br J Surg. 2005; 92: 954-959
        • Tanaka S.
        • Hirohashi K.
        • Tanaka H.
        • Shuto T.
        • Lee S.H.
        • Kubo S.
        • et al.
        Incidence and management of bile leakage after hepatic resection for malignant hepatic tumors.
        J Am Coll Surg. 2002; 195: 484-489
        • Ijichi M.
        • Takayama T.
        • Toyoda H.
        • Sano K.
        • Kubota K.
        • Makuuchi M.
        Randomized trial of the usefulness of a bile leakage test during hepatic resection.
        Arch Surg. 2000; 135: 1395-1400
        • Antolovic D.
        • Koch M.
        • Galindo L.
        • Wolff S.
        • Music E.
        • Kienle P.
        • et al.
        Hepaticojejunostomy—analysis of risk factors for postoperative bile leaks and surgical complications.
        J Gastrointest Surg. 2007; 11: 555-561
        • Figueras J.
        • Llado L.
        • Miro M.
        • Ramos E.
        • Torras J.
        • Fabregat J.
        • et al.
        Application of fibrin glue sealant after hepatectomy does not seem justified: results of a randomized study in 300 patients.
        Ann Surg. 2007; 245: 536-542
        • Nagano Y.
        • Togo S.
        • Tanaka K.
        • Masui H.
        • Endo I.
        • Sekido H.
        • et al.
        Risk factors and management of bile leakage after hepatic resection.
        World J Surg. 2003; 27: 695-698
        • Yamashita Y.
        • Hamatsu T.
        • Rikimaru T.
        • Tanaka S.
        • Shirabe K.
        • Shimada M.
        • et al.
        Bile leakage after hepatic resection.
        Ann Surg. 2001; 233: 45-50
        • Lo C.M.
        • Fan S.T.
        • Liu C.L.
        • Lai E.C.
        • Wong J.
        Biliary complications after hepatic resection: risk factors, management, and outcome.
        Arch Surg. 1998; 133: 156-161
        • Bruce J.
        • Krukowski Z.H.
        • Al-Khairy G.
        • Russell E.M.
        • Park K.G.
        Systematic review of the definition and measurement of anastomotic leak after gastrointestinal surgery.
        Br J Surg. 2001; 88: 1157-1168
        • Pratt W.B.
        • Maithel S.K.
        • Vanounou T.
        • Huang Z.S.
        • Callery M.P.
        • Vollmer Jr., C.M.
        Clinical and economic validation of the International Study Group of Pancreatic Fistula (ISGPF) classification scheme.
        Ann Surg. 2007; 245: 443-451
        • Dindo D.
        • Demartines N.
        • Clavien P.A.
        Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey.
        Ann Surg. 2004; 240: 205-213