Biliary Leakage After Hepatobiliary and Pancreatic Surgery: A Classification System to Guide the Proper Percutaneous Treatment

  • Giancarlo Mansueto
  • Francesco Lorenzo GattiEmail author
  • Enrico Boninsegna
  • Simone Conci
  • Alfredo Guglielmi
  • Alberto Contro
Clinical Investigation Biliary
Part of the following topical collections:
  1. Biliary



To investigate the effectiveness of percutaneous approaches to treat bile leak and to propose an anatomical classification of biliary fistula to guide the most appropriate percutaneous approach.

Materials and Methods

Fifty-six patients with bile leakage after hepatobiliary surgery were included. Based on preoperative images and postoperative fistulogram images, three categories of bile leakage were defined. Every category was treated with non-surgical approaches (internal–external percutaneous drainage, percutaneous/endoscopic biliodigestive anastomosis with rendez-vous technique and biliodigestive percutaneous anastomosis with totally radiologic rendez-vous).


In 44/56 (78%) patients, anatomical conformation was “direct communication” (bile ducts upstream from the leak present a direct communication with downstream ducts) and their treatment was conventional percutaneous drainage. In 5/56 (9%), anatomical conformation was “indirect communication” (bile ducts upstream from the leak communicate with downstream ducts through a bile collection) and treatment was percutaneous/endoscopic rendez-vous technique. In 7/56 (12%), anatomical conformation was “no communication” (ducts upstream from the leak are completely excluded from ducts downstream) and treatment was totally radiologic rendez-vous. In 54/56 (96%) during the follow-up, cholangiography revealed complete resolution of the leak without residual stenosis and drains were removed. Complications occurred in 12/56 (21%). Procedure-related mortality was 0%. Ten patients, after > 6 months from resolution of their fistula and drain removal, died due to cancer recurrence. Currently, 44/56 patients (77%) at long-term follow-up (> 12 months) are alive, without bile leak.


Our classification helps to choose the most proper percutaneous approach in all kinds of bile leakage, even in severe cases; these are safe techniques with a high success rate.


Biliary fistula Neoplasms Cholangiography Drainage Biliary tract diseases 



Percutaneous transhepatic biliary drainage


International Study Group of Liver Surgery


Computed tomography



This study was not supported by any funding.

Compliance with Ethical Standards

Conflict of interest

The authors declare that they have no conflict of interest.

Consent for Publication

Consent for publication was obtained for every individual person’s data included in the study.

Human and Animal Rights and Informed

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards.

Informed Consent

Informed consent was obtained from all individual participants included in the study.


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Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature and the Cardiovascular and Interventional Radiological Society of Europe (CIRSE) 2019

Authors and Affiliations

  1. 1.Department of RadiologyUniversity of VeronaVeronaItaly
  2. 2.Department of SurgeryUniversity of VeronaVeronaItaly

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