Transient Biliary Fistula After Pancreatoduodenectomy Increases Risk of Biliary Anastomotic Stricture



Biliary fistula after pancreatoduodenectomy (PD) is associated with significant morbidity and mortality. The aim of this study was to determine the risk of early postoperative biliary fistula for developing biliary anastomotic stricture after PD.


Retrospective review of all PD performed for various indications at a single institution between 2013 and 2018. Postoperative biliary fistulae were graded according to the International Study Group of Liver Surgery (ISGLS) as grade A–C. Multivariable analysis was performed for all comparative patient subgroups.


A total of 843 patients underwent PD for malignant (68%) and benign (32%) indications. Postoperative biliary fistula developed in 66 (8%) patients; ISGLS grade A in 29 (3%), grade B in 32 (4%), and grade C in 5 (0.6%). Ninety-day mortality was 3% (25 patients). The remaining 818 patients were evaluated with a median follow-up of 16 months (IQR, 5–32 months). Biliary anastomotic stricture developed in 41 (5%) patients at a median of 10 months (IQR, 6–18 months) postoperatively. Strictures were managed with percutaneous (27 patients, 66%) or endoscopic (14 patients, 34%) stenting. No biliary stricture required operative anastomotic revision. Postoperative biliary fistula (HR, 4.4; 95% CI, 2.0–9.9; P = 0.0002) was associated with biliary anastomotic stricture; an increased risk for biliary anastomotic stricture was seen in patients with grade A (HR, 6.4; 95% CI, 2.4–16.9; P = 0.0002) and grade B (HR, 3.6; 95% CI, 1.2–10.9; P = 0.02) postoperative biliary fistula.


Postoperative biliary fistula after pancreatoduodenectomy, including clinically insignificant, transient biliary fistula, is associated with an increased risk of a late biliary anastomotic stricture requiring stenting.

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Author information




TKM, AJL, KFF, and RES were involved in the conception of the project, acquisition, analysis, and interpretation of data, and drafting and revising the work. MGH serves as the mentor and corresponding author for the work and was involved in the conception, interpretation, revision, and final approval of the work; MGH agrees to be accountable for the work. EPC, AN, TKN, CMS, NJZ, were involved in the conception of the project, revision of the work, and final approval.

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Correspondence to Michael G. House.

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Maatman, T.K., Loncharich, A.J., Flick, K.F. et al. Transient Biliary Fistula After Pancreatoduodenectomy Increases Risk of Biliary Anastomotic Stricture. J Gastrointest Surg 25, 169–177 (2021).

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  • Anastomosis, surgical
  • Anastomotic leak
  • Biliary tract surgical procedures
  • Pancreaticoduodenectomy
  • Choledochostomy