Comment on: Management of bilioenteric anastomosis leakage after major liver resection

Correspondence to: Christian Sturesson (email: christian.sturesson@ki.se)

Department of Clinical Science

Intervention and Technology

Division of Surgery and Oncology

Karolinska Institutet

14152

Stockholm

Sweden

BJS Open, https://doi.org/10.1093/bjsopen/zraf075, published 15 July 2025

We read with interest the study by Dezfouli et al.1 on the management of postoperative leakage from the bilioenteric anastomosis following major liver resection combined with resection of the extrahepatic bile ducts. The authors should be commended for employing a structured protocol to guide intervention for this common complication, which is associated with well-documented morbidity.

The reported leakage rate of the bilioenteric anastomosis is comparable to that in previous reports. In the present study, a strategy of early reoperation was applied in most patients with leakage, resulting in resolution in the majority of cases.

However, patients with anastomotic leakage had a higher 90-day mortality rate (27%) compared with patients without leakage (13.5%) (P = 0.043). We would like to raise the question of whether the high reoperation rate in the present study might have contributed to the increased mortality observed in the leakage group. In a recent multicentre study, the intervention rate (reoperation, percutaneous, or endoscopic biliary drainage) was 5%, compared with 19% in the present study, without any difference in postoperative mortality between groups2. This suggests that a substantial proportion of biliary leakages may resolve with intraperitoneal drainage alone.

We would therefore urge caution regarding overly aggressive early intervention for anastomotic leakage after major liver resection with bilioenteric anastomosis. Providing adequate intraperitoneal biliary drainage to prevent or treat sepsis may be considered as an initial measure, with other interventions postponed until the likelihood of spontaneous healing is excluded and the risk of liver failure has passed—reserving reoperation for patients with signs of unexplained or severe sepsis or peritonitis.