Hepaticojejunostomy leak after pancreaticoduodenectomy

TLDR: HJ leak is the second common anastomotic failure after pancreaticoduodenectomy (PD), but only a few studies have focused on this complication and it may be associated with nutritional status, width of common bile duct and surgical procedures.

Abstract: Background: Hepaticojejunostomy (HJ) leak is the second common anastomotic failure after pancreaticoduodenectomy (PD), but only a few studies have focused on this complication. We evaluated the incidence of HJ leak after PD and described its presentation, treatment, and outcome. Methods: Records of 292 consecutive patients who underwent PD between 2007 and 2014 were retrospectively analysed. Clinicopathologic data were compared with patients without HJ leaks, and presentation, radiologic findings, treatment, and outcome of HJ leaks were analysed. Results: HJ leak was identified in 14 (4.8%) patients. Low serum albumin on postoperative day 1 (POD1) was associated with an increased risk, while dilation of common hepatic duct and preoperative biliary decompression were two protected factors. Median postoperative day of diagnosis was 5 (range, 1-15).  Typical clinical signs included bilious drainage in the surgically placed drains, with fever, abdominal pain and leukocytosis. Patients with HJ leaks had more pancreatic fistulas and other complications included Intra-abdominal abscess, wound infection and delayed gastric emptying. 4 (29%) patients were treated operatively, 5 required percutaneous drainage and 5 underwent conservative management. One patient died in hospital, resulting in a mortality of 7%. Conclusion: Hepaticojejunostomy leaks are rare after PD. The complication severity ranges from trivial to life threatening. It may be associated with nutritional status, width of common bile duct and surgical procedures. Surgical interventions are required for more than half of HJ leaks. A good outcome can be expected.