Pure biliary leak vs. pancreatic fistula associated: non-identical twins following pancreatoduodenectomy

Background: Biliary leak (BL) after pancreatoduodenectomy (PD) may have diffrent severity depending on its association with postoperative pancreatic fistula (POPF).Methods: Data of 2715 patients undergoing PD between 2011 and 2020 at two European third-level referral Centers for pancreatic surgery were retrospectively reviewed. These included BL incidences, grading, outcomes, specific treatments, and association with POPF. Results: BL occurred in 6% of patients undergoing PD. Among 143 BL patients, 47% had an asso-ciated POPF and 53% a pure BL. Major morbidity (64% vs 36%) and mortality (19% vs 4%) were higher in POPF-associated BL group (all P< 0.01). Day of BL onset was similar between groups (POD 2 vs 3; P = 0.2), while BL closure occurred earlier in pure BL (POD 12 vs 23; P < 0.01). Conservative treatment was more frequent (55% vs 15%; P < 0.01), and the rate of percutaneous and/or trans-hepatic drain placement was lower (30% vs 16%; P = 0.04) in pure BL group. Relaparotomy was more common in POPF-associated BL group (42% VS 17%; P < 0.01) but was performed earlier in pure BL (POD 2 vs 10; P = 0.02).Conclusions: Pure BL represents a more benign entity, managed conservatively in half of the cases.