Management of Challenging Post-hepatectomy Bile Leakage with Concurrent Bile Duct Stenosis

Purpose Bile leakage remains a serious complication following hepatic resection, with particularly high incidence in procedures involving hilar manipulation. Such cases are often complicated by bile duct strictures, presenting unique management challenges. This study evaluated our institutional experience in managing post-hepatectomy bile leakage, focusing on high-risk procedures and complex cases with concurrent bile duct stenosis. Methods We retrospectively analyzed patients who underwent liver resection without biliary reconstruction between January 2008 and December 2023. Based on established risk factors, patients were stratified into high- and low-risk procedure groups. Treatment approaches and outcomes were compared between groups, with detailed analysis of cases complicated by bile duct stenosis. Results Of 894 patients, 73 (8.0%) developed bile leakage: 45 in the low-risk and 28 in the high-risk group. Approximately 75% of low-risk cases resolved with drainage alone, compared to 52.0% in the high-risk group (P = 0.041). Among patients requiring endoscopic intervention, bile duct stenosis was significantly more common in the high-risk group (63.6% vs. 0%, P = 0.013). Five high-risk cases with concurrent stenosis required complex management, presenting with both proximal and peripheral leakage. These cases were successfully managed using a combination of surgical resection, transarterial embolization, and advanced interventional techniques. Conclusion Post-hepatectomy bile leakage management is particularly challenging in high-risk procedures, frequently complicated by bile duct stenosis. Successful outcomes require accurate characterization of leakage patterns and appropriate selection of therapeutic interventions. Our proposed algorithm emphasizes systematic evaluation and stepwise intervention, including bridging stent placement and alternative approaches for complex cases.