Percutaneous Transhepatic Biliary Drainage in High-Risk Postoperative Pancreatic Fistula after Pancreaticoduodenectomy

Background and objectives: Postoperative pancreatic fistula (POPF) is one of the most severe complications after pancreaticoduodenectomy (PD), particularly in the presence of high-output fistulas, infection, and radiological evidence of anastomotic dehiscence. Percutaneous transhepatic biliary drainage (PTBD) with external bile diversion may promote fistula healing by reducing intraluminal pressure, microbial exposure, and bile reflux. This study aimed to evaluate the role of PTBD in high-risk POPF management after PD. Methods: Between January 2022 and December 2024, 122 PDs were performed at our center. Seventeen patients (13.9%) developed clinically relevant POPF. Nine were treated conservatively with antibiotics ± percutaneous drainage, while eight met criteria for high-risk POPF (very high output >400 mL/day, positive cultures, CT evidence of dehiscence) and underwent PTBD. Results: In the PTBD group, 7/8 patients (87.5%) achieved fistula resolution with a median of 15 days (IQR: 12-19) from surgery, but only 5 days (IQR 4-6; mean 5.4) after PTBD placement. One patient (12.5%) progressed to Grade C, and 2 (25%) required additional percutaneous drainage. No PTBD-related complications occurred, and follow-up cholangiograms confirmed the absence of bile leaks. Importantly, no biliary fistulas were observed. In the non-PTBD group, 7/9 patients achieved resolution with a median of 19 days (IQR 15-22; mean 18.0); 2 patients (22.2%) progressed to Grade C, and 5 (55.5%) required percutaneous drainage. Conclusions: PTBD with external bile diversion is a safe and effective tool for managing high-risk pancreatic fistulas following PD. By modifying intraluminal pressure and microbial exposure in the child's limb, PTBD significantly promotes fistula healing and may prevent progression to Grade C. Our findings support the incorporation of PTBD into POPF management protocols for selected patients. Larger prospective studies are needed to confirm these results.