Risk identification and technical modifications reduce the incidence of post-cholecystectomy bile leakage: analysis of 5675 laparoscopic cholecystectomies

Abstract

Purpose The main sources of post-cholecystectomy bile leakage (PCBL) not involving major duct injuries are the cystic duct and subvesical/hepatocystic ducts. Of the many studies on the diagnosis and management of PCBL, few addressed measures to avoid this serious complication. The aim of this study was to examine the causes and mechanisms leading to PCBL and to evaluate the effects of specific preventative strategies. Methods A prospectively maintained database of 5675 consecutive laparoscopic cholecystectomies was analysed. Risk factors for post-cholecystectomy bile leakage were identified and documented and technical modifications and strategies were adopted to prevent this complication. The incidence, causes and management of patients who suffered bile leaks were studied and their preoperative characteristics, operative data and postoperative outcomes were compared with patients where potential risks were identified and PCBL avoided and with the rest of the series. Results Twenty-five patients (0.4%) had PCBL (7 expected and less than half requiring reintervention): 11 from cystic ducts (0.2%), 3 from subvesical ducts (0.05%) and 11 from unconfirmed sources (0.2%). The incidence of cystic duct leakage was significantly lower with ties (0.15%) than with clips (0.7%). Fifty-two percent had difficulty grades IV or V, 36% had empyema or acute cholecystitis and 16% had contracted gallbladders. Twelve patients required 17 reinterventions before PCBL resolved; 7 percutaneous drainage, 6 ERCP and 4 relaparoscopy. The median hospital stay was 17 days with no mortality. Hepatocystic ducts were encountered in 72 patients (1.3%) and were secured with loops (54.2%), ties (25%) or sutures (20.8%) with no PCBL. Eighteen sectoral ducts were identified and secured. Conclusion Ligation of the cystic duct reduces the incidence of PCBL resulting from dislodged endoclips. Careful blunt dissection in the proper anatomical planes avoiding direct or thermal injury to subvesical and sectoral ducts and a policy of actively searching for hepatocystic ducts during gallbladder separation to identify and secure them can reduce bile leakage from such ducts.

Incidence, Risk Factors, and Time Trends for Bile Leakage After Cholecystectomy for Gallstone Disease—Results From a Population‐Based Cohort Study

“…However, all patients with bile leakage were considered clinically significant and in need of further treatment with either surgery or ERCP. Other more recent studies on post-cholecystectomy bile leakage, which are smaller in size, report an incidence of bile leakage similar to that of the current study [6,[12][13][14]16].…”

“…Emergent cholecystectomies have also previously been described as a significant risk factor for bile leakage. A study by Nassar et al reported a two-fold higher rate of bile leakage after emergency cholecystectomies [12]. Similarly, Shaik et al described an almost threefold higher rate of bile leakage from the cystic duct in patients undergoing emergent laparoscopic cholecystectomy compared with elective procedures [24].…”

“…A study by Nassar et al. reported a two‐fold higher rate of bile leakage after emergency cholecystectomies [ 12 ]. Similarly, Shaik et al.…”

Incidence, Risk Factors, and Time Trends for Bile Leakage After Cholecystectomy for Gallstone Disease—Results From a Population‐Based Cohort Study

“…However, all patients with bile leakage were considered clinically significant and in need of further treatment with either surgery or ERCP. Other more recent studies on post-cholecystectomy bile leakage, which are smaller in size, report an incidence of bile leakage similar to that of the current study [6,[12][13][14]16].…”

“…Emergent cholecystectomies have also previously been described as a significant risk factor for bile leakage. A study by Nassar et al reported a two-fold higher rate of bile leakage after emergency cholecystectomies [12]. Similarly, Shaik et al described an almost threefold higher rate of bile leakage from the cystic duct in patients undergoing emergent laparoscopic cholecystectomy compared with elective procedures [24].…”

“…A study by Nassar et al. reported a two‐fold higher rate of bile leakage after emergency cholecystectomies [ 12 ]. Similarly, Shaik et al.…”

Successful treatment of a refractory bile leak with endoclips during percutaneous necrosectomy

“… 2 More recently, studies have shown ranges of biliary injury of 0.08% to 0.5%. 1 , 3 , 4 Biliary injury can result in fistulas, peritonitis, or bilomas, as in this case presentation. 3 The risk of bile duct injury increases with certain factors such as emergent admissions, choledocholithiasis, and acute cholecystitis.…”

The incidence, operative difficulty and outcomes of staged versus index admission laparoscopic cholecystectomy and bile duct exploration for all comers: a review of 5750 patients

“…However, this was not associated with a higher Clavien-Dindo classification, a greater risk of requiring re-operation, 30-day readmissions or a higher 30-day mortality rate. Fifty patients with Clavien-Dindo grade 3a complications include an incidence of post-cholecystectomy bile leakage and retained stones which has been presented in detail in previous studies [9,10]. Within these 50 there were also four patients with postoperative collections drained percutaneously, two pneumothoraces (one due to intraoperative iatrogenic diaphragm injury and one from anaesthetic regional nerve blockade) managed by chest drain insertion and two patients with postoperative symptomatic pancreatitis.…”

Incidence, Risk Factors, and Time Trends for Bile Leakage After Cholecystectomy for Gallstone Disease—Results From a Population‐Based Cohort Study

“…However, all patients with bile leakage were considered clinically significant and in need of further treatment with either surgery or ERCP. Other more recent studies on post-cholecystectomy bile leakage, which are smaller in size, report an incidence of bile leakage similar to that of the current study [6,[12][13][14]16].…”

“…Emergent cholecystectomies have also previously been described as a significant risk factor for bile leakage. A study by Nassar et al reported a two-fold higher rate of bile leakage after emergency cholecystectomies [12]. Similarly, Shaik et al described an almost threefold higher rate of bile leakage from the cystic duct in patients undergoing emergent laparoscopic cholecystectomy compared with elective procedures [24].…”

“…A study by Nassar et al. reported a two‐fold higher rate of bile leakage after emergency cholecystectomies [ 12 ]. Similarly, Shaik et al.…”

Successful treatment of a refractory bile leak with endoclips during percutaneous necrosectomy

“… 2 More recently, studies have shown ranges of biliary injury of 0.08% to 0.5%. 1 , 3 , 4 Biliary injury can result in fistulas, peritonitis, or bilomas, as in this case presentation. 3 The risk of bile duct injury increases with certain factors such as emergent admissions, choledocholithiasis, and acute cholecystitis.…”

The incidence, operative difficulty and outcomes of staged versus index admission laparoscopic cholecystectomy and bile duct exploration for all comers: a review of 5750 patients

“…However, this was not associated with a higher Clavien-Dindo classification, a greater risk of requiring re-operation, 30-day readmissions or a higher 30-day mortality rate. Fifty patients with Clavien-Dindo grade 3a complications include an incidence of post-cholecystectomy bile leakage and retained stones which has been presented in detail in previous studies [9,10]. Within these 50 there were also four patients with postoperative collections drained percutaneously, two pneumothoraces (one due to intraoperative iatrogenic diaphragm injury and one from anaesthetic regional nerve blockade) managed by chest drain insertion and two patients with postoperative symptomatic pancreatitis.…”

Incidence, Risk Factors, and Time Trends for Bile Leakage After Cholecystectomy for Gallstone Disease—Results From a Population‐Based Cohort Study

“…However, all patients with bile leakage were considered clinically significant and in need of further treatment with either surgery or ERCP. Other more recent studies on post-cholecystectomy bile leakage, which are smaller in size, report an incidence of bile leakage similar to that of the current study [6,[12][13][14]16].…”

“…Emergent cholecystectomies have also previously been described as a significant risk factor for bile leakage. A study by Nassar et al reported a two-fold higher rate of bile leakage after emergency cholecystectomies [12]. Similarly, Shaik et al described an almost threefold higher rate of bile leakage from the cystic duct in patients undergoing emergent laparoscopic cholecystectomy compared with elective procedures [24].…”

“…A study by Nassar et al. reported a two‐fold higher rate of bile leakage after emergency cholecystectomies [ 12 ]. Similarly, Shaik et al.…”

Successful treatment of a refractory bile leak with endoclips during percutaneous necrosectomy

“… 2 More recently, studies have shown ranges of biliary injury of 0.08% to 0.5%. 1 , 3 , 4 Biliary injury can result in fistulas, peritonitis, or bilomas, as in this case presentation. 3 The risk of bile duct injury increases with certain factors such as emergent admissions, choledocholithiasis, and acute cholecystitis.…”

The incidence, operative difficulty and outcomes of staged versus index admission laparoscopic cholecystectomy and bile duct exploration for all comers: a review of 5750 patients

“…However, this was not associated with a higher Clavien-Dindo classification, a greater risk of requiring re-operation, 30-day readmissions or a higher 30-day mortality rate. Fifty patients with Clavien-Dindo grade 3a complications include an incidence of post-cholecystectomy bile leakage and retained stones which has been presented in detail in previous studies [9,10]. Within these 50 there were also four patients with postoperative collections drained percutaneously, two pneumothoraces (one due to intraoperative iatrogenic diaphragm injury and one from anaesthetic regional nerve blockade) managed by chest drain insertion and two patients with postoperative symptomatic pancreatitis.…”