Bile leakage after loop closure vs clip closure of the cystic duct during laparoscopic cholecystectomy: A retrospective analysis of a prospective cohort

Abstract

Background: Laparoscopic cholecystectomy (LC) is one of the most frequently performed surgical procedures. Cystic stump leakage is an underestimated, potentially life threatening complication that occurs in 1%-6% of the patients. With a secure cystic duct occlusion technique during LC, bile leakage becomes a preventable complication.

Aim: To investigate the effect of polydioxanone (PDS) loop closure of the cystic duct on bile leakage rate in LC patients.

Methods: In this retrospective analysis of a prospective cohort, the effect of PDS loop closure of the cystic duct on bile leakage complication was compared to patients with conventional clip closure. Logistic regression analysis was used to develop a risk score to identify bile leakage risk. Leakage rate was assessed for categories of patients with increasing levels of bile leakage risk.

Results: Of the 4359 patients who underwent LC, 136 (3%) underwent cystic duct closure by a PDS loop. Preoperatively, loop closure patients had significantly more complicated biliary disease compared to the clipped closure patients. In the loop closure cohort, zero (0%) bile leakage occurred compared to 59 of 4223 (1.4%) clip closure patients. For patients at increased bile leakage risk (risk score ≥ 1) rates were 1.6% and up to 13% (4/30) for clip closure patients with a risk score ≥ 4. This risk increase paralleled a stepwise increase of actual bile leakage complication for clip closure patients, which was not observed for loop closure patients.

Conclusion: Cystic duct closure with a PDS loop during LC may reduce bile leakage in patients at increased risk for bile leakage.

Keywords: Bile leak; Cystic duct occlusion; Endo-loop; Laparoscopic cholecystectomy.

Figure 1

Identified risk for a bile leakage complication and bile leakage rate for clip closure and loop closure patients. X-axis: Summarised risk score for bile leakage complication; Y-axis: Percentage of patients with and without bile leakage in loop closure patients and cystic duct closure patients.

Figure 2

Bile leakage complication rate in patients after laparoscopic cholecystectomy for the period with only clip closure of the cystic duct (clip closure only period) and the period after loop cystic duct closure had been introduced (mixed closure period). No risk score: No bile leakage risk according to risk score prediction of Table 2; Risk score ≥ 1: Bile leakage risk score ≥ 1 according to risk score prediction of Table 2.