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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 8  |  Issue : 1  |  Page : 15-20

Management of postcholecystectomy biliary leakage: Five-year experience of a tertiary centre in Northeast India


1 Department of Surgery, Downtown Hospital, Guwahati, Assam, India
2 Department of Hepato-Pancreato-Biliary Surgery and Liver Transplant, Downtown Hospital, Guwahati, Assam, India
3 Department of Gastroenterology, Downtown Hospital, Guwahati, Assam, India

Date of Submission24-Sep-2020
Date of Acceptance09-Dec-2020
Date of Web Publication19-Jan-2021

Correspondence Address:
Dr. Anup Kumar Roy
Department of Surgery, Downtown Hospital, Guwahati, Assam
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ssj.ssj_39_20

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  Abstract 

Background: Bile leakage is a well-known serious complication of treatment of gallstones and other procedures on the bile duct. They are important because they are preventable; however, once they occur, they may be associated with considerable morbidity and mortality. This study intends help to get a differentiated point of view of treating bile leak.
Materials and Methods: This was a prospective study. All bile leak cases admitted between August 1, 2015, and July 31, 2020, were examined and the results were noted.
Results: A total of 1485 cholecystectomies were done in the given period. Chronic cholecystitis was the most common indication for surgery. Most leaks were treated conservatively.
Conclusions: Most common site of bile leak was found to be gall bladder bed, duct of Luschka, and other minor bile ducts. Most of the postoperative bile leaks were managed conservatively and by endoscopic procedures, rarely requiring re-operation.

Keywords: Bile leak, cholecystitis, conservative management, postcholecystectomy, prospective study


How to cite this article:
Roy AK, Das NN, Deka UJ. Management of postcholecystectomy biliary leakage: Five-year experience of a tertiary centre in Northeast India. Saudi Surg J 2020;8:15-20

How to cite this URL:
Roy AK, Das NN, Deka UJ. Management of postcholecystectomy biliary leakage: Five-year experience of a tertiary centre in Northeast India. Saudi Surg J [serial online] 2020 [cited 2021 Feb 28];8:15-20. Available from: https://www.saudisurgj.org/text.asp?2020/8/1/15/307420


  Introduction Top


The biliary tract is a complex organ system that performs the simple though vital task of collecting, storing, and delivering bile to the gastrointestinal tract. Diseases of the biliary tract can be extremely painful, debilitating, and occasionally life-threatening. Since its introduction in the late 1980s, laparoscopic cholecystectomy (LC) has rapidly replaced open cholecystectomy as a treatment of choice for symptomatic gallbladder disease.[1] LC does, however, carry an increased risk for biliary tract injury.[2] These injuries occur in 0.2%–0.5% of patients undergoing open cholecystectomy and in 0.5%–2.7% after LC.[3],[4],[5],[6] The seriousness of this complication relates in part of problems of biliary fistula and uncontrolled sepsis and in part to the technical difficulties of successful repair of bile duct injuries.[7],[8] Bile duct injuries are important because they are preventable; however, once they occur, they may be associated with considerable morbidity and mortality.[9],[10] Given that as many as 90% of injuries will not be diagnosed during surgery, a high index of suspicion is required in patients who become unwell in the early postoperative period. Apart from early postoperative complications, there is also a risk of long-term sequelae as strictures of the common bile duct and repeated attacks of cholangitis. In addition, such injuries represent a vast economic burden to the society[11] and mental burden on surgeons and also represent a high rate of medicolegal claims.[12] Treatment for most bile leaks varies from ultrasonography (USG)/computerized tomography (CT)-guided percutaneous drainage, endoscopic retrograde cholangiopancreatography (ERCP), laparoscopic toileting of biliary sepsis, and endoscopic procedures such as stents and endoscopic sphincterotomy, whereas the more severe cases will still need a repair of the common bile duct.[13],[14] This study at hand intends help to get a differentiated point of view of treating bile leak in postcholecystectomy patients and to provide a stringent therapy for satisfactory outcome in postcholecystectomy bile leak patients.


  Materials and Methods Top


A prospective observational study was carried out for 110 cases of postcholecystectomy bile leakage attending the outpatient department (OPD) and Emergency Department of General Surgery, Downtown Hospital, Guwahati, who met the inclusion and exclusion criteria outlined below. After obtaining clearance and approval from the institutional ethics committee, written, informed consent was taken from the patients included in the study. The study was conducted for a period of 5 years from August 1, 2015, to July 31, 2020.

All the cases were managed and followed up under direct supervision of a senior consultant for a minimum period of 1 month.

Inclusion criteria

  • 100 ml bile leak or more
  • Bile leak lasting for 2 days or more in the postoperative period
  • Failure to recover along expected lines postcholecystectomy
  • Complaints of abdominal pain and distension in postoperative period.


Exclusion criteria

  • Patients who had LC converted to open cholecystectomy for any indication other than bile duct injury (e.g., adhesions)
  • Patients who had surgery performed involving the biliary tract other than LC (e.g., liver transplantation)
  • Injuries recognized during surgery and repaired in patients who never came to ERCP
  • Patients unwilling for study.


All the patients who were operated in our institute as well as the patients who were referred from other centres attending the OPD and emergency were evaluated, and the suspected bile leak cases were selected on the basis of history and examination.

Clinical history with reference to indication of surgery, type of surgery, complications, postoperative symptoms, drains used and amount of collections, and personal histories were recorded. All the patients underwent through clinical examination as well as laboratory and radiological investigations. Preoperative preparations including shaving of the part, cutting the nails short, and prophylactic injectable antibiotics (after negative skin test) were given 1 h before surgery. Postoperatively, the patient was discharged on the 3rd day if no complication after dressing and the patient was called on postoperative day 7 for wound inspection. In case any complications occur, it was recorded and treated accordingly.

Further follow-up of the patient was done at 1 month and was further evaluated for any complaints or complications.

The data thus obtained were analyzed using appropriate statistical tests, and conclusions were drawn based on the analysis.

Tools

Direct observations, interview schedule, protocols, tests, examination of medical records, and collection of writing samples were the tools used.

Statistical analysis

Descriptive statistical analysis was carried out in the present study. Results of continuous and categorical measurement are presented on mean and percentage – age, gender, and other variables. Data are presented in charts, table formats, bar diagram, and pie diagram for ease of understanding and interpretation.

Microsoft Office Word 2007 and Microsoft Office Excel 2007 were used to generate table, bar diagram, and pie diagram.


  Observations and Results Top


A total of 1485 cholecystectomies were done in our institute during the study period. Among them, there were 1436 LCs and 49 open cholecystectomies. There were 19 cases of bile leak among LCs. No cases were observed in open cholecystectomy. Rest of the cases were referred to our hospital as it is a tertiary center. The incidences of bile leak for laparoscopic procedure and open cholecystectomies were 1.32% and nil, respectively, so the overall incidence of bile leak following cholecystectomy is 1.28%.

In our study, we evaluated 110 cases of bile leak. In comparison, the incidence of bile leak was found to be higher in the laparoscopic approach. Most patients were seen of the age group 41–50 (39.09%) and 31–40 (25.45%) years, respectively [Table 1]. There were 65.45% females as compared to males (34.55%) [Table 2].
Table 1: Age-wise distribution

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Table 2: Gender-wise distribution

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The most common indication for cholecystectomy was found to be chronic calculus cholecystitis (61.81%) who had bile leak in the postoperative period as compared to patient who underwent cholecystectomy for acute cholecystitis (38.18%) [Figure 1]. Out of 110 cases of bile leak, most cases were operated laparoscopically (76.19%) followed by open method (9.52%) and 14.28% of cases were converted to open method from laparoscopic due to technical difficulties or distorted anatomy. In around 80.95% of cases drains were used during initial surgery which were later used as controlled external biliary fistula in the management of bile leak. Only 19.05% of cases had no history of drains used. Most cases were recognized in the early postoperative period (80%) followed by 16.36% of cases recognized after a week, and only 3.63% of cases of bile leak were diagnosed intraoperatively [Table 3].
Figure 1: Most frequent mode of surgery undertaken

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Table 3: Timing of recognition of bile leak

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Clinically, most of the patients in the present study had abdominal distension (90%) and tachycardia (80%) as their primary complaints. Fifty-five percent of the patients had guarding. Forty percent of cases had abdominal pain, 15% had vomiting, and 10% had fever.

The distribution of radiological evaluation of all 110 biliary leak cases showed the following data: USG whole abdomen was done in 90% cases (99 patients) to look for intra-abdominal collections; magnetic resonance cholangiopancreatography (MRCP) and CT abdomen were done in 44.5% (49 patients) and 24.5% of cases (27 patients), respectively, to look for relevant anatomy and site of leak [Figure 2]a and [Figure 2]b. In this study, 60.9% leak was presumed to be from liver bed injury, duct of Luschka, and other minor accessory bile ducts. Bile leak from common bile duct injury (BDI) was found to be 23.6%, whereas 9.09% of cases had cystic duct stump leak and only 6.36% of cases had injury to common hepatic duct [Figure 3]. Majority of the patients (63.64%) were managed conservatively including drainage of biloma followed 32.7% being managed with ERCP and stenting, whereas in 3.63% of cases, surgical repair in the form of hepaticojejunostomy was done [Figure 4] and [Table 4]. The mortality was found to be 1.81% (2 patients), whereas in most of the patients, recovery was uneventful.
Figure 2: (a) The endoscopic retrograde cholangiopancreatography image of bile leak (b) showing a magnetic resonance cholangiopancreatography image locating the site of bile leak (Type A of Strasberg's classification)

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Figure 3: Percentages of different leak sites

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Figure 4: (a) Intraoperative picture of the site of bile leak, (b) intraoperative picture of repair done for bile leak

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Table 4: Management of bile leak

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  Discussion Top


Gallstones are an extremely common condition, occurring in approximately 10%–20% of the adult population.[15] LC has now replaced open surgery as the “gold standard” in the treatment of symptomatic cholelithiasis and cholecystitis. Currently, about 90% of cholecystectomies are performed using the laparoscopic approach. Postoperative bile duct leaks may occur after any type of surgical procedure involving the biliary tract. Bile collections within the peritoneal cavity have various causes, but most often occur as a manifestation of BDI or some other technical complications of cholecystectomy.

Despite advancements in surgical technology, bile leak continues to pose a significant clinical challenge. Proper diagnosis and appropriate treatment of bile leak are paramount in preventing life-threatening complications of biliary peritonitis, sepsis, and death. In the present study, 110 patients were included who had postcholecystectomy biliary leakage and presented to the Department of General Surgery, Down Town Hospital, Guwahati, between August 1, 2015, and July 31, 2020.

The incidence of bile leak in our study is less (1.28%) compared to the studies conducted by previous Indian published studies of Kishore et al.[16] (study on 10 patients), Baskey et al.[17] (study on 12 patients), and Goswami et al.[18] (study on 20 patients) on postoperative bile leakage following cholecystectomy. It can be attributed to the higher learning curve of the surgeons performing cholecystectomy. Although the incidence is higher than the Western studies,[19] it is more with the laparoscopic approach (1.32%) than open cholecystectomy which is similar to them. Patients were between the age group of 20 and 80 years. Among them, the most commonly affected age groups were 41–50 years (39.09%) and 31–40 years (25.45%). Mean age group was 46.28. In this study, there are 72 (65.45%) females and 38 (34.54%) males. Decamp et al.[20] reported 4:1 female-to-male ratio and Tiwari et al.[21] reported 3:1 female-to-male ratio; however, in our study, female-to-male ratio is 1.8:1 clearly indicating female preponderance.

Maximum number of patients who had bile leak in the postoperative period underwent cholecystectomy (open or laparoscopic) for the indication of chronic cholecystitis (61.81%) as compared to acute cholecystitis (38.18%); thus, chronic cholecystitis was found to be the most common cause of BDI in our study. These are similar to studies by Goswami et al.[18] and Kishore et al.[16] Baskey et al.[17] in their study showed that acute cholecystitis is the most common cause of BDI. This controversy is due to the fact that extensive fibrosis is encountered in chronic cholecystitis during the dissection of Calot's triangle. Moreover, there is increased number of cases of chronic cholecystitis as they delay in approaching for treatment when compared to the Western patients getting the earliest possible treatment.[22] Seventy-six percent of the bile leak cases were operated laparoscopically. 14.28% of laparoscopic cases were converted to open procedure due to distorted anatomy and technical difficulties, and only in 9.5% of the cases, bile leak was during open procedure. The conversion rate of laparoscopic to open procedure in our study is 0.99% which is way lower than the Western study of Genc et al.,[23] 2011 owing to the small sample size of our study compared to theirs.

Eighty-eight percent of the cases were recognized in the early postoperative period (<1 week) followed by 16.36% of cases being detected in the late postoperative period (>1 week). Only 3.63% cases of bile leak were detected intraoperatively from the liver bed and were repaired immediately. Majority of postcholecystectomy biliary leak patients showed clinical features of abdominal distension (90%) and tachycardia (80%) due to biloma. Clinical features of generalized biliary peritonitis with abdominal pain (40%) and guarding (55%) were other major complaints. Vomiting (15%) and fever (10%) were less common. The findings were similar to the studies of Goswami et al.,[18] 2017 and Kishore et al., 2016.[16]

Multidisciplinary approach involving surgeons, hepatobiliary surgeon, and interventional radiologists in management of complications is essential. Ultrasound and CT scan of the abdomen and pelvis were the frequently performed investigations in postoperative biliary leak cases as compared to Karvonen et al., 2007.[24] In few cases, MRCP was used to further delineate the bile duct anatomy and ERCP was done to locate the site of injury. Mostly, type A BDI was encountered in our study which is similar to the study by Strasberg et al., 1995.[25] After stabilizing the patient, all patients were evaluated for site of BDI. The site of BDI was determined to be CHD in 6.36% (7), CBD in 23.6% (26), and cystic duct in 9.09% (10). In this study, the most common site of bile leakage was presumed to be from GB bed, duct of Luschka, and other minor accessory bile duct, which was 60.9% (67) of cases, as it resolved spontaneously after controlled external biliary fistula which is similar to the Indian studies mentioned above.

Conservative treatment in the form of controlled external biliary fistula was considered in 63.64% (70) of patients. Intervention in the form of ERCP and stenting was required for 36.7% of cases (36 patients) which were higher when compared to study by Kishore et al. (24%).[16] Surgical repair in the form of hepaticojejunostomy was done in 3.63% cases which is lower when compared to the study of Goswami et al., 2017.[18] This is due to the fact that most cases of bile leak respond to conservative and endoscopic management well and rarely require surgical repair.

Goswami et al.[18] showed a mortality of 10% (2 patients) compared to our study in which it was found to be 1.81% (2 patients) died of bile peritonitis with sepsis following biliary leak owing to of better understanding and management of bile leaks in the current era.


  Conclusions Top


Because of the frequent and often serious complications associated with a fairly common procedure like cholecystectomy, this study was conducted to determine the effectiveness of various management options and their outcomes in relation to bile leak. The overall incidence was found to be decreasing in the present time, owing to familiarity of surgeons with laparoscopic approaches. Inadequate exposure during surgery was the most important factor for bile duct injuries. Most of the bile leaks were found to be from minor ducts or liver bed and can be managed easily with conservative treatment. Use of intraoperative drains was found to be useful as they can be used as external biliary fistula in case of postoperative bile leaks. Combined conservative and endoscopic methods have bypassed the need of surgery, resulting in decreasing the morbidity and mortality related to bile leaks.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

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Kishore PK, Sruthi BM, Obulesu G. Study of post cholecystectomy biliary leakage and its management. Int Arch Integrated Med 2016;3:228-237.  Back to cited text no. 16
    
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Baskey SC, Rana RS, Bodra P, Malua S. A prospective study of biliary leakage and its management of patients attending tertiary care centre of Jharkhand. IOSR J Dent Med Sci 2016;15:57-62.  Back to cited text no. 17
    
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Karvonen J, Gullichsen R, Laine S, Salminen P, Grönroos JM. Bile duct injuries during laparoscopic cholecystectomy: Primary and long-term results from a single institution. Surg Endosc 2007;21:1069-73.  Back to cited text no. 24
    
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Strasberg SM, Hertl M, Soper NJ. An analysis of the problem of biliary injury during laparoscopic cholecystectomy. J Am Coll Surg 1995;180:101-25.  Back to cited text no. 25
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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