Donkervoort SC, Dijksman LM, van Dijk AH, Clous EA, Boermeester MA, van Ramshorst B, Boerma D. Bile leakage after loop closure vs clip closure of the cystic duct during laparoscopic cholecystectomy: A retrospective analysis of a prospective cohort. World J Gastrointest Surg 2020; 12(1): 9-16 [PMID: 31984120 DOI: 10.4240/wjgs.v12.i1.9]
Corresponding Author of This Article
Sandra C Donkervoort, MD, PhD, Surgeon, Department of Surgery, Onze Lieve Vrouwe Gasthuis, PO-box 95500, Amsterdam 1090 HM, Netherlands. s.c.donkervoort@olvg.nl
Research Domain of This Article
Gastroenterology & Hepatology
Article-Type of This Article
Retrospective Cohort Study
Open-Access Policy of This Article
This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
World J Gastrointest Surg. Jan 27, 2020; 12(1): 9-16 Published online Jan 27, 2020. doi: 10.4240/wjgs.v12.i1.9
Bile leakage after loop closure vs clip closure of the cystic duct during laparoscopic cholecystectomy: A retrospective analysis of a prospective cohort
Sandra C Donkervoort, Lea M Dijksman, Aafke H van Dijk, Emile A Clous, Marja A Boermeester, Bert van Ramshorst, Djamila Boerma
Sandra C Donkervoort, Emile A Clous, Department of Surgery, Onze Lieve Vrouwe Gasthuis, Amsterdam 1090 HM, Netherlands
Lea M Dijksman, Bert van Ramshorst, Djamila Boerma, Department of Research and Epidemiology, St. Antonius Hospital, Nieuwegein 3435 CM, Netherlands
Aafke H van Dijk, Marja A Boermeester, Department of Surgery, Academic Medical Centre, Amsterdam 1105 AZ, Netherlands
Author contributions: Donkervoort SC designed the study and wrote the manuscript; Dijksman LM performed the statistical analysis and deducted a risk score; van Dijk AH collected the data and reference articles; Clous EA collected the data; Boermeester MA helped write the manuscript with emphasis on how to present the findings; van Ramshorst B critically reviewed the presented data; Boerma D co-designed the study and helped write the manuscript.
Institutional review board statement: The subject of this study concerns usual care without an intervention. The study was reviewed and approved by the MEC OLVG Institutional Review Board.
Informed consent statement: The subject of this study concerns usual care without an intervention. An informed consent was not applicable to our study.
Conflict-of-interest statement: The authors declare no conflicts of interest.
STROBE statement: The authors have read the STROBE Statement-checklist of items, and the manuscript was prepared and revised according to the STROBE Statement-checklist of items.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Corresponding author: Sandra C Donkervoort, MD, PhD, Surgeon, Department of Surgery, Onze Lieve Vrouwe Gasthuis, PO-box 95500, Amsterdam 1090 HM, Netherlands. s.c.donkervoort@olvg.nl
Received: June 16, 2019 Peer-review started: June 19, 2019 First decision: August 2, 2019 Revised: October 19, 2019 Accepted: November 20, 2019 Article in press: November 20, 2019 Published online: January 27, 2020 Processing time: 193 Days and 13.4 Hours
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.
Core tip: Laparoscopic cholecystectomy is one of the most frequently performed surgical procedures. Cystic duct leakage is an underestimated, potentially life threatening complication. With a secure cystic duct occlusion technique, bile leakage becomes a preventable complication. Assessing leakage rates for both clipped and looped patients, we found that in clip closure patients, leakage rates increased from 0.9% up to 13% depending upon their bile leakage risk, whereas loop closure patients leakage rates remained 0%, even for patients at highest risk. Cystic duct closure with a polydioxanone loop may well be a secure occlusion technique.
