Retrospective Cohort Study
Copyright ©The Author(s) 2020. Published by Baishideng Publishing Group Inc. All rights reserved.
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
ARTICLE HIGHLIGHTS
Research background

Laparoscopic cholecystectomy (LC) is one of the most frequently performed surgical procedures. Cystic stump leakage is an underestimated, potentially life threatening complication and still occurs in 1%-6% of the patients. If a secure cystic duct occlusion technique can be found bile leakage becomes a preventable complication and morbidity from LC significantly reduced. With our study we believe to contribute to a reduction in bile leakage rates.

Research motivation

The main topic is cystic stump leakage complication after LC. The key problem is that this complication is underestimated and still occurs in 1%-6% of patients. We can solve this unnecessary complication by finding a secure cystic duct closure technique. As yet data on cystic duct closure technique is scars, using a polydioxanone (PDS) loop has not been described in a significant cohort yet. We find the use of a loop very promising and an interesting topic for future research.

Research objectives

To investigate the effect of PDS loop closure of the cystic duct on bile leakage rate in LC patients and compare bile leakage complication with the conventional clipped closure technique in patients with and without increased bile leakage risk. We show that PDS loop closure is a safe closure technique, as 0% bile leakage complications occurred even in high risk patients; whereas, in clipped closure patients the bile leakage rate increased from 0.9 up to 13%, dependent upon the bile leakage risk. PDS loop closure technique deserves more attention.

Research 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. This is a novel approach to the problem.

Research results

We show that PDS loop closure is a safe closure technique, as 0% bile leakage complications occurred even in high risk patients; whereas, in clipped closure patients bile the leakage rate increased from 0.9% up to 13%, dependent upon the bile leakage risk. PDS loop closure technique deserves more attention. This study contributes to a more secure cystic duct closure technique during LC and can motivate to further investigate this closure technique to increase the level of evidence.

Research conclusions

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

Research perspectives

PDS loop is a potential secure cystic duct closure technique with no bile leakage complication risk even in high-risk patients. A change in cystic duct closure technique has already been implemented in our institution. The conventional clipped closure technique is not used in patients at risk for bile leakage complication. Randomised controlled trial or large prospective multicentre cohort.