Bile Leak Following Cholecystectomy

Jason T Ryan, MD, Saad A Shebrain, MBBCh, MMM, Leandra H Burke, MPA, Evan J White, BS, Colleen L MacCallum, MS. WMU School of Medicine

OBJECTIVE: Bile leak is a dreadful complication after cholecystectomy, and can be associated with significant morbidity, and potential mortality, if not treated. We hypothesized that identifying risk factors, both patient-related and surgeon-related, associated with increased risk of this problem in patients undergoing cholecystectomy, could help in risk stratification to reduce the incidence and subsequent sequelae of this problem.

METHODS AND PROCEDURES: From January 2011 to December 2013, a total of 1,617 patients underwent cholecystectomy for various reasons at two community hospitals. Twenty-six patients (1.6%) developed bile leak (BL), of which 22 patients (92%) had laparoscopic cholecystectomy. The BL group was temporarily matched to 28 patients who did not develop bile leak (NBL) during the same period. The demographic and clinicopathologic characteristics, intraoperative and postoperative variables, comorbidities, and the length of hospital stay were reviewed retrospectively and analyzed in the BL group and then between the BL and NBL groups.

RESULTS: There were no significant differences between BL and NBL groups in regard to demographics: Age (50 ± 18 vs. 48 ± 20 years, p=0.8); gender (73% vs. 64% females, p=0.56); BMI (32±6.3 vs. 30±6 Kg/m2, p=0.28); and number of comorbidities (average 2 in each group, p=0.7), respectively. Intraoperative time was similar in both groups (63 ±45 vs. 59±35 minutes, p=0.9). There were no significant differences between the groups when the procedure was performed by the attending as the primary surgeon (p=0.17). However, there was a slight trend of increased bile leak when the procedure was performed by junior vs. senior residents as primary surgeons (p=0.09 vs. p=0.12). Chronic cholecystitis and cholelithiasis were the most common pathology in both groups (p=0.10). Abnormal anatomy was higher in the BL group [27% (7/26) vs. 7% (2/28), p=0.07]. The mean length of stay was higher in the BL group (average 8 days vs. 1.5 days, p=0.0119). Ninety-two percent of patients in the BL group had laparoscopic vs. open cholecystectomy, compared to 100% of the NBL group (p=0.2),but this could be explained by the fact that laparoscopic procedure is the most commonly performed in this era of minimally invasive biliary surgery. Twenty patients (77%) in the BL group underwent post-operative interventions to manage the bile leak, including ERCP, stent placement, and/or sphincterotomy.

CONCLUSION: Determining risk factors for bile leaks remains difficult. However, our review showed that bile leak is higher when there is abnormal biliary anatomy, although not statistically significant. In addition, there is a slight trend upward in the incidence of bile leak when junior residents performed cholecystectomies as primary surgeon. Vigilant understanding of the biliary anatomy and meticulous surgical procedure are important factors that could reduce this complication. The length of stay in the BL group was significantly longer than in the NBL group.