Bile leaks after cholecystectomy: the significance of patient selection

A retrospective analysis of laparoscopic and open cholecystectomies, with introduction of selection criteria and estimation of postoperative bile leaks.

All patients who underwent cholecystectomy in a tertiary surgical unit from January 2007 to June 2008 formed 2 categories, laparoscopic and open. The choice of operation was based on patient's present status and past medical history, whereas the decision to convert came from intraoperative findings. All surgeons were experienced in both open and laparoscopic surgeries.

Laparoscopic cholecystectomy was initially attempted in 230 patients. In 218 of these patients, cholecystectomy was accomplished laparoscopically (group A), whereas in 12 laparoscopic was converted to open cholecystectomy (group B). In 36 patients open cholecystectomy was the first choice according to predecided criteria (group C). Patients of groups B and C were older (P=0.0001), presented higher incidence of cholecystitis (P=0.0001), and required longer postoperative hospitalization (P=0.0001) compared with patients of group A. Postoperative bile leak was evident in 8 patients; no patient from group A, 2 patients from group B, and 6 patients from group C. Patients with bile leak were older (P=0.0001), they required a longer hospitalization (P=0.0001), and cholecystitis was more frequent (P=0.007). Regarding treatment followed, 4 patients required no intervention, whereas 1 required computed tomography-guided drainage of a biloma. Two patients with persistent bile leak, required stenting of the common bile duct with endoscopic sphincterotomy, whereas one, suffering from common bile duct injury, was cured with hepatojejunostomy.

The study highlights the significance of patient selection based on clinical criteria with respect to the type of operation performed. It seems that when patients are selected for laparoscopy according to carefully chosen criteria, the expected postoperative bile leaks could be minimal.