腹腔鏡下胆嚢摘出術後の胆汁漏：経胆嚢管的器械使用および胆嚢管閉鎖法との関連

Cystic duct (CD) leaks represent the most usual form of bile leak (BL) after laparoscopic cholecystectomy (LC). Adequate closure of the CD stump is therefore essential. Titanium clips (TC) are the most frequently used method; however, alternative techniques such as extracorporeal ties (ET) or locking polymeric clips (LPC) may be required in cases of large CD diameter or when its integrity is compromised. The aim of this study was to evaluate the association between CD closure method, transcystic instrumentation (TCI), and the occurrence of BL after elective LC.

A retrospective analysis of all elective LC performed between May 2014 and May 2024 was conducted. Patients requiring procedures beyond TCI (including preoperative ERCP, choledochotomy, biliary-enteric anastomosis) were excluded. All procedures followed the principles of safe cholecystectomy. Data were obtained from a prospectively maintained database.

2,910 patients (95.5%) met inclusion criteria. CD closure methods were TC in 2,332 patients (80.1%), ET in 543 (18.7%), laparoscopic sutures in 26 (0.9%), and LPC in 9 (0.3%). Eight BL were identified (0.27%). TCI was required in 466 patients (16.0%). In the TCI subgroup, the most frequently used closure method was ET in 266 patients (57.1%). The incidence of BL was higher in patients who underwent TCI compared with those who did not (0.86 vs 0.16%; OR 5.28, 95% CI 1.32-21.19; Fisher's exact test p = 0.018). No significant association was found between BL and the method of CD closure, either in the overall cohort or in the TCI subgroup.

TCI was associated with a higher incidence of BL, with no difference detected across CD closure methods, although analyses were underpowered. These findings do not argue against TCI itself, but rather underscore the importance of careful technique, minimization of ductal trauma and of appropriate selection of the CD closure method.