Biomedical Research

DOI: 10.4066/biomedicalresearch.29-17-2123

Letter to the Editor

Undoubtedly, laparoscopic cholecystectomy (LC) has become a “golden standard” for majority of cholethiasis. But cystic duct stump leakage with high-volume flow after LC will replete with challenge due to potential risks of acute peritonitis’s or even septic shock.[1] The possible causes of the complication include three aspects in my view of points:

A. Improper closure of cystic duct remnant: Generally, unskilled surgeons more likely lead to it in early learning curve (i.e. incomplete “naked” Calot triangle or undesired diathermy burn of cystic duct) [2].

B. Secondary to further inflammatory necrosis: Even for senior surgeons, the potential risks of closure-loosen of cystic duct stump occurs in a delayed time due to regional infection worsens or local edema reduced.

C. Distal occlusion to cystic duct: Residual stones including interwall stone of cystic duct stump and common bile duct stone may increase cystic duct pressure through bile accumulation and refluxing of intestinal juice.

In any way, the key to success is to early identify the etiology and make preliminary evaluation on severity of bile leakage. Computed tomography of abdomen and MRCP are essential to help better assessment-making of cystic duct stump. Whatever you found, timely adequate drainage of abdominal fluid accumulation really does matter to avoid reoperation. It's very important to place nasobiliary tube that is favorable with decompression of bile duct [3]. Ultrasound-guided percutaneous catheter drainage is also an essential practical step to improve symptoms of biliary peritonitis’s. Otherwise, patients' loss may outweigh their gain on the initial goal of minimally invasive surgery and cosmetic advantage. If possible, residual stones might be removed by using spy-glass tool. The conservative therapeutic period usually needs 4~6 w to promise natural complete closure of cystic duct stump by itself.

Overall, severe cystic duct stump leakage can be complete cured if making an early, dual-channel drainage mentioned above.

References

1. Mehmedovic Z, Mehmedovic M, Hasanovic J. A rare case of biliary leakage after laparoscopic cholecystectomy-diagnostic evaluation and nonsurgical treatment: a case report. Acta Informatica Medica 2015; 23: 116.
2. Eisenstein S, Greenstein A J, Kim U. Cystic duct stump leaks: after the learning curve. Arc Surg 2008; 143: 1178-1183.
3. Himal HS. The role of ERCP in laparoscopic cholecystectomy-related cystic duct stump leaks. Surg Endosc 1996; 10: 653-655.