Cystic duct leak after laparoscopic cholecystectomy

Background: Cystic duct leak is a rare complication of laparoscopic surgery. To study the incidence, presentation, and management of cystic duct leak (CDL) after laparoscopic cholecystectomy (LC) a retrospective study of centers doing large numbers of LC was done. Methods: Patient information was obtained by a questionnaire sent to experienced laparoscopic surgeons. This queried demographic information, course of the original operation, presentation, diagnostic studies, and management of CDL after LC. Results: Some 22,165 LCs were performed by 24 surgeons; there were 58 cases of CDL (0.26%); 21% of the surgeons reported no CDLs; 60% of CDLs occurred in the first 25% of each surgeon's experience, but CDLs continue to occur even in their most recent 10% of cases. Preoperative symptoms, prior surgery, and comorbid conditions did not predict CDL. Acute cholecystitis was present at initial surgery in 47%. Symptoms of CDL an average of 3.1 days post-LC were abdominal pain 78%, fever 26%, nausea 35%, vomiting 22%, abdominal distention 26%, and shoulder pain 12%. WBCs and LFTs were elevated in more than two-thirds of the cases. ERCP was most frequently used to diagnose CDL (53%) and was successful in 97%, although sonogram (40%) and HIDA scan (26%) and CT (26%) were also used. Management included ERCP and ductal decompression in 27 patients, percutaneous drainage in 13 patients, open laparotomy in 14, laparoscopy in three, and observation in two. Patients were discharged an average of 7.4 days post discovery of leak. Stents were removed an average of 30 days post ERCP. Ninety-four percent were complete cures. There was one post-treatment abscess. Two deaths due to multisystem failure unrelated to leak occurred. Conclusions: Cystic duct leak is rare and fairly easily diagnosed. It occurs more frequently during the learning curve, but also after much experience. ERCP and ductal decompression play a large role in treatment, but almost all standard methods of treatment yield successful outcomes with low morbidity.