Rajeev Sinha1, Sharad Chandra. 1. Department of Surgery, M.L.B. Medical College, Jhansi, Uttar Pradesh, India. sinha_rga@yahoo.co.in
Abstract
BACKGROUND: Leakage from the clipped cystic duct stump (cystic duct stump leak [CDSL]) as a cause of biliary peritonitis has not been emphasized enough. It deserves special mention because it is not an uncommon cause and it is easier to treat. With the advent of laparoendoscopic single-site (LESS) cholecystectomy, its occurrence in relation to other causes of biliary peritonitis needs reexamination. SUBJECTS AND METHODS: Details of 756 patients undergoing LESS cholecystectomy were analyzed, and patients presenting with biliary peritonitis were identified. The investigative profile included an ultrasound, contrast-enhanced computed tomography scan, and endoscopic retrograde cholangiopancreatography (ERCP) to identify the site of leak. The management in addition to stenting included abdominal tube drainage. RESULTS: There were 5 (0.66%) patients, all female, with biliary peritonitis, and 4 of them (0.53%) had cystic stump leakage as identified by ERCP. The usual time of presentation was in the first week after surgery, with acute abdominal pain and vomiting. Common bile duct stenting was carried out, after choledocholithotomy where required, at the same ERCP session. Tube abdominal drain was required in 2 patients, and 1 patient had to undergo exploratory laparotomy for an associated acute intestinal obstruction. All the patients recovered completely. The stent was removed between 4 and 6 weeks after ERCP. CONCLUSIONS: Effective CDSL management requires early recognition and management. ERCP is the cornerstone for correct identification, and common bile duct stenting was curative in all patients.
BACKGROUND: Leakage from the clipped cystic duct stump (cystic duct stump leak [CDSL]) as a cause of biliary peritonitis has not been emphasized enough. It deserves special mention because it is not an uncommon cause and it is easier to treat. With the advent of laparoendoscopic single-site (LESS) cholecystectomy, its occurrence in relation to other causes of biliary peritonitis needs reexamination. SUBJECTS AND METHODS: Details of 756 patients undergoing LESS cholecystectomy were analyzed, and patients presenting with biliary peritonitis were identified. The investigative profile included an ultrasound, contrast-enhanced computed tomography scan, and endoscopic retrograde cholangiopancreatography (ERCP) to identify the site of leak. The management in addition to stenting included abdominal tube drainage. RESULTS: There were 5 (0.66%) patients, all female, with biliary peritonitis, and 4 of them (0.53%) had cystic stump leakage as identified by ERCP. The usual time of presentation was in the first week after surgery, with acute abdominal pain and vomiting. Common bile duct stenting was carried out, after choledocholithotomy where required, at the same ERCP session. Tube abdominal drain was required in 2 patients, and 1 patient had to undergo exploratory laparotomy for an associated acute intestinal obstruction. All the patients recovered completely. The stent was removed between 4 and 6 weeks after ERCP. CONCLUSIONS: Effective CDSL management requires early recognition and management. ERCP is the cornerstone for correct identification, and common bile duct stenting was curative in all patients.
Authors: Aafke H van Dijk; Stijn van Roessel; Philip R de Reuver; Djamila Boerma; Marja A Boermeester; Sandra C Donkervoort Journal: World J Gastrointest Surg Date: 2018-09-27