Cystic Duct Stump Leaks After the Learning Curve

Objectives: To describe a series of patients who have had cystic duct stump leaks ( CDSLs) after laparoscopic cholecystectomy and to compare the current presentation and management with that in previous studies. Design: Two-institution retrospective case series and review of the previously published literature. Setting: Two teaching hospitals. Patients: Twelve patients who had CDSLs of 5751 patients who underwent total laparoscopic cholecystectomy. Main Outcome Measures: Symptoms at presentation, laboratory values, imaging modalities, treatment modalities, and operative indications and techniques. Results: Between January 1, 1998, and March 31, 2007, 12 patients ( 0.21%) developed CDSLs a mean of 2.3 days postoperatively. Five patients ( 42%) were reported to have abnormal cystic ducts. A mean of 3 surgical clips were used for closure. Abdominal pain ( 58%) was the most common presenting symptom; 9 patients ( 75%) had an elevated white blood cell count, and 9 ( 75%) had abnormal liver function test results. Ten patients ( 83%) underwent endoscopic retrograde cholangiopancreatography ( ERCP), and 8 ( 67%) were definitively treated with ERCP stenting of the common bile duct. Two patients ( 17%) required adjunctive computed tomography guided drainage. There was 1 death. Conclusions: A CDSL can occur for a variety of reasons. Any patient with a postoperative picture consistent with a bile leak should undergo ERCP. If a CDSL is discovered, the common bile duct should be stented. Computed tomography-guided drainage is indicated if the patient does not improve after ERCP. Operative intervention should be reserved for the most serious of circumstances.