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.