FROM THE JOURNAL OF THE AMERICAN COLLEGE OF SURGEONS

Bile spillage that happens during laparoscopic gallbladder removal is a known problem, but a large study has put some numbers to quantify the risks to patients.

A research team at Massachusetts General Hospital, Boston, conducted a prospective study of 1,001 such operations to look at the impact of bile spillage. They found that wound infection rates in cases involving bile spillage were almost three times higher than were those without spillage and resulting hospital stays were 50% longer, according to an article in the Journal of the American College of Surgeons .

“This finding is very important, given that laparoscopic cholecystectomy is among the most commonly performed operations and that bile spillage is often overseen as unimportant by many surgeons,” wrote Thomas Peponis, MD , and the research team of Mass General.

The study involved adults who had laparoscopic and laparoscopic converted to open cholecystectomy at the academic hospital during May 2010-March 2017. The latter category accounted for 95 patients, a 9.5% conversion rate. Overall, bile was spilled in 591 patients (59%), with empyema in 86 (8.6%), hydrops in 62 (6.2%), and clear bile spillage in the remainder. Bile spillage along with gallstone spillage occurred in 202 patients (20.2%), with recovery of all spilled gallstones in 145 (71.8%) of those cases.

Overall, the surgical site infection (SSI) rate was 2.4% (n= 8) in patients with no bile spillage vs. 7.1% (n = 30) for those with bile spillage. Median hospital length of stay was 2 days for the nonspillage patients vs. 3 days for those with spillage. The 30-day readmission rates were 5.9% for the nonspillage group vs. 9.6% for the spillage group.

The bile spillage rate in this study was considerably higher than previous studies had reported, the researchers noted. A retrospective study of 1,127 patients reported a spillage rate of 11.6% ( World J Surg . 1999;23:1186-90 ). “One needs to notice that a retrospective review of medical records almost certainly underappreciates the rate of bile spillage,” the investigators wrote. A Mayo Clinic study reported a bile spillage rate of 29% and an increased risk of intra-abdominal abscesses (J Gastrointest Surg . 1997;1:85-90 ). The complex and acute nature of the cases at Mass General may explain their higher spillage rates, the researchers suggested.

This study identifies bile spillage, along with conversion to open surgery and patient ASA class 2 or higher as the only independent predictors of SSI. The study also found no link between empyema and hydrops with SSI, although the small number of cases may preclude an representative sample.

Nonetheless, surgeons must face the question of how to decrease SSI in laparoscopic cholecystectomy with bile spillage, study authors wrote. “First, surgeons should acknowledge that gallbladder perforations and bile spillage come at a price,” they said, “and thus should be cautious and try to avoid them.”

When bile is spilled, liberal peritoneal irrigation may be futile; this study showed similar SSI rates after bile spillage, regardless of peritoneal irrigation. “We could consider modifying perioperative antibiotic coverage,” the investigators wrote, but they acknowledged a need for more research to validate its benefit.

The investigators reported having no financial disclosures.

SOURCE: Peponis T et al. J Am Coll Surg. 2018 Mar 1. doi: 10.1016/j.jamcollsurg.2017.11.025 .

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