Deng Shirley X, Greene Brittany, Habbel Christopher, Bubis Lev, Tsang Melanie E, Jayaraman Shiva
Division of General Surgery, University of Toronto, Toronto, ON Canada.
HPB Service, St. Joseph's Health Centre, Unity Health Toronto, ON, Canada.
Ann Surg. 2025 Apr 29. doi: 10.1097/SLA.0000000000006744.
Minimally invasive subtotal cholecystectomy is safe alternative to minimally invasive cholecystectomy that prevents bile duct injury. Nonetheless, it is associated with higher rates of other complications, namely post-operative bile leak and symptomatic remnant cholelithiasis.
Bile leak presents as biloma requiring drainage and subsequently high bilious drain output. It is more strongly associated with fenestrating subtotal cholecystectomy. Fortunately, the majority are self-limited and do not require endoscopic intervention. Symptomatic remnant cholelithiasis presents as recurrent gallstone disease post-operative cholecystectomy.
In this paper, we review available literature on these two complications and share our institutional algorithm on the management of bile leak.
Our approach to bile leak advocates for intra-operative drain placement, early characterization of the leak, watchful waiting, the use of sinogram, and reserving ERCP and stenting for high-grade leaks or refractory cases. Symptomatic remnant cholelithiasis is more strongly associated with reconstituting subtotal cholecystectomy, particularly in cases where the gallbladder stump is long or stones are not completely evacuated from the remnant. This complication should be treated with completion cholecystectomy when possible, but can also be managed with gallbladder-preserving choleystolithomy in patients with aberrant biliary anatomy and/or significant comorbidities. Completion cholecystectomy is a technically challenging operation that benefits from hepatopancreaticbiliary expertise and intra-operative adjuncts such as near-infrared fluorescent cholangiography or intra-operative cholangiogram.
Minimally invasive subtotal cholecystectomy effectively prevents bile duct injury but at the expense of increased post-operative morbidity; it is a bailout strategy that should be used judiciously.
微创次全胆囊切除术是预防胆管损伤的一种安全的微创胆囊切除术替代方法。尽管如此，它与其他并发症的发生率较高相关，即术后胆漏和有症状的残余胆结石。
胆漏表现为需要引流的胆汁瘤，随后胆汁引流量高。它与开窗式次全胆囊切除术的相关性更强。幸运的是，大多数胆漏是自限性的，不需要内镜干预。有症状的残余胆结石表现为胆囊切除术后复发性胆结石疾病。
在本文中，我们回顾了关于这两种并发症的现有文献，并分享了我们机构关于胆漏管理的算法。
我们处理胆漏的方法主张术中放置引流管、早期明确漏口特征、密切观察、使用造影图，并为高级别漏口或难治性病例保留内镜逆行胰胆管造影（ERCP）和支架置入术。有症状的残余胆结石与重建次全胆囊切除术的相关性更强，特别是在胆囊残端较长或结石未从残余部分完全清除的情况下。这种并发症应尽可能通过完成胆囊切除术治疗，但对于胆管解剖异常和/或有严重合并症的患者，也可采用保留胆囊的胆囊结石切除术进行处理。完成胆囊切除术是一项技术上具有挑战性的手术，受益于肝胰胆专业知识和术中辅助手段，如近红外荧光胆管造影或术中胆管造影。
微创次全胆囊切除术有效预防胆管损伤，但以术后发病率增加为代价；它是一种应谨慎使用的补救策略。
