Published online Sep 27, 2018. doi: 10.4240/wjgs.v10.i6.57
Peer-review started: August 3, 2018
First decision: August 8, 2018
Revised: August 18, 2018
Accepted: August 28, 2018
Article in press: August 28, 2018
Published online: September 27, 2018
Processing time: 54 Days and 0.4 Hours
Cystic duct leakage (CDL) is reported in laparoscopic cholecystectomy (LC) in 0.5%-3% of patients, and is even reported to increase to up to 4%-7% in patients with complicated gallstone disease.
Although CDL is classified as a minor injury of the bile ducts, it is associated with significant morbidity and even mortality, so adequate closure of the cystic duct is essential to prevent CDL.
Several techniques are used during cholecystectomy to close the cystic duct, but it is currently unknown which technique has the lowest rate of CDL. The aim of this systematic review was to assess the risk of CDL and the CDL rate for different techniques of cystic duct closure after LC, both in uncomplicated and complicated gallbladder disease.
A systematic review and meta-analysis was performed according to PRISMA guidelines. A search of MEDLINE, Cochrane and EMBASE was done. Studies were eligible for conclusion when patients underwent cholecystectomy and methods of closure of the cystic duct were described. The primary outcome was leakage of the cystic duct. The risk of bias was evaluated with the MINORS score for non-randomized studies and the Cochrane Library guide for the randomized studies. Odds ratios were analyzed for comparison of techniques and pooled event rates for non-comparative analyses. Pooled event rates were compared for each of included techniques.
A total of 1491 articles were found by searching the databases. Out of 1491 articles 102 full texts were screened and 38 articles included. A total of 47491 patients were included, of which 38683 (81.5%) underwent cystic duct closure with non-locking (metal) clips. All studies were of low-moderate methodological quality. Only two studies reported separate data on uncomplicated and complicated gallbladder disease. For overall CDL, an odds ratio of 0.4 (95%CI: 0.06-2.48) was found for harmonic energy vs clip closure and an odds ratio of 0.17 (95%CI: 0.03-0.93) for locking vs non-locking clips. Pooled CDL rate was around 1% for harmonic energy and metal clips, and 0% for locking clips and ligatures.
Based on the available evidence as appraised in this systematic review it is not possible to either recommend or discourage any of the techniques for cystic duct closure during LC with respect to CDL. The data do point out a slight preference for locking clips and ligatures vs harmonic energy or (non-locking) metal clips. This is the first systematic review on methods of cystic duct closure that focuses on CDL. As CDL is an important and potentially serious complication of cholecystectomy, this subject should warrant further research.
It is interesting to see that no separate recommendation could be made for complicated gallbladder disease as subgroup analysis was not possible due to a lack of reported data per subgroup of complicated and uncomplicated gallbladder disease. It could be hypothesized that cystic duct closure is especially important in these patients and that data on this subject would be readily available. Future research should therefore focus on good quality evidence from high sample size trials that include patients with both uncomplicated and complicated gallstone disease.