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Date of last update: 8/19/2017.

Forum Name: Surgery Topics

Question: When can i stop worrying about a bile leak after surgery

 contramundum18 - Tue Jul 20, 2010 12:14 am

I had a planned Cholecystectomy on 7/7/10 , i have had no complications and generally feel good.I am curious about the clips left in after the surgery.How long does it take scar tissue to form over these clips and if no tissue does, how long does it take for the bile duct to deal itself?I am nervous that a clip is going to migrate or slip off and i will have a leak, the surgeon did not explain if the bile duct seals itself off after awhile.

My second question is weather or not the cystic artery was cauterized, i have a clip on the artery as well but what would happen if that clip came loose, would i have significant bleeding inside?
 Dr.M.Aroon kamath - Mon Jul 26, 2010 11:00 am

User avatar Hi,
When exactly the scar tissue will form deep inside the body cavities in relation to structures that have been traumatized is difficult to answer as it may depend on a number of variables.

But, i will try to provide you with some information about the clips that are routinely used nowadays during laparoscopic cholecystectomy procedures.

Clips in common use can be
- non-absorbable(titanium) or
- absorbable(biodegradable polydioxanone-PDS).

Clips may also be,
- simple clips(non-locking), or
- the newer 'locking' absorbable clips

Clip applicators can be
- single clip delivering applicators or
- the newer multiple fire clip applicators.

The advantage of the multiple fire clip applicators is mainly that multiple clips may be applied one after the other without multiple instrument changes.Whereas, for the single clip delivering applicators, following one clip application, the applicator needs to be brought out of the abdomen, re-loaded and re-inserted(often multiple times).This has the potential for causing unintended trauma(including to the bile duct or cystic duct).

Cystic duct leak is an infrequent but potentially serious complication of open or laparoscopic cholecystectomy. Several studies indicate that incidence of cystic duct leak using simple clips is approximately 0.11–2%. Locking clips are reported to be a safe and effective means for cystic duct closure. The incidence of bile leaks associated with simple metallic clips appears to be about five times greater than those associated with locking absorbable clips.

Factors that may increase the risk of clip slippage are,
- selection of incorrect size of clip for the vessel or cystic duct
(selected clip too small),
- failure of clip to project beyond the whole width of the vessel or duct,
- clip that is not applied at right angles to the vessel or duct,
- clip includes fat or adventitial tissue around the vessel,
- clip subjected to undue traction.

The correctly applied clips generally are said to offer a pressure between 450 and 700 mbar. Clips with pressure less than 100 mbar are not tight enough and may slip off.

Post-cholecystectomy clip migration (PCCM): is rare and can lead to complications which include clip-related biliary stones.

It is suggested that metallic clips can migrate from their initial location at various intervals within the peritoneal cavity or into the common duct and serve as a nidus for biliary stone formation. Metallic clip migration in most cases is due to technical factors and can usually be prevented. However, it is not always possible to prevent clip migration in every case, since even well applied clips are known to migrate due to local ischemic damage or local suppuration.

You are well past the risk of a reactionary hemorrhage. As the surgery seems to have been uneventful, hopefully you should do well. In any individual who undergoes biliary surgery, occurrence of late biliary complications and the risks such as clip migration can not be predicted.I hope this information is helpful.
Good luck!

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