Causes of Biliary Leak after Cholecystectomy in Rural and Tribal India: A 12-Year Single-Surgeon Experience

Abstract

Background: Biliary leakage is an uncommon but clinically important complication of cholecystectomy. Although most postoperative bile leaks can be managed successfully with timely drainage, endoscopic intervention, or conservative treatment, bile duct and sectoral duct injuries may result in substantial morbidity. Data describing biliary leaks after cholecystectomy in rural and tribal populations in India remain limited. This study evaluated the incidence, causes, timing, clinical presentation, and management of biliary leaks following cholecystectomy in a rural and tribal healthcare setting. Methods: A retrospective observational study was conducted involving consecutive patients who underwent cholecystectomy under the care of a single surgeon at rural and tribal hospitals between January 2011 and December 2022. Demographic characteristics, operative approach, postoperative bile leak, timing of presentation, source of leakage, imaging findings, interventions, and outcomes were obtained from hospital records, operative notes, and follow-up registers. Descriptive statistical analysis was performed. The incidence of bile leak was calculated with a 95% confidence interval, and gender association was assessed using Fisher's exact test. Results: A total of 1,071 cholecystectomies were performed during the study period. There were 407 male patients (38.0%) and 664 female patients (62.0%). Laparoscopic cholecystectomy was performed in 1,026 patients (95.8%), while 45 patients (4.2%) underwent open cholecystectomy. Seven laparoscopic procedures were converted to open surgery. Postoperative bile leakage occurred in 10 patients, giving an overall incidence of 0.93% (10/1,071). Eight of the 10 patients with bile leakage were male (80%) and two were female (20%). The male-specific incidence was 1.97% compared with 0.30% among females (Fisher's exact test, p=0.008). Three leaks were identified intraoperatively, comprising one common bile duct injury and two right sectoral duct injuries. Two patients developed cystic duct stump leaks on postoperative day 1 and were successfully treated with endoscopic retrograde cholangiopancreatography (ERCP). Two patients developed low-output leaks during postoperative days 2–7 and were managed conservatively. Three patients presented after postoperative day 10, including two patients with bile duct-related leaks and one with a bilioma; these patients were managed using combinations of percutaneous drainage and ERCP, including stone extraction and biliary stenting where indicated. No mortality was reported. Conclusion: In this 12-year single-surgeon rural and tribal hospital series, postoperative bile leakage occurred in 0.93% of patients undergoing cholecystectomy. Bile duct and sectoral duct injuries accounted for important intraoperative causes, while cystic duct stump leakage and delayed biliary complications were also observed. Early recognition, appropriate imaging, percutaneous drainage when required, and timely ERCP were associated with favorable outcomes. Adherence to the critical view of safety and strengthening access to biliary imaging and therapeutic endoscopy may further reduce morbidity in resource-limited settings.

Keywords: bile leak; cholecystectomy; laparoscopic cholecystectomy; bile duct injury; ERCP; bilioma; rural India; tribal India; critical view of safety.