Evaluation of Surgical Site Infection in Bile Spillage Cases Compared to Non-Bile Spillage Cases Following Laparoscopic Cholecystectomy

Authors: Ishwor Paudel, Pratima Gautam, Sandeep Bhattarai

Abstract:

Bile spillage occurs frequently during laparoscopic cholecystectomy, yet its impact on postoperative outcomes remains unknown. It might not be as innocuous as some surgeons tend to believe and in fact might be associated with post-operative surgical site infections (SSI). It often leads to patient dissatisfaction, emergency department visit, with subsequent readmission and additional procedures. Thus, this study sought to examine whether bile spillage is indeed associated with increased risk of postoperative wound infections after laparoscopic cholecystectomy. We hypothesize that patients who experience bile spillage (BS) during operation, have an increased risk of SSI compared to those who do not. This is a prospective observational study conducted in the Department of Surgery, Patan Hospital over a period of one year. Patients undergoing laparoscopic cholecystectomy were included and bile spillage, if happened was noted. All cases were followed up for 30 days and SSI was diagnosed as per Center for disease control and prevention (CDC) defined criteria. Fisher’s test was applied to compare SSI in bile spillage versus non bile spillage cases. A total of 112 patients were included in the final analysis. Bile spillage occurred in 20 cases and absent in the rest i.e., 92 cases. Among bile spillage cases, SSI was found in 4 cases (20%), whereas in non-bile spillage cases SSI was found in 8 cases (8.7%). However, it was statistically not significant (p value > 0.05). 11 (92%) cases were superficial SSI and one was organ-space infection. No mortality or 30-day readmission was found in our study period. Spillage of gallbladder content does not lead to an increase in SSIs. However, as the rate of SSI is still higher, surgeons should be careful to avoid iatrogenic gallbladder perforation and in case of bile spillage, thorough peritoneal irrigation with normal saline should be done.

Keywords: Biliary spillage, organ space infection, Laparoscopic cholecystectomy, surgical site infection.

References:

[1] Barbara L, Sama C, Morselli Labate AM, Taroni F, Rusticali AG, Festi D, et al. A population study on the prevalence of gallstone disease: the Sirmione Study. Hepatology. 1987;7(5):913–7. https://doi.org/10.1002/hep.1840070520
[2] Shaffer EA. Epidemiology and risk factors for gallstone disease: has the paradigm changed in the 21st century? Curr Gastroenterol Rep. 2005 May;7(2):132–40. https://doi.org/10.1007/s11894-005-0051-8
[3] Panthee MR, Pathak YR, Acharya AP, Mishra C, Jaiswal RK. Prevalence of Gall Stone Disease In Nepal: Multi Center Ultrasonographic Study. Vol. 7, Post Graduate Journal of National Academy of Medical Sciences. 2007. p. 45–50.
[4] Shah JN, Maharjan SB, Paudyal S. Routine use of antibiotic prophylaxis in low-risk laparoscopic cholecystectomy is unnecessary: a randomized clinical trial. Asian J Surg. 2012 Oct;35(4):136–9. https://doi.org/10.1016/j.asjsur.2012.06.011
[5] Marcari RS, Lupinacci RM, Nadal LR, Rego RE, Coelho AM, Farah FDM. Outcomes of Laparoscopic Cholecystectomy in Octogenarians. J Soc Laparoendosc Surg. 2012;16:271–5. https://doi.org/10.4293/108680812X13427982376428
[6] Karanikas M, Bozali F, Vamvakerou V, Markou M, Chasan ZTM, Efraimidou E, et al. Biliary tract injuries after lap cholecystectomy-types, surgical intervention and timing. Ann Transl Med. 2016;4(9):1–9. https://doi.org/10.21037/atm.2016.05.07
[7] Memon MA, Deeik RK, Maffi TR, Fitzgibbons RJJ. The outcome of unretrieved gallstones in the peritoneal cavity during laparoscopic cholecystectomy. A prospective analysis. Surg Endosc. 1999 Sep;13(9):848–57. https://doi.org/10.1007/s004649901118
[8] Suh SW, Park JM, Lee SE, Choi YS. Accidental gallbladder perforation during laparoscopic cholecystectomy: does it have an effect on the clinical outcomes? J Laparoendosc Adv Surg Tech A. 2012;22(1):40–5. https://doi.org/10.1089/lap.2011.0219
[9] Warren DK, Nickel KB, Wallace AE, Mines D, Tian F, Symons WJ, et al. Risk Factors for Surgical Site Infection After Cholecystectomy. Open forum Infect Dis. 2017;4(2):ofx036. https://doi.org/10.1093/ofid/ofx036
[10] Rice DC, Memon MA, Jamison RL, Agnessi T, Ilstrup D, Bannon MB, et al. Long-term consequences of intraoperative spillage of bile and gallstones during laparoscopic cholecystectomy. J Gastrointest Surg Off J Soc Surg Aliment Tract. 1997;1(1):81–5. https://doi.org/10.1007/s11605-006-0014-x
[11] Magill SS, Hellinger W, Cohen J, Kay R, Bailey C, Boland B, et al. Prevalence of healthcare-associated infections in acute care hospitals in Jacksonville, Florida. Infect Control Hosp Epidemiol. 2012 Mar;33(3):283–91. https://doi.org/10.1086/664048
[12] Brill A, Ghosh K, Gunnarsson C, Rizzo J, Fullum T, Maxey C, et al. The effects of laparoscopic cholecystectomy, hysterectomy, and appendectomy on nosocomial infection risks. Surg Endosc Other Interv Tech. 2008;22(4):1112–8. https://doi.org/10.1007/s00464-008-9815-1
[13] Jain N, Neogi S, Bali RS, Harsh N. Relationship of Gallbladder Perforation and Bacteriobilia with Occurrence of Surgical Site Infections following Laparoscopic Cholecystectomy. Minim Invasive Surg. 2015;2015:204508. https://doi.org/10.1155/2015/204508
[14] Siddiqua SS, Sayeed S. Port site infection following laparoscopic cholecystectomy. Bangladesh J Med. 2018;29:51–8.
[15] Peponis T, Eskesen TG, Mesar T, Saillant N, Kaafarani HMA, Yeh DD, et al. Bile Spillage as a Risk Factor for Surgical Site Infection after Laparoscopic Cholecystectomy: A Prospective Study of 1,001 Patients. J Am Coll Surg. 2018 Jun;226(6):1030–5. https://doi.org/10.1016/j.jamcollsurg.2017.11.025
[16] Baev S, Pozarliev T, Todorov GT. Laparoscopic cholecystectomy: 700 consecutive cases. Int Surg. 1995;80(4):296–8.
[17] Taki-Eldin A, Badawy A-E. Outcome of Laparoscopic Cholecystectomy in Patients with Gallstone Disease at a Secondary Level Care Hospital. Arq Bras Cir Dig ABCD = Brazilian Arch Dig Surg. 2018 Jun;31(1):e1347. https://doi.org/10.1590/0102-672020180001e1347
[18] Malatani TS, Bobo RA, Al-Kassab AS, Al-Saigh AS, Ajao OG, Jastaniah S, et al. Gallbladder stones analyzes, bile and wound cultures in cholelithiasis. Saudi J Gastroenterol Off J Saudi Gastroenterol Assoc. 1996 Sep;2(3):146–9.
[19] Jawien M, Wojkowska-Mach J, Rozanska A, Bulanda M, Heczko PB. Surgical Site Infection Following Cholecystectomy:Comparison of procedures performed with and without a laparoscope. Int J Infect Control. 2008;4(1):4–8. https://doi.org/10.3396/ijic.v4i1.004.08
[20] Gaur Sqn Ldr A. SLA, Pujahari GCAK. Role of prophylactic antibiotics in laparoscopic cholecystectomy. Med J Armed Forces India (Internet). 2010;66(3):228–30. https://doi.org/10.1016/s0377-1237(10)80043-7
[21] Porwal R, Soni A, Singh A, Somani SK, Sagar P. Bile spillage and bacterobilia as risk factors for surgical site infection after laparoscopic cholecystectomy: a prospective study at tertiary care hospital. Int Surg J. 2019;6(9):3223. https://doi.org/10.18203/2349-2902.isj20194055
[22] Sarli L, Pietra N, Costi R, Grattarola M. Gallbladder perforation during laparoscopic cholecystectomy. World J Surg. 1999 Nov;23(11):1186–90. https://doi.org/10.1007/s002689900644
[23] Mir SA, Wani AH, Gilkar IA, Hassan Y. Relationship of Gall Bladder Perforation and Bacteriobilia with Occurrence of Surgical Site Infection Following Laparoscopic Cholecystectomy. J Evid Based Med Healthc. 2018;5(41):2901–6. https://doi.org/10.18410/jebmh/2018/593
[24] Klaiber C, Metzger A, Saager C. The “shuttle” stone collector — a new device for collecting lost gallstones in laparoscopic cholecystectomy. Surg Endosc (Internet). 1992;6(2):84. https://doi.org/10.1007/BF02281089