Bile duct injury and bile leakage in laparoscopic cholecystectomy

[Potential risk to patient safety by discontinuation of production of classical T-drains? : Nationwide survey in Germany and statement of the surgical working group for liver, gall bladder and pancreatic diseases (CALGP) of the German Society for General and Visceral Surgery (DGAV)]

The revision of the medical device regulation (MDR) legislation by the European Union and supplementations by the member states has been implemented for good reasons but causes dramatic side effects. It is no longer allowed to produce some rarely used medical devices by various manufacturers that have been successfully used for decades. Before production, a new application to the MDR would be necessary, which is not a realistic business case for companies producing rarely used devices. This problem currently relates to the Kehr T‑drain made from soft rubber or latex that has been in use since the late nineteenth century. A surgically placed T‑drain, although rarely necessary nowadays, is still in use worldwide for special indications in an attempt to avoid severe complications. These special indications include complex hepato-pancreato-biliary (HPB) procedures and perforations of the upper gastrointestinal (GI) tract where T‑drains may be used to secure the hepatojejunostomy or to create a stable fistula. The HPB working group (CALGP) of the German Society of General and Visceral Surgery (DGAV) provides a statement from a surgical perspective on this matter after a survey of all its members. Politics should be very careful not to generalize when implementing useful new regulations at a European and national level. Established and comprehensible treatment concepts should not be restricted and exemption permits should be quickly granted in these cases because the discontinuation of these niche products may lead to potential patient safety issues and even fatalities.

Difficult situations in laparoscopic cholecystectomy: a multicentric retrospective study

INTRODUCTION

Difficult laparoscopic cholecystectomy (LC) is the most common "difficult" surgical procedure performed today, which possesses the potential to place the patient at significant operative risk. We present our retrospective study and experience of 8347 patients with LC since June 1995 to December 2011 at 2 large centers: Mariampur and GSVM Medical College, LLR Hospital, Kanpur, with discussions regarding the practical aspects of LC in difficult situations with respect to conversion to open cholecystectomy.

METHODS

A retrospective analysis of patients who underwent LC from June 1995 to December 2011 was performed. The analysis was performed in relation to the need for conversion and the factors responsible for conversion.

RESULTS

Out of 8347 cases, 2187 cases (26.2%) were identified as difficult. LC was performed successfully in 8265 cases (total completion rate, 99.02%). Of the 2187 difficult cases, LC was completed successfully in 2105 cases (completion rate in difficult cases, 96.25%) and converted to open cholecystectomy in 82 cases (conversion rate in difficult cases, 3.75%).

CONCLUSIONS

Because of the increasing exposure and expertise of surgeons dealing with complex gall bladder laparoscopies, rates of conversion to open cholecystectomy are decreasing and many difficult cases are now handled laparoscopically. However, if required, conversion should not be considered as a failure for the benefit of the patient.

Single-incision laparoscopic surgery and the necessity for prospective evidence

Laparoscopic surgery has become the standard approach for most thoracic, abdominal, and pelvic procedures in adults and children. We now know that laparoscopy has proven benefits; however, at its introduction, laparoscopy was adopted without appropriate clinical evidence to justify the approach as an alternative to open surgery. In continued efforts to increase the benefits of minimally invasive surgery to their patients, surgeons have innovated new techniques to further decrease the impact of the operation on patients. These innovations range from decreasing the size of ports and instruments to the current group of techniques termed "scarless" surgery. In the current era of evidence-based medicine, it is the surgeon's responsibility to prove that the benefits outweigh the risk before new techniques are widely applied to patients. This article seeks to review the history of laparoscopic surgery, apply lessons learned to the evolution of single-incision laparoscopic surgery, and make a statement urging for sound prospective evaluation.

Laparoscopic cholecystectomy: incidents and complications. A retrospective analysis of 9542 consecutive laparoscopic operations

BACKGROUND

Even though laparoscopic cholecystectomy (LC) has become the customary method for treating gallstones, some incidents and complications appear rather more frequently than with the open technique. Several aspects of these complications and their treatment possibilities are analysed.

MATERIALS AND METHODS

Over the last 9 years 9542 LCs have been performed at this centre, of which 13.9% were carried out for acute cholecystitis, 38.4% in obese patients and 7.6% in patients aged >65 years.

RESULTS

The main operative incidents encountered were haemorrhage (224 cases, 2.3%), iatrogenic perforation of the gallbladder (1517 cases, 15.9%) and common bile duct (CBD) injuries (17 cases, 0.1%). Conversion to open operation was necessary in 184 patients (1.9%), usually due to obscure anatomy as a result of acute inflammation. The main postoperative complications were bile leakage (54 cases), haemorrhage (15 cases), sub-hepatic abscess (10 cases) and retained bile duct stones (11 cases). Ten deaths were recorded (0.1%).

DISCUSSION

Most of the postoperative incidents (except bile duct injuries) were solved by laparoscopic means. Among patients with postoperative complications 28.9% required revisional surgery. In 42.2% of cases minimally invasive procedures were used successfully: 15 laparoscopic re-operations (for choleperitoneum, haemoperitoneum and subhepatic abscess) and 22 endoscopic sphincterotomies (for bile leakage from the subhepatic drain and for retained CBD stones soon after operation). The good results obtained allow us to recommend these minimally invasive procedures in appropriate patients.

Biliary tree and cholecyst: post surgery imaging

Recently, with improvements in surgical techniques there has been a substantial reduction in the incidence of biliary complications of hepatobiliary surgery. Nevertheless, bile duct injuries and other post-cholecystectomy complications are a serious problem and a major cause of morbidity and mortality. Early complications may include bile duct injury caused by mistakenly placed clips, erroneous cutting of bile ducts based on misinterpretation of biliary anatomy, periductal bile leakage that causes edema, fibrosis and secondary stricturing, and ischemia due to injury to the right hepatic artery. Bile duct strictures are the most common of the late complications and can develop a few months or many years after surgery. Early detection and accurate diagnosis have a fundamental importance for the successful treatment of these complications. Therefore, early and meaningful application of the imaging methods immediately after detection of the first symptoms is essential. Peroperative ultrasound and direct iodine contrast application into the biliary tree (operative cholangiography) are highly important for immediate visualization of the complications during surgery. Ultrasound can be used to aid in identification of ductal structures and the cholangiogram should be obtained to document the anatomy. Plain abdominal film could be made in the patients in poor clinical conditions after biliary surgery. Oral cholecystography has largely been replaced by ultrasonography (US) for evaluation of cholelithiasis and complications like post-cholecystectomy fluid collections. The same methodology replaced the conventional intravenous cholangiography. Nowadays computed tomography (CT), endoscopic retrograde cholangiopancreatography (ERCP), magnetic resonance cholangiography (MRCP) and ultrasound (US) have essential roles as primary imaging modalities after biliary tree and gallbladder surgery in the evaluation of associated complications and residual biliary stones. We review the role of the imaging in complications after biliary tree and gallbladder surgery.

Laparoscopic cholecystectomy: incidents and complications. A retrospective analysis of 9542 consecutive laparoscopic operations

BACKGROUND

Even though laparoscopic cholecystectomy (LC) has become the customary method for treating gallstones, some incidents and complications appear rather more frequently than with the open technique. Several aspects of these complications and their treatment possibilities are analysed.

MATERIALS AND METHODS

Over the last 9 years 9542 LCs have been performed at this centre, of which 13.9% were carried out for acute cholecystitis, 38.4% in obese patients and 7.6% in patients aged >65 years.

RESULTS

The main operative incidents encountered were haemorrhage (224 cases, 2.3%), iatrogenic perforation of the gallbladder (1517 cases, 15.9%) and common bile duct (CBD) injuries (17 cases, 0.1%). Conversion to open operation was necessary in 184 patients (1.9%), usually due to obscure anatomy as a result of acute inflammation. The main postoperative complications were bile leakage (54 cases), haemorrhage (15 cases), sub-hepatic abscess (10 cases) and retained bile duct stones (11 cases). Ten deaths were recorded (0.1%).

DISCUSSION

Most of the postoperative incidents (except bile duct injuries) were solved by laparoscopic means. Among patients with postoperative complications 28.9% required revisional surgery. In 42.2% of cases minimally invasive procedures were used successfully: 15 laparoscopic re-operations (for choleperitoneum, haemoperitoneum and subhepatic abscess) and 22 endoscopic sphincterotomies (for bile leakage from the subhepatic drain and for retained CBD stones soon after operation). The good results obtained allow us to recommend these minimally invasive procedures in appropriate patients.

Colecistectomia laparoscópica: experiência em 500 casos, enfatizando as vantagens da colecistocolangiografia e da ligadura do ducto e artéria cística utilizando fio de náilon

São apresentados os resultados clínicos de quinhentos pacientes submetidos a colecistectomia laparoscópica (CL), com o emprego da colecistocolangiografia intra-operatória e da ligadura do ducto cístico e da artéria cística utilizando- se fio de náilon em vez de clipes metálicos. A maioria (79,4%) dos pacientes era do sexo feminino. A média de idade foi de 48,2 anos. Colecistite crônica ocorreu em 424 casos, colecistite aguda em 68, câncer da vesícula em quatro, colecistite alitiásica em três e um paciente apresentava pólipo de vesícula biliar. Coledocolitíase foi detectada em vinte (4%) pacientes. O tempo médio de cirurgia foi de 84 minutos. A permanência hospitalar foi de um a dois dias para 93,4% dos pacientes. A mortalidade foi de 0,4%. Conversão se fez necessária em 39 (7,8%) casos, principalmente por coledocolitíase (15 pacientes) e colecistite aguda (14 pacientes). Complicações importantes ocorreram em 12 (2,4%) casos, incluindo uma (0,2%) lesão de colédoco. A co1ecistocolangiografia foi satisfatória em 80,5% e inconclusiva em 19,5% dos pacientes. A co1ecistoco1angiografia é uma excelente opção técnica na CL, principalmente nos pacientes com colecistite crônica. Todavia, nos casos com obstrução flagrante do ducto cístico, ou quando a vesícu1a contém barro biliar, é preferível utilizar a colangiografia transcística. Na CL, a ligadura do ducto e da artéria cística com clipes está associada a maiores riscos de coleperitônio e hemorragia, pela soltura dos clipes, além de originar expressivo custo monetário, quando se leva em consideração o grande número de CL realizadas anualmente. Ao contrário dos clipes, a ligadura do ducto e da artéria cística com fio de náilon apresenta absoluta segurança e significativa economia financeira.

Incidence and nature of bile duct injuries following laparoscopic cholecystectomy: an audit of 5913 cases. West of Scotland Laparoscopic Cholecystectomy Audit Group

The rapid introduction of laparoscopic cholecystectomy has been associated with an apparently increased incidence of bile duct injury which has provoked worldwide concern. The true incidence and mechanism of iatrogenic ductal injury during the development of this procedure remain unclear. To assess this, the introduction of laparoscopic cholecystectomy in the West of Scotland has been audited prospectively over a 5-year period. All cases of biliary ductal injury have been independently reviewed. Some 48 surgeons undertaking laparoscopic cholecystectomy in 19 hospitals submitted prospective data between September 1990 and September 1995. A total of 5913 laparoscopic cholecystectomies were attempted with 98.3 per cent completion of data collection. During this period 37 laparoscopic bile duct injuries occurred. The annual incidence peaked at 0.8 per cent and has fallen to 0.4 per cent in the final year of audit. Injuries occurred after a median personal experience of 51 (range 3-247) laparoscopic cholecystectomies in 22 surgeons. Major bile duct injuries occurred in 20 of 37 patients, giving an incidence of 0.3 per cent. Five mechanisms for laparoscopic ductal injury were identified, including tenting, confluence and diathermy injuries as well as the classical and variant classical types. Ductal injuries were discovered at operation in 18 patients with consequent repair giving a good clinical outcome in 17. Contributory factors (severe inflammation, aberrant anatomy and poor visualization) were present in only 13 of 37 cases. This audit suggests that, at least in the introductory period, laparoscopic cholecystectomy is associated with an overall bile duct injury rate higher than that reported previously after open cholecystectomy, although the incidence of major ductal injury is similar. The late downward trend in bile duct injury, however, suggests there may be a prolonged learning curve for this procedure. Improved understanding of the mechanism of injury may lead to yet further reductions in this complication.

A learning curve for laparoscopic fundoplication. Definable, avoidable, or a waste of time?

OBJECTIVE

The objective of this study was to determine whether a learning curve for laparoscopic fundoplication can be defined, and whether steps can be taken to avoid any difficulties associated with it.

SUMMARY BACKGROUND DATA

Although early outcomes after laparoscopic fundoplication have been promising, complications unique to the procedure have been described. Learning curve problems may contribute to these difficulties. Although training recommendations have been published by some professional bodies, there is disagreement about what constitutes adequate supervised experience before the solo performance of laparoscopic antireflux surgery, and the true length of the learning curve.

METHODS

The outcome of 280 laparoscopic fundoplications undertaken by 11 surgeons during a 46-month period was assessed prospectively. The experience was analyzed in three different ways: 1) by an assessment of the overall learning experience within chronologically arranged groups, 2) by an assessment of all individual experiences grouped according to the experience of individual surgeons, and 3) by a comparison of early outcomes of operations performed by the surgeons who initiated laparoscopic fundoplication with the early experience of surgeons beginning laparoscopic fundoplication later in the overall institutional experience.

RESULTS

The complication, reoperation, and laparoscopic to open conversion rates all were higher in the first 50 cases performed by the overall group, and in the first 20 cases performed by each individual surgeon. These rates were even higher in the initial first 20 cases, and the first 5 individual cases. However, adverse outcomes were less likely when surgeons began fundoplication later in the overall experience, when experienced supervision could be provided.

CONCLUSIONS

A learning curve for laparoscopic fundoplication can be defined. Experienced supervision should be sought by surgeons beginning laparoscopic fundoplication during their first 20 procedures. This should minimize adverse outcomes associated with an individual's learning curve.

Post cholecystectomy admission to the intensive care unit. Comparison between open, mini-lap and laparoscopic techniques

Admissions to the intensive care unit following techniques for cholecystectomy, the open, mini-lap and laparoscopic methods, were studied over an 18-month period. Of 1078 cases of operative cholecystectomy performed during that period, 28 cases (2.6%) from all groups were admitted to the intensive care unit. Cases in the open and mini-lap cholecystectomy groups were admitted for postoperative monitoring because of pre-existing medical diseases and were discharged after an average period of stay of 2.4 and 4.7 days respectively. In contrast, the average stay of patients in the laparoscopic group was 14.8 days and the majority were admitted as a result of complications related to the procedure. In this group, one patient died on the first day of admission to the unit (mortality of 8.3%). This study has shown that laparoscopic surgery, from the intensive care point of view, is a very costly surgical procedure.

Outcome of 49 repairs of bile duct injuries after laparoscopic cholecystectomy

Treatment of bile duct injuries after laparoscopic cholecystectomy is still under discussion. The aim of this study was to evaluate the results of end-to-end or biliodigestive anastomosis for various types of bile duct injury. Patient charts of 49 (0.81%) classified bile duct injuries from a national survey of 6076 laparoscopic cholecystectomies in The Netherlands were analyzed. The median follow-up after repair was 183 days (range 14-570 days). Statistical analysis showed that an end-to-end anastomosis was preferred by the surgeons for less severe bile duct injuries and a biliodigestive repair for more severe injuries. Three patients died owing to a delayed detected bile duct injury. Twelve bile duct strictures occurred after repair, leading to a stricture rate of 25%. The time elapsed between repair and occurrence of a stricture was 134 days (range 13-270 days). The type of repair or the severity of the bile duct injury did not determine the outcome of the repair. Histologically proved cholecystitis predisposed a stricture at the repair site. It was concluded that treatment of bile duct injuries is associated with a high stricture rate at the repair site of the anastomosis. End-to-end anastomosis is mostly successful for the less severe injury detected during laparoscopic cholecystectomy. For all other cases this repair can at least be considered a temporary internal drainage procedure. The biliodigestive anastomosis can best be considered a delayed repair after a drainage procedure has resolved the local inflammatory status.

Bile duct injury and bile leakage in laparoscopic cholecystectomy

The introduction of laparoscopic cholecystectomy has been associated with an increased incidence of bile duct injury. This review presents the incidence of bile duct injury in reported series and examines the role of the learning curve and other contributing factors. There is good evidence to suggest that, with adequate training and experience, the incidence of biliary injury can be reduced to a level comparable to that of open cholecystectomy. Continued audit is required to ensure that the low complication rates achieved in selected centres with wide experience are reproduced by the surgical community in general.