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Huang W, Xu H, Guo Y, Li M, Peng G, Wu T. Efficacy of early laparoscopic cholecystectomy compared with percutaneous transhepatic gallbladder drainage in treating acute calculous cholecystitis in elderly patients. Acta Chir Belg 2024; 124:178-186. [PMID: 37578137 DOI: 10.1080/00015458.2023.2232672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Accepted: 06/28/2023] [Indexed: 08/15/2023]
Abstract
BACKGROUND Acute calculous cholecystitis is a common acute disease in elderly patients. This study aimed to evaluate the efficacy of early laparoscopic cholecystectomy (ELC) compared to percutaneous transhepatic gallbladder drainage (PTGD) for treating acute calculous cholecystitis in elderly patients. METHODS This retrospective study compared the clinical outcomes of two groups of elderly patients treated with ELC (group A) and PTGD (group B) from January 2018 to December 2021. Preoperative clinical characteristics and postoperative treatment outcomes were analyzed for both groups. RESULTS There were no statistically significant differences in preoperative clinical characteristics between the ELC and PTGD groups. ELC took longer to perform (69.8 ± 15.9 min vs. 29.6 ± 5.3 min, p < 0.001) but resulted in a significantly shorter duration of pain (1.9 ± 0.9 days vs. 3.9 ± 1.0 days, p < 0.001) and hospital stay (6.3 ± 2.5 days vs. 9.9 ± 3.6 days, p < 0.001), and a lower rate of sepsis (3.4% vs. 16.9%, p < 0.019). Time to soft diet was faster in the ELC group (1.5 ± 0.9 days vs. 3.0 ± 1.6 days, p < 0.001). Fewer patients in the ELC group experienced surgical reintervention than in the PTGD group (0% vs. 5.6%, p = 0.043). The incidence of postoperative complications and readmission rates in the ELC group were significantly lower than those in the PTGD group (ELC, 3.6%; PTGD, 25.4%, p = 0.001). CONCLUSIONS ELC is an effective treatment option for acute calculous cholecystitis in elderly patients, and has the added benefits of low postoperative complication rates, rapid recovery, shorter duration of pain, and excellent curative effects as compared to PTGD.
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Affiliation(s)
- Wenhao Huang
- The Second Clinical Medical College, Jinan University, Shenzhen, China
| | - Haisong Xu
- The Second Clinical Medical College, Jinan University, Shenzhen, China
| | - Yuehua Guo
- Department of Hepatobiliary and Pancreatic Surgery, Shenzhen People's Hospital (The Second Clinical Medical College, Jinan University; The First Affiliated Hospital, Southern University of Science and Technology), Shenzhen, China
| | - Mingyue Li
- Department of Hepatobiliary and Pancreatic Surgery, Shenzhen People's Hospital (The Second Clinical Medical College, Jinan University; The First Affiliated Hospital, Southern University of Science and Technology), Shenzhen, China
| | - Gongze Peng
- Department of Hepatobiliary and Pancreatic Surgery, Shenzhen People's Hospital (The Second Clinical Medical College, Jinan University; The First Affiliated Hospital, Southern University of Science and Technology), Shenzhen, China
| | - Tianchong Wu
- Department of Hepatobiliary and Pancreatic Surgery, Shenzhen People's Hospital (The Second Clinical Medical College, Jinan University; The First Affiliated Hospital, Southern University of Science and Technology), Shenzhen, China
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Lim YP, Leow VM, Koong JK, Subramaniam M. Is there a role for routine intraoperative cholangiogram in diagnosing CBD stones in patients with normal liver function tests? A prospective study. Innov Surg Sci 2024; 9:37-45. [PMID: 38826633 PMCID: PMC11138406 DOI: 10.1515/iss-2023-0059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Accepted: 02/19/2024] [Indexed: 06/04/2024] Open
Abstract
Objectives Cholecystectomy with or without intraoperative cholangiogram (IOC) is an accepted treatment for cholelithiasis. Up to 11.6 % of cholecystectomies have incidental common bile duct (CBD) stones on IOC and 25.3 % of undiagnosed CBD stones will develop life-threatening complications. These will require additional intervention after primary cholecystectomy, further straining the healthcare system. We seek to examine the role of IOC in patients with normal LFTs by evaluating its predictive values, intending to treat undiagnosed CBD stones and therefore ameliorate these issues. Methods All patients who underwent cholecystectomies with normal LFTs from October 2019 to December 2020 were prospectively enrolled. IOC was done, ERCPs were performed for filling defects and documented as "true positive" if ERCP was congruent with the IOC. "False positives" were recorded if ERCP was negative. "True negative" was assigned to normal IOC and LFT after 2 weeks of follow-up. Those with abnormal LFTs were subjected to ERCP and documented as "false negative". Sensitivity, specificity, and predictive values were calculated. Results A total of 180 patients were analysed. IOC showed a specificity of 85.5 % and a NPV of 88.1 % with an AUC of 73.7 %. The positive predictive value and sensitivity were 56.5 and 61.9 % respectively. Conclusions Routine IOC is a specific diagnostic tool with good negative predictive value. It is useful to exclude the presence of CBD stones when LFT is normal. It does not significantly prolong the length of hospitalization or duration of the cholecystectomy hence reducing the incidence of undetected retained stones and preventing its complications effectively.
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Affiliation(s)
- Yi Ping Lim
- Department of Surgery, University Malaya, Kuala Lumpur, Malaysia
| | - Voon Meng Leow
- USMMC, Bertam, Kepala Batas, USM, Penang, Malaysia
- Hepatobiliary Unit, Department of General Surgery, Hospital Sultanah Bahiyah, Alor Setar, Kedah, Malaysia
| | - Jun Kit Koong
- Department of Surgery, University Malaya, Kuala Lumpur, Malaysia
| | - Manisekar Subramaniam
- Hepatobiliary Unit, Department of General Surgery, Hospital Sultanah Bahiyah, Alor Setar, Kedah, Malaysia
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Reinsoo A, Kirsimägi Ü, Kibuspuu L, Košeleva K, Lepner U, Talving P. Bile duct injuries during laparoscopic cholecystectomies: an 11-year population-based study. Eur J Trauma Emerg Surg 2023; 49:2269-2276. [PMID: 36462050 DOI: 10.1007/s00068-022-02190-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 11/27/2022] [Indexed: 12/07/2022]
Abstract
PURPOSE Iatrogenic bile duct injuries (BDI) following laparoscopic cholecystectomy (LC) result in major morbidity and incidental mortality. There is a lack of unselected population-based cross-sectional studies on the incidence, management, and outcomes of BDI. We hypothesised that due to improved imaging capabilities and collective laparoscopic experience, BDI incidence will decrease over the study period and compare favourably with contemporary literature. METHODS After IRB approval, all cholecystectomies performed at national public healthcare facilities between 2008 and 2018 were retrospectively reviewed. BDIs were classified according to the Strasberg classification. The follow-up period ranged from 36 to 156 months. RESULTS A total of 241 BDIs of 29,739 laparoscopic cholecystectomies (LC) resulted in overall, minor, and major BDI incidence rates of 0.81%, 0.68%, and 0.13%, respectively. No significant decline in the BDIs was noted during the study period. Drainage in 66 (42.6%) and cases ERCP stent placement in 65 (41.9%) cases were equally used in Strasberg A lesions. Suture over T-tube in 20 (42.6%) and ERCP stenting in 19 (40.4%) cases were used in Strasberg D lesions. Roux-en-Y hepatojejunostomy (RYHJ) was performed in 30 (88.9%) of Strasberg E lesions. There were 27 (11.2%) patients with long-term bile duct strictures after BDI management. The overall mortality rate of BDIs and subsequent complications was 4.6%. CONCLUSIONS The annual incidence of iatrogenic bile duct injury over an 11-years' time after laparoscopic cholecystectomy did not decline significantly. We noted an overall BDI incidence of 0.81% comprising of 0.68% minor and 0.13% of major lesions. The management of injuries met contemporary guidelines with comparable outcomes.
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Affiliation(s)
- Arvo Reinsoo
- Division of Acute Care Surgery, Department of Surgery, North Estonia Medical Centre, Sütiste Tee 19, Tallinn, Estonia.
- Department of Surgery, Institute of Clinical Medicine, University of Tartu, Tartu, Estonia.
| | - Ülle Kirsimägi
- Department of Surgery, Institute of Clinical Medicine, University of Tartu, Tartu, Estonia
| | - Liis Kibuspuu
- Faculty of Medicine, University of Tartu, Tartu, Estonia
| | | | - Urmas Lepner
- Department of Surgery, Institute of Clinical Medicine, University of Tartu, Tartu, Estonia
| | - Peep Talving
- Division of Acute Care Surgery, Department of Surgery, North Estonia Medical Centre, Sütiste Tee 19, Tallinn, Estonia
- Department of Surgery, Institute of Clinical Medicine, University of Tartu, Tartu, Estonia
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Marchegiani F, Conticchio M, Zadoroznyj A, Inchingolo R, Memeo R, De'angelis N. Detection and management of bile duct injury during cholecystectomy. Minerva Surg 2023; 78:545-557. [PMID: 36883937 DOI: 10.23736/s2724-5691.23.09866-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2023]
Abstract
INTRODUCTION Cholecystectomy represents one of the most performed surgical procedures. Bile duct injuries (BDIs) are a dangerous complication of this intervention. With the advent of the laparoscopy, the rate of BDIs showed a growing trend that was partially justified by the learning curve of this technique. EVIDENCE ACQUISITION A literature search was conducted on Embase, Medline, and Cochrane databases to identify studies published up to October 2022 that analyzed the intraoperative detection and management of BDIs diagnosed during cholecystectomy. EVIDENCE SYNTHESIS According to the literature, approximately 25% of BDIs is diagnosed during the laparoscopic cholecystectomy. In the clinical suspicion of BDI, an intraoperative cholangiography is performed to confirm it. Complimentary technology, such as near-infrared cholangiography, can be also adopted. Intraoperative ultrasound represents a useful tool to furtherly define the biliary and the vascular anatomy. The proper classification of the type of BDI allows to identify the correct treatment. When a good expertise in hepato-pancreato-biliary surgery is available, a direct repair is performed with good outcomes both in case of simple and complex lesions. When the local resources are limited or there is a lack of dedicated surgical experience, patient referral to a reference center shows better outcomes. In particular, complex vasculo-biliary injuries require a highly specialized treatment. The key elements to transfer the patients are a good documentation of the injury, a proper drainage of the abdomen, and an antibiotic therapy. CONCLUSIONS BDI management requires a proper diagnostic process and prompt treatment to reduce the morbidity and mortality of this feared complication occurring during cholecystectomy.
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Affiliation(s)
- Francesco Marchegiani
- Unit of Colorectal and Digestive Surgery, DIGEST Department, Beaujon University Hospital, AP-HP, University of Paris Cité, Clichy, France
| | - Maria Conticchio
- Unit of Hepato-Pancreato-Biliary Surgery, F. Miulli General Regional Hospital, Acquaviva delle Fonti, Bari, Italy
| | - Alizée Zadoroznyj
- Unit of Colorectal and Digestive Surgery, DIGEST Department, Beaujon University Hospital, AP-HP, University of Paris Cité, Clichy, France
| | - Riccardo Inchingolo
- Unit of Interventional Radiology, F. Miulli General Regional Hospital, Acquaviva delle Fonti, Bari, Italy
| | - Riccardo Memeo
- Unit of Hepato-Pancreato-Biliary Surgery, F. Miulli General Regional Hospital, Acquaviva delle Fonti, Bari, Italy
| | - Nicola De'angelis
- Unit of Colorectal and Digestive Surgery, DIGEST Department, Beaujon University Hospital, AP-HP, University of Paris Cité, Clichy, France -
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Wahi JE, Warmack T, Barghout R, Kashif K, Rosario LE, Davies J, Unger SW, Joshi D, Jorge I. Five-Year Experience with Transcystic Laparoscopic Common Bile Duct Exploration. J Laparoendosc Adv Surg Tech A 2023; 33:276-280. [PMID: 36459625 DOI: 10.1089/lap.2022.0408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Background: Common bile duct (CBD) stones associated with cholecystitis can be treated by single-stage CBD exploration at the time of cholecystectomy or a two-stage approach with endoscopic stone extraction before or after cholecystectomy. The ideal management remains a matter of debate. The aim of this study is to analyze our outcomes with transcystic laparoscopic common bile duct exploration (LCBDE). Material and Methods: A retrospective review of patients who underwent transcystic LCBDE between 2015 and 2019 was performed. Results: A total of 106 patients underwent transcystic LCBDE over 5 years. We performed 1192 laparoscopic cholecystectomies with cholangiograms from March 2015 to December 2019. Fifteen patients had a preoperative endoscopic retrograde cholangiopancreatography (ERCP) for CBD stones seen on magnetic resonance cholangiopancreatography that during laparoscopic cholecystectomy with intraoperative cholangiogram (IOC), there were stones and/or sludge found in the CBD, which required clearance through a transcystic approach. Of the 91 patients who did not have a preoperative ERCP, clearance of the CBD was successful through a transcystic approach in 78 patients (86%). In the 13 patients that intraoperative clearance was not achieved (n = 13, 14%), a postoperative ERCP was performed. A total of 28 patients underwent either pre- or postoperative ERCP (n = 28, 26%). Choledochotomy was not performed in any of the patients. The mean operative time was 127 minutes (127 ± 48). The mean hospital length of stay (LOS) was 4 days (3.9 ± 2.8) with a median LOS of 3 days. Complications observed include wound infection (n = 2, 2%), pancreatitis after ERCP (n = 1, 1%), pneumonia (n = 1, 1%), and right hepatic duct injury (n = 1, 1%). Conclusion: Transcystic LCBDE is an effective and safe option for treatment of CBD stones. While a transcystic approach does not guarantee clearance of the CBD, it avoids the morbidity associated with a choledochotomy and can often prevent patients from having to undergo an additional procedure.
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Affiliation(s)
- Jessica E Wahi
- Department of Surgery, Mount Sinai Medical Center (MSMC), Miami Beach, Florida, USA
| | - Tyler Warmack
- Department of Surgery, Mount Sinai Medical Center (MSMC), Miami Beach, Florida, USA
| | - Robert Barghout
- Department of Surgery, Mount Sinai Medical Center (MSMC), Miami Beach, Florida, USA
| | - Kareem Kashif
- Department of Surgery, Mount Sinai Medical Center (MSMC), Miami Beach, Florida, USA
| | - Luis E Rosario
- Department of Surgery, Mount Sinai Medical Center (MSMC), Miami Beach, Florida, USA
| | - Jennifer Davies
- Department of Surgery, Mount Sinai Medical Center (MSMC), Miami Beach, Florida, USA
| | - Stephen W Unger
- Department of Surgery, Mount Sinai Medical Center (MSMC), Miami Beach, Florida, USA
| | - Devendra Joshi
- Department of Surgery, Mount Sinai Medical Center (MSMC), Miami Beach, Florida, USA
| | - Irving Jorge
- Department of Surgery, Mayo Clinic Arizona, Phoenix, Arizona, USA
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Geers J, Jaekers J, Topal H, Collignon A, Topal B. Bile duct injury in laparoscopic cholecystectomy with a posterior infundibular approach. INTERNATIONAL JOURNAL OF HEPATOBILIARY AND PANCREATIC DISEASES 2022. [DOI: 10.5348/100100z04mc2022ra] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Aims: Bile duct injury (BDI) in laparoscopic cholecystectomy (LC) has a significant impact on morbidity and mortality. Although the critical view of safety (CVS) concept is the most widely supported approach to prevent BDI, alternative approaches are used as well. The aim was to evaluate the incidence, severity, and management of bile duct injury in LC, using a posterior infundibular approach.
Methods: This retrospective, monocentric cohort study includes patients who underwent LC for gallstone disease. Data were collected in a prospectively maintained database. Patients with BDI were identified and were analyzed in-depth.
Results: Between 1999 and 2018, 8389 consecutive patients were included (M/F 3288/5101; mean age 55 (standard deviation; SD ± 17) years). Mean length of postoperative hospital stay was two days (SD ± 4). Fourteen patients died after LC and 21 patients were identified with BDI. Seventeen BDI (81%) patients were managed minimally invasive (14 endoscopic, 3 laparoscopic), and 4 patients via laparotomy (3 hepaticojejunostomy, 1 primary suture). Severe complications (Clavien-Dindo ≥3) after BDI repair were observed in 6 patients. There was no BDI-related mortality. Median follow-up time was 113 months (range 5–238).
Conclusion: A posterior infundibular approach in LC was associated with a low incidence of BDI and no BDI-related mortality.
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Affiliation(s)
- Joachim Geers
- Department of Visceral Surgery, University Hospitals KU Leuven, Herestraat 49, 3000 Leuven, Belgium
| | - Joris Jaekers
- Department of Visceral Surgery, University Hospitals KU Leuven, Herestraat 49, 3000 Leuven, Belgium
| | - Halit Topal
- Department of Visceral Surgery, University Hospitals KU Leuven, Herestraat 49, 3000 Leuven, Belgium
| | - André Collignon
- Department of Management Information and Reporting, University Hospitals KU Leuven, Herestraat 49, 3000 Leuven, Belgium
| | - Baki Topal
- Department of Visceral Surgery, University Hospitals KU Leuven, Herestraat 49, 3000 Leuven, Belgium
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Cano ME, Uad P, Ardiles V, Sanchez Claria R, Mazza O, Palavecino M, de Santibañes E, Pekolj J, de Santibañes M. Impact of resident involvement on patient outcomes in laparoscopic cholecystectomy of different degrees of complexity: analysis of 2331 cases. Surg Endosc 2022; 36:8975-8980. [PMID: 35687252 DOI: 10.1007/s00464-022-09349-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 05/20/2022] [Indexed: 01/06/2023]
Abstract
BACKGROUND Resident involvement in the operating room is a vital component of their medical education. Laparoscopic cholecystectomy (LC) represents the paradigmatic minimally invasive training procedure, both due to its prevalence and its different forms of complexity. We aim to evaluate whether the supervised participation of residents as operative surgeons in LC of different degrees of complexity affects postoperative outcomes in a university hospital. METHODS This is a retrospective, single-center study that included all consecutive adult (> 18 years old) patients operated for a LC between January 1, 2012 and December 31, 2017. Each surgical procedure was recorded according to the level of complexity that we established in three types of categorization (level 1: elective surgery; level 2: cholecystitis; level 3: biliary instrumentation). Patients were clinically monitored at an outpatient clinic 7 and 30-day postoperative. Postoperative outcomes of patients operated by supervised residents (SR) and trained surgeons (TS) were compared. Postoperative complications were graded according to the Clavien-Dindo classification of surgical complications. RESULTS A total of 2331 patients underwent LC during the study period, of whom 1573 patients (67.5%) were operated by SR and 758 patients (32.5%) by TS. There were no significant differences among age, sex, and BMI between patients operated in both groups, with the exception of ASA (P = 0.0001). Intraoperative cholangiography was performed in 100% of the patients, without bile duct injuries. There were no deaths in the 30 postoperative days. The overall complication rate was 5.70% (133 patients), with no significant differences when comparing LC performed by SR and TS (5.09 vs. 6.99%; P = 0.063). The severity rates of complications were similar in both groups (P = 0.379). Patient readmission showed a statistical difference comparing SR vs TS (0.76% vs. 2.2%; P = 0.010). The postoperative complications rate according to the complexity level of LC was not significant in level 1 and 2 for both groups. However in complexity level 3 the TS group experienced a greater rate of complications compared to the SR group (18.12% vs. 9.38%; P = 0.058). In the multivariate analysis, the participation of the residents as operating surgeons was not independently associated with an increased risk of complications (OR 1.22, 95% CI 0.84-1.77; P = 0.275), neither other risk factors like age ≥ 65 years, BMI, complexity level 2-3, or ASA ≥ 3-4. The association of another surgical procedure with the LC was an independent factor of morbidity (OR 3.85, 95% CI 2.54-5.85; P = 0.000). CONCLUSION Resident involvement in LC with different degrees of complexity did not affect postoperative outcomes. The participation of a resident as operating surgeon is not an independent risk factor and may be considered ethical, safe, and reliable whenever implemented in the background of a residency-training program with continuous supervision and national accreditation. The sum of other procedures not related to a LC should be taken as a risk factor of morbidity.
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Affiliation(s)
- Maria Emilia Cano
- Department of General Surgery, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Pedro Uad
- Department of General Surgery, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Victoria Ardiles
- Division of HPB Surgery and Liver Transplant Unit, Department of General Surgery, Hospital Italiano de Buenos Aires, Juan D. Perón 4190, C1181ACH, Buenos Aires, Argentina
| | - Rodrigo Sanchez Claria
- Division of HPB Surgery, Department of General Surgery, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Oscar Mazza
- Division of HPB Surgery, Department of General Surgery, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Martin Palavecino
- Division of HPB Surgery, Department of General Surgery, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Eduardo de Santibañes
- Division of HPB Surgery and Liver Transplant Unit, Department of General Surgery, Hospital Italiano de Buenos Aires, Juan D. Perón 4190, C1181ACH, Buenos Aires, Argentina
| | - Juan Pekolj
- Division of HPB Surgery and Liver Transplant Unit, Department of General Surgery, Hospital Italiano de Buenos Aires, Juan D. Perón 4190, C1181ACH, Buenos Aires, Argentina
| | - Martín de Santibañes
- Division of HPB Surgery and Liver Transplant Unit, Department of General Surgery, Hospital Italiano de Buenos Aires, Juan D. Perón 4190, C1181ACH, Buenos Aires, Argentina.
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Brunt LM. Should We Utilize Routine Cholangiography? Adv Surg 2022; 56:37-48. [PMID: 36096576 DOI: 10.1016/j.yasu.2022.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
Intraoperative cholangiography (IOC) is an essential skill that surgeons need for the safe performance of cholecystectomy and intraoperative diagnosis and management of bile duct stones. Whether it should be performed routinely or selectively is an ongoing debate that goes back to the early days of laparoscopic cholecystectomy (LC). Benefits of IOC include ability to detect bile duct stones, recognition of aberrant anatomy, and, in some circumstances, mitigation of the risk of bile duct injury. In this review, key aspects of this debate, technical aspects of performing IOC, evidence regarding its benefits, and imaging alternatives to IOC during LC are presented.
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Affiliation(s)
- L Michael Brunt
- Section of Minimally Invasive Surgery, Department of Surgery, Washington University School of Medicine, 660 S Euclid Avenue, St. Louis, MO 63110, USA.
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Georgiou K, Sandblom G, Alexakis N, Enochsson L. Intraoperative cholangiography 2020: Quo vadis? A systematic review of the literature. Hepatobiliary Pancreat Dis Int 2022; 21:145-153. [PMID: 35031229 DOI: 10.1016/j.hbpd.2022.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 01/03/2022] [Indexed: 02/05/2023]
Abstract
BACKGROUND There are few randomized controlled trials with sufficient statistical power to assess the effectiveness of intraoperative cholangiography (IOC) in the detection and treatment of common bile duct injury (BDI) or retained stones during cholecystectomy. The best evidence so far regarding IOC and reduced morbidity related to BDI and retained common bile duct stones was derived from large population-based cohort studies. Population-based studies also have the advantage of reflecting the outcome of the procedure as it is practiced in the community at large. However, the outcomes of these population-based studies are conflicting. DATA SOURCES A systematic literature search was conducted in 2020 to search for articles that contained the terms "bile duct injury", "critical view of safety", "bile duct imaging" or "retained stones" in combination with IOC. All identified references were screened to select population-based studies and observational studies from large centers where socioeconomic or geographical selections were assumed not to cause selection bias. RESULTS The search revealed 273 references. A total of 30 articles fulfilled the criteria for a large observational study with minimal risk for selection bias. The majority suggested that IOC reduces morbidity associated with BDI and retained common bile duct stones. In the short term, IOC increases the cost of surgery. However, this is offset by reduced costs in the long run since BDI or retained stones detected during surgery are managed immediately. CONCLUSIONS IOC reduces morbidity associated with BDI and retained common bile duct stones. The reports reviewed are derived from large, unselected populations, thereby providing a high external validity. However, more studies on routine and selective IOC with well-defined outcome measures and sufficient statistical power are needed.
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Affiliation(s)
- Konstantinos Georgiou
- First Department of Propaedeutic Surgery, Hippokration General Hospital of Athens, Athens Medical School, National and Kapodistrian University of Athens, Athens 10679, Greece
| | - Gabriel Sandblom
- Department of Clinical Science and Education, Department of Surgery, Karolinska Institutet, Södersjukhuset, Stockholm 17177, SE, Sweden
| | - Nicholas Alexakis
- First Department of Propaedeutic Surgery, Hippokration General Hospital of Athens, Athens Medical School, National and Kapodistrian University of Athens, Athens 10679, Greece
| | - Lars Enochsson
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå 90187, SE, Sweden.
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Julian D, Martín DS, Martín P, Rodrigo SC, Guillermo A, Oscar M, Juan P. Role of laparoscopy in the immediate, intermediate, and long-term management of iatrogenic bile duct injuries during laparoscopic cholecystectomy. Langenbecks Arch Surg 2022; 407:663-673. [DOI: 10.1007/s00423-022-02452-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 01/20/2022] [Indexed: 12/17/2022]
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Xu Q, Liu M, Wu Q, Ling W, Guo S. Retrospective Analysis of the Accuracy of High-Frequency Ultrasound for Pancreaticobiliary Maljunction in Pediatrics at a Single Center. Front Pediatr 2022; 10:775378. [PMID: 35498787 PMCID: PMC9047754 DOI: 10.3389/fped.2022.775378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 02/08/2022] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE To determine the clinical value of high-frequency ultrasonography (US) in the evaluation and diagnosis of pancreaticobiliary maljunction (PBM) among children. METHODS The clinical subjects consisted of 31 pediatric patients who were diagnosed with PBM from January 2015 to May 2021 in Fujian Provincial Maternity and Children's Hospital. The primary outcomes included diagnosis accuracy, imaging characteristics of each type of PBM based on JSPBM, time length of operation, and cost of service. Secondary outcomes were the serum amylase and bilirubin levels. RESULTS The diagnostic accuracy of US was 90.3% and comparable to the other imaging methods-MRCP (82.6%), IOC (79.2%), and ERCP (100%), respectively. The time length of operation and direct cost were significantly lower than other imaging pathways. Stenotic type (A) is associated with a high internal diameter of CBD, and dilated channel type (C) presents increased internal diameter and length of CC as well as internal diameter of PD. There were higher levels of the serum bilirubin seen in type A and of serum amylase in type C compared with others. CONCLUSION High-frequency US is a safe, cost-effective, and non-invasive imaging tool for the diagnosis and evaluation of PBM in pediatrics.
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Affiliation(s)
- Qiuchen Xu
- Department of Medical Ultrasonics, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Min Liu
- Department of Medical Ultrasonics, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Qiumei Wu
- Department of Medical Ultrasonics, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Wen Ling
- Department of Medical Ultrasonics, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Shan Guo
- Department of Medical Ultrasonics, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, China
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Fratantoni ME, Giuffrida P, Di Menno J, Ardiles V, de Santibañes M, Clariá RS, Palavecino M, de Santibañes E, Pekolj J, Mazza O. Prevalence of Persistent Common Bile Duct Stones in Acute Biliary Pancreatitis Remains Stable Within the First Week of Symptoms. J Gastrointest Surg 2021; 25:3178-3187. [PMID: 34159556 DOI: 10.1007/s11605-021-05068-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 06/07/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND Acute biliary pancreatitis (ABP) is often associated with persistent common bile duct (CBD) stones. The best strategy in terms of timing of surgery is still controversial. The aim of the current study is to describe the prevalence of persistent common bile duct (CBD) stones in ABP during the first week of symptoms at a high-volume referral center. STUDY DESIGN Single-institution retrospective analysis of a prospectively collected database. Patients with diagnosis of ABP who underwent laparoscopic cholecystectomy (LC) between January 2009 and December 2019 were extracted. RESULTS Two hundred thirty-one patients were included. Cholecystectomy was performed laparoscopically in 230 (99.57%) patients. Intraoperative cholangiogram was performed in all patients. Two hundred nine (90%) patients had surgery within the first 7 days. Global prevalence of persistent CBD stones during IOC was 19.91% (95% CI 14.96-25.65). No significant association between timing to surgery and presence of CBD stones was found for the first week since the initial attack (p=0.28). Prevalence of CBD stones was significantly higher after day 7 (p=0.007 and 0.005). Positive findings in preoperative MRCP are significantly related to intraoperative CBD stones (p=0.0001). Mild postoperative complications (CD I/II) were present in 21 patients (9.09%). No difference was found in morbidity between CBD stones group and non-CBD stones group (p=0.48). We observed no severe complications nor mortality. CONCLUSIONS In patients with mild acute biliary pancreatitis, the prevalence of persistent CBD stones does not change within the first 7 days since the onset of symptoms. This fact may have major clinical relevance when deciding the optimal therapeutic strategy in this population.
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Affiliation(s)
- Maria Eugenia Fratantoni
- HPB Surgery Section, Department of General Surgery, Hospital Italiano de Buenos Aires, Tte. Gral. Juan D. Perón 4190, C1181ACH, Buenos Aires, Argentina.
| | - Pablo Giuffrida
- HPB Surgery Section, Department of General Surgery, Hospital Italiano de Buenos Aires, Tte. Gral. Juan D. Perón 4190, C1181ACH, Buenos Aires, Argentina
| | - Juliana Di Menno
- HPB Surgery Section, Department of General Surgery, Hospital Italiano de Buenos Aires, Tte. Gral. Juan D. Perón 4190, C1181ACH, Buenos Aires, Argentina
| | - Victoria Ardiles
- HPB Surgery Section and Liver Transplant Unit, General Surgery Service, Hospital Italiano de Buenos Aires, Juan D. Perón 4190, C1181ACH, Buenos Aires, Argentina
| | - Martín de Santibañes
- HPB Surgery Section and Liver Transplant Unit, General Surgery Service, Hospital Italiano de Buenos Aires, Juan D. Perón 4190, C1181ACH, Buenos Aires, Argentina
| | - Rodrigo Sanchez Clariá
- HPB Surgery Section, Department of General Surgery, Hospital Italiano de Buenos Aires, Tte. Gral. Juan D. Perón 4190, C1181ACH, Buenos Aires, Argentina
| | - Martin Palavecino
- HPB Surgery Section, Department of General Surgery, Hospital Italiano de Buenos Aires, Tte. Gral. Juan D. Perón 4190, C1181ACH, Buenos Aires, Argentina
| | - Eduardo de Santibañes
- HPB Surgery Section and Liver Transplant Unit, General Surgery Service, Hospital Italiano de Buenos Aires, Juan D. Perón 4190, C1181ACH, Buenos Aires, Argentina
| | - Juan Pekolj
- HPB Surgery Section and Liver Transplant Unit, General Surgery Service, Hospital Italiano de Buenos Aires, Juan D. Perón 4190, C1181ACH, Buenos Aires, Argentina
| | - Oscar Mazza
- HPB Surgery Section, Department of General Surgery, Hospital Italiano de Buenos Aires, Tte. Gral. Juan D. Perón 4190, C1181ACH, Buenos Aires, Argentina
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Cirocchi R, Panata L, Griffiths EA, Tebala GD, Lancia M, Fedeli P, Lauro A, Anania G, Avenia S, Di Saverio S, Burini G, De Sol A, Verdelli AM. Injuries during Laparoscopic Cholecystectomy: A Scoping Review of the Claims and Civil Action Judgements. J Clin Med 2021; 10:jcm10225238. [PMID: 34830520 PMCID: PMC8622805 DOI: 10.3390/jcm10225238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Revised: 11/04/2021] [Accepted: 11/08/2021] [Indexed: 11/16/2022] Open
Abstract
Background. To define what type of injuries are more frequently related to medicolegal claims and civil action judgments. Methods. We performed a scoping review on 14 studies and 2406 patients, analyzing medicolegal claims related to laparoscopic cholecystectomy injuries. We have focalized on three phases associated with claims: phase of care, location of injuries, type of injuries. Results. The most common phase of care associated with litigation was the improper intraoperative surgical performance (47.6% ± 28.3%), related to a “poor” visualization, and the improper post-operative management (29.3% ± 31.6%). The highest rate of defense verdicts was reported for the improper post-operative management of the injury (69.3% ± 23%). A lower rate was reported in the incorrect presurgical assessment (39.7% ± 24.4%) and in the improper intraoperative surgical performance (21.39% ± 21.09%). A defense verdict was more common in cystic duct injuries (100%), lower in hepatic bile duct (42.9%) and common bile duct (10%) injuries. Conclusions. During laparoscopic cholecystectomy, the most common cause of claims, associated with lower rate of defense verdict, was the improper intraoperative surgical performance. The decision to take legal action was determined often for poor communication after the original incident.
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Affiliation(s)
- Roberto Cirocchi
- Department of Medicine and Surgery, University of Perugia, 06132 Perugia, Italy; (R.C.); (M.L.); (S.A.)
| | - Laura Panata
- Legal Medicine and Insurance Office, Santa Maria della Misericordia Hospital, 06129 Perugia, Italy; (L.P.); (A.M.V.)
| | - Ewen A. Griffiths
- Department of Upper Gastrointestinal Surgery, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Trust, Birmingham B15 2GW, UK;
- Institute of Cancer and Genomic Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TT, UK
| | - Giovanni D. Tebala
- Surgical Emergency Unit, John Radcliffe Hospital, Oxford University NHS Foundation Trust, Oxford OX3 9DU, UK;
| | - Massimo Lancia
- Department of Medicine and Surgery, University of Perugia, 06132 Perugia, Italy; (R.C.); (M.L.); (S.A.)
| | - Piergiorgio Fedeli
- School of Law, Legal Medicine, University of Camerino, 62032 Camerino, Italy;
| | - Augusto Lauro
- Department of Surgical Sciences, Hospital “Policlinico Umberto I”, “Sapienza” University of Rome, 00161 Rome, Italy;
| | - Gabriele Anania
- Department of Medical Science, University of Ferrara, 44121 Ferrara, Italy;
| | - Stefano Avenia
- Department of Medicine and Surgery, University of Perugia, 06132 Perugia, Italy; (R.C.); (M.L.); (S.A.)
| | - Salomone Di Saverio
- Department of General Surgery, ASUR Marche, AV5, Hospital of San Benedetto del Tronto, 63074 San Benedetto del Tronto, Italy;
| | - Gloria Burini
- Department of General and Emergency Surgery, Hospital “Ospedali Riuniti di Ancona”, 60126 Ancona, Italy
- Correspondence: ; Tel.: +39-3465700300
| | - Angelo De Sol
- Department of General Surgery, St. Maria Hospital, 05100 Terni, Italy;
| | - Anna Maria Verdelli
- Legal Medicine and Insurance Office, Santa Maria della Misericordia Hospital, 06129 Perugia, Italy; (L.P.); (A.M.V.)
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When Should We Perform Intraoperative Cholangiography? A Prospective Assessment of 1000 Consecutive Laparoscopic Cholecystectomies. SURGICAL LAPAROSCOPY, ENDOSCOPY & PERCUTANEOUS TECHNIQUES 2021; 32:3-8. [PMID: 34369481 DOI: 10.1097/sle.0000000000000985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Accepted: 06/18/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Intraoperative cholangiography (IOC) has been historically used to detect common bile duct (CBD) stones, delineate biliary anatomy, and avoid or promptly diagnose bile duct injuries (BDIs) during laparoscopic cholecystectomy (LC). We aimed to determine the usefulness of routine IOC during LC in an urban teaching hospital. METHODS A consecutive series of patients undergoing LC with routine IOC from 2016 to 2018 was prospectively analyzed. Primary outcomes of interest were: CBD stones, BDI, and anatomical variations of the biliary tract. Secondary outcomes of interest were: IOC success rate, IOC time, and readmission for residual lithiasis. A comparative analysis was performed between patients with and without preoperative suspicion of CBD stones. RESULTS A total of 1003 LC were analyzed; IOC was successful in 918 (91.5%) patients. Mean IOC time was 10 (4 to 30) minutes. Mean radiation received by the surgeon per procedure was 0.06 millisieverts (mSv). Normal IOC was found in 856 (93.2%) patients. CBD stones and aberrant biliary anatomy were present in 58 (6.3%) and 4 (0.4%) cases, respectively. Two patients (0.2%) underwent unnecessary CBD exploration because of false-positive IOC. Four patients (0.4%) with normal IOC were readmitted for residual CBD stones. Five (0.5%) minor BDI undetected by the IOC were diagnosed. Patients with preoperative suspicion of CBD stones had significantly higher rates of CBD stones detected on IOC as compared with those without suspicion (23.2% vs. 2.1%, P<0.0001). CONCLUSION Routine use of IOC resulted in low rates of BDI diagnosis, aberrant biliary anatomy identification and/or CBD stones detection. Selection of patients for IOC, rather than routine use of IOC appears a more reasonable approach.
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Bansal VK, Misra MC, Agarwal AK, Agrawal JB, Agarwal PN, Aggarwal S, Aslam M, Krishna A, Baksi A, Behari A, Bhattacharjee HK, Bhojwani R, Chander J, Chattopadhyay TK, Chintamani, Chowbey P, Dalvi A, Dash NR, Dhawan IK, Gamangatti S, Garg PK, Gupta NM, Gupta R, Gupta SK, Gupta V, Kaman L, Kapur BML, Kataria K, Khan M, Khanna AK, Khullar R, Kumar A, Kumar A, Kumar S, Kumar S, Lal P, Maurya SD, Moirangthem GS, Pal S, Panwar R, Parshad R, Pottakkat B, Prajapati OP, Puntambekar S, Ranjan P, Rathore YS, Sahni P, Sarangi R, Seenu V, Sharma R, Shukla VK, Singh DP, Singh J, Singh R, Sinha R, Sikora SS, Srivastava A, Srivastava A, Srivastava KN, Thomas S, Verma GR, Wig JD, Kapoor VK. SELSI Consensus Statement for Safe Cholecystectomy—Prevention and Management of Bile Duct Injury—Part B. Indian J Surg 2021. [DOI: 10.1007/s12262-019-01994-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Keeratibharat N. Initial experience of intraoperative fluorescent cholangiography during laparoscopic cholecystectomy: A retrospective study. Ann Med Surg (Lond) 2021; 68:102569. [PMID: 34345426 PMCID: PMC8319025 DOI: 10.1016/j.amsu.2021.102569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 07/10/2021] [Accepted: 07/13/2021] [Indexed: 11/29/2022] Open
Abstract
Background Fluorescent cholangiography (FC) during laparoscopic cholecystectomy (LC) is a novel method to facilitate real-time visualization of extrahepatic biliary structures that avoiding risk of bile duct injury. Aims of this study are to investigate the feasibility and the safety of FC during LC. Method We evaluated the outcomes of FC during elective LC at our hospital from August 2017 to April 2018. Fifty-five patients who underwent FC during elective LC were enrolled in this study. Demographic and peri-operative data were recorded and analyzed. The primary endpoints were visualization rate of FC during LC. The secondary endpoint was the optimal conditions and technical details for FC included to detect any potential adverse event. Results The visualization rate after FC of the cystic duct, common hepatic duct and common bile duct were increased significantly compared to before FC. The identification rate of the cystic duct and common bile duct were not associated with BMI and history of acute cholecystitis. Conclusions FC enabled real-time visualization of extrahepatic biliary structures during LC. FC appears to be a safe and efficient approach for elective LC. Bile duct injury is one of the most complication of laparoscopic cholecystectomy. Fluorescent cholangiography is offer real-time detection of the biliary anatomy. Cholangiogram was associated with a low incidence of bile duct injury.
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Affiliation(s)
- Nattawut Keeratibharat
- School of Surgery, Institute of Medicine, Suranaree University of Technology, 111 Mahawitthayalai Ave., Suranaree, Muang, Nakhon Ratchasima, 30000, Thailand
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17
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Askari A, Riaz AA, Brittain R, Zhou J, Irwin S, Talbot M. Benefits of intraoperative cholangiogram for acute cholecystitis. SURGICAL PRACTICE 2021. [DOI: 10.1111/1744-1633.12491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2022]
Affiliation(s)
- Alan Askari
- West Hertfordshire Hospitals NHS Trust Watford UK
| | | | | | - Joel Zhou
- St. George Hospital Sydney New South Wales Australia
| | - Saskia Irwin
- St. George Hospital Sydney New South Wales Australia
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Borie F, Mathonnet M, Deleuze A, Gravié JF, Gugenheim J. The Cost and the Effectiveness of Cholangiography for the Diagnosis and Treatment of a Bile Duct Injury After Difficult Identification of the Cystic Duct. J Gastrointest Surg 2021; 25:1430-1436. [PMID: 32410182 DOI: 10.1007/s11605-020-04640-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Accepted: 04/30/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND This study aims to assess the cost and the effectiveness of intraoperative cholangiography (IOC) for the diagnosis and treatment of a bile duct injury (BDI) after incorrect or difficult identification of the cystic duct (DICD) during a cholecystectomy. METHODS Between 2009 and 2015, 810 surgeons reported 1161 treatment-related adverse events related to the DICD during cholecystectomy in the French REX database; 623 patients (54%) underwent IOC, and 30% (n = 348) of DICD had a BDI. The therapeutic procedures and the treatment costs have been compared between the IOC group (CG) and the group without IOC (WCG). RESULTS The BDI intraoperative diagnosis was significantly higher in the CG: 96% vs. 67% p = 0.001. The number of therapeutic procedure was significantly higher in the WCG OR: 6 (3-10.6). The rate of biliodigestive anastomosis (8.3%) was similar between the both groups. The average cost of cholecystectomy in the at-risk population of DICD was higher in the group that did not undergo IOC (6204 euros vs. 8831 euros). The estimated loss without IOC in the studied population was between 788,170 and 2,039,020 euros. CONCLUSION The IOC was an assurance of quality and cost reduction in the immediate management of the BDI and should be systematic in front of a DICD during a cholecystectomy.
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Affiliation(s)
- Frédéric Borie
- Fédération de chirurgie viscérale et digestive (FCVD), 12, rue BAYARD, 31000, Toulouse, France.
| | - Muriel Mathonnet
- Fédération de chirurgie viscérale et digestive (FCVD), 12, rue BAYARD, 31000, Toulouse, France
| | - Alain Deleuze
- Fédération de chirurgie viscérale et digestive (FCVD), 12, rue BAYARD, 31000, Toulouse, France
| | - Jean-François Gravié
- Fédération de chirurgie viscérale et digestive (FCVD), 12, rue BAYARD, 31000, Toulouse, France
| | - Jean Gugenheim
- Fédération de chirurgie viscérale et digestive (FCVD), 12, rue BAYARD, 31000, Toulouse, France
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Mui J, Mayne DJ, Davis KJ, Cuenca J, Craig SJ. Increasing use of intraoperative cholangiogram in Australia: is it evidence-based? ANZ J Surg 2021; 91:1534-1541. [PMID: 33982363 DOI: 10.1111/ans.16912] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 04/21/2021] [Indexed: 01/12/2023]
Abstract
BACKGROUND The role of routine intraoperative cholangiograms (IOCs) for prevention of bile duct injury (BDI) is contentious. There are recent reports of limited utility of IOC in preventing BDI. In Australia, IOCs are used more frequently than internationally. This study aimed to evaluate the rate of IOC use in Australia and explore potential changes in practice in light of evolving evidence for the utility of IOC. METHODS Data were collated using service item numbers in Medicare Benefits Scheme records on the Australian Government Medicare website, for services claimed between 1 January 2001 and 31 December 2019. These data were used to analyse trends in rates of IOC, cholecystectomy and BDI repair. Data were age-standardized to account for changes in the population over time. RESULTS The number of IOCs claimed increased by 31.8% and cholecystectomies by 7.0% over the study period. Age-standardized service rates per 100 000 persons increased by 5.5 and 32.6, respectively. Rates of IOC per 100 000 cholecystectomies steadily increased across the study period, while BDI repair rates remained low and erratic. CONCLUSION Increasing use of IOC over the last 20 years reflects a trend towards routine rather than selective IOC; however, there is little discernible change in the number of BDIs requiring repair procedures. This suggests that routine IOC use to prevent or minimize BDI is unwarranted. Further investigation is required into the selective IOC use in high-risk patients rather than mandatory use in all patients.
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Affiliation(s)
- Jasmine Mui
- Department of Surgery, St George Hospital, Sydney, New South Wales, Australia
| | - Darren J Mayne
- Public Health Unit, Illawarra Shoalhaven Local Health District, Wollongong, New South Wales, Australia.,School of Public Health, The University of Sydney, Sydney, New South Wales, Australia.,School of Medicine, University of Wollongong, Wollongong, New South Wales, Australia.,Illawarra Health and Medical Research Institute, University of Wollongong, Wollongong, New South Wales, Australia
| | - Kimberley J Davis
- School of Medicine, University of Wollongong, Wollongong, New South Wales, Australia.,Research Central, Illawarra Shoalhaven Local Health District, Wollongong, New South Wales, Australia
| | - Jose Cuenca
- Research Central, Illawarra Shoalhaven Local Health District, Wollongong, New South Wales, Australia
| | - Steven J Craig
- Illawarra Health and Medical Research Institute, University of Wollongong, Wollongong, New South Wales, Australia.,Department of Surgery, Shoalhaven District Memorial Hospital, Illawarra Shoalhaven Local Health District, Wollongong, New South Wales, Australia
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20
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Routine intraoperative cholangiography during laparoscopic cholecystectomy: application of the 2016 WSES guidelines for predicting choledocholithiasis. Surg Endosc 2021; 36:461-467. [PMID: 33523267 PMCID: PMC8741698 DOI: 10.1007/s00464-021-08305-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Accepted: 01/09/2021] [Indexed: 02/07/2023]
Abstract
Background Routine use of intraoperative cholangiography (IOC) during laparoscopic cholecystectomy (LC) for detecting common bile duct stones remains controversial. The 2016 World Society of Emergency Surgery (WSES) guidelines on acute calculous cholecystitis proposed a risk stratification for choledocholithiasis. Our present study aimed to (1) examine the findings of common bile duct (CBD) stones in patients underwent LC with routine use of IOC, and (2) validate the 2016 WSES risk classes for predicting choledocholithiasis. Methods All patients had LC with IOC routinely performed from November 2012 to December 2017 were reviewed retrospectively. Patients were classified into high-, intermediate-, and low-risk groups based on the 2016 WSES risk classes with modification. Results A total of 990 patients with LC and routine IOC were enrolled. CBD stones were detected in 197 (19.9%) patients. The rate of CBD stone detected in low-, intermediate-, high-risk groups were 0%, 14.2%, and 89.6%, respectively. Predictors as following: evidence of CBD stones on abdominal ultrasound or computed tomography, CBD diameter > 6 mm, total bilirubin > 4 mg/dL, bilirubin level = 1.8–4 mg/dL, abnormal liver biochemical test result other than bilirubin, presence of clinical gallstone pancreatitis had statistical significance between patients with and without CBD stones. Major bile duct injury was found in 4 patients (0.4%). All 4 patients had uneventful recovery after repair surgery. Conclusions Based on our study results, the 2016 WSES risk classes for choledocholithiasis could be an effective approach for predicting the risk of choledocholithiasis. Considering its advantages for detecting CBD stones and biliary injuries, the routine use of IOC is still suggested. Supplementary Information The online version contains supplementary material available at 10.1007/s00464-021-08305-4.
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Donnellan E, Coulter J, Mathew C, Choynowski M, Flanagan L, Bucholc M, Johnston A, Sugrue M. A meta-analysis of the use of intraoperative cholangiography; time to revisit our approach to cholecystectomy? Surg Open Sci 2021; 3:8-15. [PMID: 33937738 PMCID: PMC8076912 DOI: 10.1016/j.sopen.2020.07.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 07/16/2020] [Accepted: 07/27/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Despite some evidence of improved survival with intraoperative cholangiography during cholecystectomy, debate has raged about its benefit, in part because of its questionable benefit, time, and resources required to complete. METHODS An International Prospective Register of Systematic Reviews-registered (ID CRD42018102154) meta-analysis following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines using PubMed, Scopus, Web of Science, and Cochrane library from 2003 to 2018 was undertaken including search strategy "intraoperative AND cholangiogra* AND cholecystectomy." Articles scoring ≥ 16 for comparative and ≥ 10 for noncomparative using the Methodological Index for Non-Randomized Studies criteria were included. A dichotomous random effects meta-analysis using the Mantel-Haenszel method performed on Review Manager Version 5.3 was carried out. RESULTS Of 2,059 articles reviewed, 62 met criteria for final analysis. The mean rate of intraoperative cholangiography was 38.8% (range 1.6%-96.4%).There was greater detection of bile duct stones during cholecystectomy with routine intraoperative cholangiography compared with selective intraoperative cholangiography (odds ratio = 3.28, confidence interval = 2.80-3.86, P value < .001). While bile duct injury during cholecystectomy was less with intraoperative cholangiography (0.39%) than without intraoperative cholangiography (0.43%), it was not statistically significant (odds ratio = 0.88, confidence interval = 0.65-1.19, P value = .41). Readmission following cholecystectomy with intraoperative cholangiography was 3.0% compared to 3.5% without intraoperative cholangiography (odds ratio = 0.91, confidence interval = 0.78-1.06, P value = .23). CONCLUSION The use of intraoperative cholangiography still has its place in cholecystectomy based on the detection of choledocholithiasis and the potential reduction of unfavorable outcomes associated with common bile duct stones. This meta-analysis, the first to review intraoperative cholangiography use, identified a marked variation in cholangiography use. Retrospective studies limit the ability to critically define association between intraoperative cholangiography use and bile duct injury.
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Affiliation(s)
- Eoin Donnellan
- Department of Surgery, Letterkenny University Hospital and Donegal Clinical Research Academy, Letterkenny, County Donegal, Ireland
- School of Medicine, National University of Ireland, Galway, Ireland
| | - Jonathan Coulter
- Department of Surgery, Letterkenny University Hospital and Donegal Clinical Research Academy, Letterkenny, County Donegal, Ireland
- EU INTERREG Emergency Surgery Outcome Advancement Project, Centre for Personalised Medicine, Letterkenny, Ireland
| | - Cherian Mathew
- Department of Surgery, Letterkenny University Hospital and Donegal Clinical Research Academy, Letterkenny, County Donegal, Ireland
- School of Medicine, National University of Ireland, Galway, Ireland
| | - Michelle Choynowski
- Department of Surgery, Letterkenny University Hospital and Donegal Clinical Research Academy, Letterkenny, County Donegal, Ireland
| | - Louise Flanagan
- EU INTERREG Emergency Surgery Outcome Advancement Project, Centre for Personalised Medicine, Letterkenny, Ireland
| | - Magda Bucholc
- Intelligent Systems Research Centre, School of Computing, Engineering and Intelligent Systems, Ulster University, Londonderry, Northern Ireland
| | - Alison Johnston
- Department of Surgery, Letterkenny University Hospital and Donegal Clinical Research Academy, Letterkenny, County Donegal, Ireland
| | - Michael Sugrue
- Department of Surgery, Letterkenny University Hospital and Donegal Clinical Research Academy, Letterkenny, County Donegal, Ireland
- EU INTERREG Emergency Surgery Outcome Advancement Project, Centre for Personalised Medicine, Letterkenny, Ireland
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Quiroz HJ, Valencia SF, Willobee BA, Ferrantella AR, Ryon EL, Thorson CM, Sola JE, Perez EA. Utility of routine intraoperative cholangiogram during cholecystectomy in children: A nationwide analysis of outcomes and readmissions. J Pediatr Surg 2021; 56:61-65. [PMID: 33158507 DOI: 10.1016/j.jpedsurg.2020.09.047] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Accepted: 09/22/2020] [Indexed: 01/12/2023]
Abstract
PURPOSE This study aims to determine postoperative outcomes and readmissions in pediatric cholecystectomy with routine intraoperative cholangiogram (IOC) utilization. METHODS The Nationwide Readmissions Database 2010-2014 was queried for all pediatric cholecystectomies. A propensity score-matched analysis (PSMA) with over 30 covariates was performed between cholecystectomy alone (CCY) versus those with routine IOC (CCY + IOC, no biliary obstruction, dilatation, or pancreatitis). χ2 analysis or Mann-Whitney U were used for statistical analysis with p < 0.05 set as significant. RESULTS 34,390 cholecystectomies were performed: 92% were laparoscopic, most were teenage females (75%, 15 years [13-17]) and did not undergo IOC (75%). Postoperative mortality rate was 0.1%. The PSMA cohort comprised of 1412 CCY and 1453 CCY + IOC. Patients with CCY alone had higher rates of 30-day (7% vs 5%), 1-year readmissions (13% vs 11%) and had higher rates of overall complications (22% vs 12%) compared with CCY + IOC, all p < 0.05. Although uncommon, bile duct injuries were more prevalent in CCY (2% vs 0%, p < 0.001), while there was no difference in readmissions for retained stones. Resource utilization was increased in CCY patients, likely due to increased complication rates. CONCLUSION This nationwide PSMA suggests pediatric CCY with routine IOC is associated with decreased readmissions, overall resource utilization, complications, and bile duct injuries. TYPE OF STUDY Retrospective Comparative Study. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Hallie J Quiroz
- Dewitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, FL
| | | | - Brent A Willobee
- Dewitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, FL
| | - Anthony R Ferrantella
- Dewitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, FL
| | - Emily L Ryon
- Dewitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, FL
| | - Chad M Thorson
- Division of Pediatric Surgery, Dewitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Juan E Sola
- Division of Pediatric Surgery, Dewitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Eduardo A Perez
- Division of Pediatric Surgery, Dewitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida.
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Rystedt JML, Wiss J, Adolfsson J, Enochsson L, Hallerbäck B, Johansson P, Jönsson C, Leander P, Österberg J, Montgomery A. Routine versus selective intraoperative cholangiography during cholecystectomy: systematic review, meta-analysis and health economic model analysis of iatrogenic bile duct injury. BJS Open 2020; 5:6056685. [PMID: 33688957 PMCID: PMC7944855 DOI: 10.1093/bjsopen/zraa032] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 09/26/2020] [Accepted: 09/28/2020] [Indexed: 01/07/2023] Open
Abstract
Background Bile duct injury (BDI) is a severe complication following cholecystectomy. Early recognition and treatment of BDI has been shown to reduce costs and improve patients’ quality of life. The aim of this study was to assess the effect and cost-effectiveness of routine versus selective intraoperative cholangiography (IOC) in cholecystectomy. Methods A systematic review and meta-analysis, combined with a health economic model analysis in the Swedish setting, was performed. Costs per quality-adjusted life-year (QALY) for routine versus selective IOC during cholecystectomy for different scenarios were calculated. Results In this meta-analysis, eight studies with more than 2 million patients subjected to cholecystectomy and 9000 BDIs were included. The rate of BDI was estimated to 0.36 per cent when IOC was performed routinely, compared with to 0.53 per cent when used selectively, indicating an increased risk for BDI of 43 per cent when IOC was used selectively (odds ratio 1.43, 95 per cent c.i. 1.22 to 1.67). The model analysis estimated that seven injuries were avoided annually by routine IOC in Sweden, a population of 10 million. Over a 10-year period, 33 QALYs would be gained at an approximate net cost of €808 000 , at a cost per QALY of about €24 900. Conclusion Routine IOC during cholecystectomy reduces the risk of BDI compared with the selective strategy and is a potentially cost-effective intervention.
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Affiliation(s)
- J M L Rystedt
- Department of Surgery, Skane University Hospital, Clinical Sciences, Lund University, Sweden
| | - J Wiss
- Swedish Agency for Health Technology Assessment and Assessment of Social Services (SBU), Stockholm, Sweden
| | - J Adolfsson
- Swedish Agency for Health Technology Assessment and Assessment of Social Services (SBU), Stockholm, Sweden
| | - L Enochsson
- Department of Clinical Sciences, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden.,Department of Surgical and Perioperative Sciences, Umeå University, Umeå, Sweden
| | - B Hallerbäck
- Department of Surgery, Northern Alvsborg Hospital, Trollhattan, Sweden
| | - P Johansson
- PublicHealth&Economics, Stockholm, Sweden.,Research Centre for Health and Welfare, Halmstad University, Halmstad, Sweden
| | - C Jönsson
- Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - P Leander
- Department of Radiology, Skane University Hospital, Malmö, Sweden
| | - J Österberg
- Department of Surgery, Mora Hospital, Mora, Sweden
| | - A Montgomery
- Department of Surgery, Skane University Hospital, Clinical Sciences, Lund University, Sweden
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24
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Pisano M, Allievi N, Gurusamy K, Borzellino G, Cimbanassi S, Boerna D, Coccolini F, Tufo A, Di Martino M, Leung J, Sartelli M, Ceresoli M, Maier RV, Poiasina E, De Angelis N, Magnone S, Fugazzola P, Paolillo C, Coimbra R, Di Saverio S, De Simone B, Weber DG, Sakakushev BE, Lucianetti A, Kirkpatrick AW, Fraga GP, Wani I, Biffl WL, Chiara O, Abu-Zidan F, Moore EE, Leppäniemi A, Kluger Y, Catena F, Ansaloni L. 2020 World Society of Emergency Surgery updated guidelines for the diagnosis and treatment of acute calculus cholecystitis. World J Emerg Surg 2020; 15:61. [PMID: 33153472 PMCID: PMC7643471 DOI: 10.1186/s13017-020-00336-x] [Citation(s) in RCA: 153] [Impact Index Per Article: 38.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Accepted: 09/17/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Acute calculus cholecystitis (ACC) has a high incidence in the general population. The presence of several areas of uncertainty, along with the availability of new evidence, prompted the current update of the 2016 WSES (World Society of Emergency Surgery) Guidelines on ACC. MATERIALS AND METHODS The WSES president appointed four members as a scientific secretariat, four members as an organization committee and four members as a scientific committee, choosing them from the expert affiliates of WSES. Relevant key questions were constructed, and the task force produced drafts of each section based on the best scientific evidence from PubMed and EMBASE Library; recommendations were developed in order to answer these key questions. The quality of evidence and strength of recommendations were reviewed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria (see https://www.gradeworkinggroup.org/ ). All the statements were presented, discussed and voted upon during the Consensus Conference at the 6th World Congress of the World Society of Emergency Surgery held in Nijmegen (NL) in May 2019. A revised version of the statements was voted upon via an online questionnaire until consensus was reached. RESULTS The pivotal role of surgery is confirmed, including in high-risk patients. When compared with the WSES 2016 guidelines, the role of gallbladder drainage is reduced, despite the considerable technical improvements available. Early laparoscopic cholecystectomy (ELC) should be the standard of care whenever possible, even in subgroups of patients who are considered fragile, such as the elderly; those with cardiac disease, renal disease and cirrhosis; or those who are generally at high risk for surgery. Subtotal cholecystectomy is safe and represents a valuable option in cases of difficult gallbladder removal. CONCLUSIONS, KNOWLEDGE GAPS AND RESEARCH RECOMMENDATIONS ELC has a central role in the management of patients with ACC. The value of surgical treatment for high-risk patients should lead to a distinction between high-risk patients and patients who are not suitable for surgery. Further evidence on the role of clinical judgement and the use of clinical scores as adjunctive tools to guide treatment of high-risk patients and patients who are not suitable for surgery is required. The development of local policies for safe laparoscopic cholecystectomy is recommended.
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Affiliation(s)
- Michele Pisano
- General Surgery I, ASST Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Niccolò Allievi
- General Surgery I, ASST Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Kurinchi Gurusamy
- Division of Surgery and Interventional Science, University College London, London, UK
| | | | | | - Djamila Boerna
- Department of Surgery, St. Antonius Ziekenhuis, Nieuwegein, Netherlands
| | - Federico Coccolini
- General Emergency and Trauma Surgery, Pisa University Hospital, Pisa, Italy
| | - Andrea Tufo
- HPB and Liver Transplant Surgery, Royal Free Hospital, London, UK
| | | | - Jeffrey Leung
- Division of Surgery and Interventional Science, University College London, London, UK
| | | | - Marco Ceresoli
- Department of General and Emergency Surgery, University of Milano-Bicocca, Milan, Italy
| | - Ronald V. Maier
- Department of Surgery, Harborview Medical Centre, University of Washington, Seattle, USA
| | - Elia Poiasina
- General Surgery I, ASST Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Nicola De Angelis
- Unit of Digestive and HPB Surgery, CARE Department, Henri Mondor Hospital and University Paris-Est, Creteil, France
| | - Stefano Magnone
- General Surgery I, ASST Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Paola Fugazzola
- General and Emergency Surgery, Bufalini Hospital, Cesena, Italy
| | - Ciro Paolillo
- Emergency Room Brescia Spedali Civili General Hospital, Brescia, Italy
| | - Raul Coimbra
- Comparative Effectiveness and Clinical Outcomes Research Center-CECORC, Riverside University Health System Medical Center, Moreno Valley, CA USA
| | | | - Belinda De Simone
- Department of General Surgery, Azienda USL-IRCSS di Reggio Emilia, Guastalla Hospital, Guastalla, Italy
| | - Dieter G. Weber
- Department of General Surgery Royal Perth Hospital, The University of Western Australia, Perth, Australia
| | - Boris E. Sakakushev
- Research Institute at Medical University Plovdiv/University Hospital St George, Plovdiv, Bulgaria
| | | | - Andrew W. Kirkpatrick
- General, Acute Care, Abdominal Wall Reconstruction, and Trauma Surgery, Foothills Medical Centre, Calgary, AB Canada
| | - Gustavo P. Fraga
- Division of Trauma Surgery, School of Medical Sciences, University of Campinas, Campinas, SP Brazil
| | - Imitaz Wani
- Department of Surgery, Sheri-Kashmir Institute of Medical Sciences, Srinagar, India
| | | | - Osvaldo Chiara
- General Surgery Trauma Team ASST-GOM Niguarda, Milan, Italy
| | - Fikri Abu-Zidan
- Department of Surgery, College of Medicine, UAE University, Al Ain, UAE
| | - Ernest E. Moore
- Ernest E Moore Shock Trauma Center at Denver Health, Denver, CO USA
| | - Ari Leppäniemi
- Abdominal Center Helsinki University Hospital, Helsinki, Finland
| | - Yoram Kluger
- Department of General Surgery, the Rambam Academic Hospital, Haifa, Israel
| | - Fausto Catena
- Emergency Surgery, University Parma Hospital, Parma, Italy
| | - Luca Ansaloni
- General and Emergency Surgery, Bufalini Hospital, Cesena, Italy
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25
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The “critical view of safety (CVS)” cannot be applied—What to do? Strategies to avoid bile duct injuries. Eur Surg 2020. [DOI: 10.1007/s10353-020-00660-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
SummaryLaparoscopic cholecystectomy has become the standard procedure worldwide since the early 1990s for those patients whose gallbladder has to be removed as part of their underlying disease (NIH Consensus Statement 1992). The most common complication is iatrogenic bile duct injury, which has not improved significantly since the introduction of open laparoscopic cholecystectomy as compared with open cholecystectomy. The intraoperative injuries are mostly the result of a misinterpretation of anatomical structures due to severe inflammation or topographical variations. In order to minimize this risk, a number of improved operative techniques and behavioral measures have been formulated. Here, we present methodological and operative possibilities as well as techniques that in unclear situations can help to minimize the risk of intraoperative injuries of the biliary tract and the accompanying vascular system.
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26
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Tufo A, Pisano M, Ansaloni L, de Reuver P, van Laarhoven K, Davidson B, Gurusamy KS. Risk Prediction in Acute Calculous Cholecystitis: A Systematic Review and Meta-Analysis of Prognostic Factors and Predictive Models. J Laparoendosc Adv Surg Tech A 2020; 31:41-53. [PMID: 32716737 DOI: 10.1089/lap.2020.0151] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Background: Laparoscopic cholecystectomy is the main treatment of acute cholecystitis. Although considered relatively safe, it carries 6%-9% risk of major complications and 0.1%-1% risk of mortality. There is no consensus regarding the evaluation of the preoperative risks, and the management of patients with acute cholecystitis is usually guided by surgeon's personal preferences. We assessed the best method to identify patients with acute cholecystitis who are at high risk of complications and mortality. Methods: We performed a systematic review of studies that reported the preoperative prediction of outcomes in people with acute cholecystitis. We searched the Cochrane Library, MEDLINE, EMBASE, WHO ICTRP, ClinicalTrials.gov, and Science Citation Index Expanded until April 27, 2019. We performed a meta-analysis when possible. Results: Six thousand eight hundred twenty-seven people were included in one or more analyses in 12 studies. Tokyo guidelines 2013 (TG13) predicted mortality (two studies; Grade 3 versus Grade 1: odds ratio [OR] 5.08, 95% confidence interval [CI] 2.79-9.26). Gender predicted conversion to open cholecystectomy (two studies; OR 1.59, 95% CI 1.06-2.39). None of the factors reported in at least two studies had significant predictive ability of major or minor complications. Conclusion: There is significant uncertainty in the ability of prognostic factors and risk prediction models in predicting outcomes in people with acute calculous cholecystitis. Based on studies of high risk of bias, TG13 Grade 3 severity may be associated with greater mortality than Grade 1. Early referral of such patients to high-volume specialist centers should be considered. Further well-designed prospective studies are necessary.
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Affiliation(s)
- Andrea Tufo
- HPB and Liver Transplant Surgery, Royal Free Hampstead NHS Foundation Trust, Royal Free Hospital, London, United Kingdom
| | - Michele Pisano
- 1st Surgical Unit, Department of Emergency, Papa Giovanni Hospital XXIII, Bergamo, Italy
| | - Luca Ansaloni
- Department of Emergency and Trauma Surgery, Bufalini Hospital, Cesena, Italy
| | - Philip de Reuver
- Department of Surgery, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Kees van Laarhoven
- Department of Surgery, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Brian Davidson
- HPB and Liver Transplant Surgery, Royal Free Hampstead NHS Foundation Trust, Royal Free Hospital, London, United Kingdom.,Division of Surgery and Interventional Science, University College London, London, United Kingdom
| | - Kurinchi Selvan Gurusamy
- Division of Surgery and Interventional Science, University College London, London, United Kingdom
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27
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O'Neill RS, Wennmacker SZ, Bhimani N, Dijk AH, Reuver P, Hugh TJ. Unsuspected choledocholithiasis found by routine intra‐operative cholangiography during laparoscopic cholecystectomy. ANZ J Surg 2020; 90:2279-2284. [DOI: 10.1111/ans.16016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Revised: 05/08/2020] [Accepted: 05/09/2020] [Indexed: 02/06/2023]
Affiliation(s)
- Robert S. O'Neill
- Upper GI Surgery Unit Royal North Shore Hospital Sydney New South Wales Australia
| | - Sarah Z. Wennmacker
- Department of Surgery Radboud University Medical Center Nijmegen The Netherlands
| | - Nazim Bhimani
- Upper GI Surgery Unit Royal North Shore Hospital Sydney New South Wales Australia
| | - Aafke H. Dijk
- Department of Surgery Academic Medical Center Amsterdam The Netherlands
| | - Philip Reuver
- Department of Surgery Radboud University Medical Center Nijmegen The Netherlands
| | - Thomas J. Hugh
- Upper GI Surgery Unit Royal North Shore Hospital Sydney New South Wales Australia
- Northern Clinical School University of Sydney Sydney New South Wales Australia
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28
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Chen X, Cheng B, Wang D, Zhang W, Dai D, Zhang W, Yu B. Retrograde tracing along "cystic duct" method to prevent biliary misidentification injury in laparoscopic cholecystectomy. Updates Surg 2020; 72:137-143. [PMID: 32008215 DOI: 10.1007/s13304-020-00716-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Accepted: 01/23/2020] [Indexed: 11/26/2022]
Abstract
Bile duct injury remains the most serious complication of laparoscopic cholecystectomy (LC), the main cause was misidentification of cystic duct (CD). The aim of this study was to evaluate the effectiveness and security of retrograde tracing along "cystic duct" (RTACD) method for the prevention of biliary misidentification injury in LC. The conception of RTACD method was first described and then illustrated by simulation dissection with extrahepatic biliary structure charts. A total of 840 patients undergoing LC were selected. After the "CD" was separated during operation, its authenticity was identified by RTACD method according to its course and origin. The "CD" can be clipped/divided only when it was identified to be true CD. Among 840 patients, the initially separated "CD" was identified as actual CD in 831 cases, common hepatic (bile) duct in six cases, accessory right posterior sectoral duct in two cases, and right haptic duct in one case. LCs were successfully finished in 837 patients, and converted to open cholecystectomy in three cases. The average operation time was 64.23 min (range 25-225 min), and the average blood loss was 8.07 ml (range 2-200 ml). No biliary misidentification injury was found. All patients recovered smoothly. No jaundice or abdominal pain was noted in the patients during 1-19 months follow-up. RTACD method is a safe and effective new technique of preventing biliary misidentification injury.
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Affiliation(s)
- Xiaopeng Chen
- First Department of Hepatobiliary Surgery, Affiliated Yijishan Hospital of Wannan Medical College, Wuhu, China.
| | - Bin Cheng
- Department of Hepatobiliary Surgery, Huangshan People's Hospital, Huangshan, China
| | - Dong Wang
- First Department of Hepatobiliary Surgery, Affiliated Yijishan Hospital of Wannan Medical College, Wuhu, China
| | - Wenjun Zhang
- First Department of Hepatobiliary Surgery, Affiliated Yijishan Hospital of Wannan Medical College, Wuhu, China
| | - Dafei Dai
- First Department of Hepatobiliary Surgery, Affiliated Yijishan Hospital of Wannan Medical College, Wuhu, China
| | - Weidong Zhang
- First Department of Hepatobiliary Surgery, Affiliated Yijishan Hospital of Wannan Medical College, Wuhu, China
| | - Beibei Yu
- First Department of Hepatobiliary Surgery, Affiliated Yijishan Hospital of Wannan Medical College, Wuhu, China
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29
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Rhaiem R, Piardi T, Renard Y, Chetboun M, Aghaei A, Hoeffel C, Sommacale D, Kianmanesh R. Preoperative magnetic resonance cholangiopancreatography before planned laparoscopic cholecystectomy: is it necessary? JOURNAL OF RESEARCH IN MEDICAL SCIENCES 2019; 24:107. [PMID: 31949458 PMCID: PMC6950362 DOI: 10.4103/jrms.jrms_281_19] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Revised: 08/01/2019] [Accepted: 10/07/2019] [Indexed: 12/24/2022]
Abstract
Background: The most feared complication of laparoscopic cholecystectomy (LC) is biliary tract injuries (BTI). We conducted a prospective study to evaluate the role of preoperative magnetic resonance cholangiopancreatography (MRCP) in describing the biliary tract anatomy and to investigate its potential benefit to prevent BTI. Materials and Methods: From January 2012 to December 2016, 402 patients who underwent LC with preoperative MRCP were prospectively included. Routine intraoperative cholangiography was not performed. Patients' characteristics, preoperative diagnosis, biliary anatomy, conversion to laparotomy, and the incidence of BTI were analyzed. Results: Preoperative MRCP was performed prospectively in 402 patients. LC was indicated for cholecystitis and pancreatitis, respectively, in 119 (29.6%) and 53 (13.2%) patients. One hundred and five (26%) patients had anatomical variations of biliary tract. Three BTI (0.75%) occurred with a major BTI (Strasberg E) and two bile leakage from the cystic stump (Strasberg A). For these 3 patients, biliary anatomy was modal on MRCP. No BTI occurred in patients presenting “dangerous” biliary anatomical variations. Conclusion: MRCP could be a valuable tool to study preoperatively the biliary anatomy and to recognize “dangerous” anatomical variations. Subsequent BTI might be avoided. Further randomized trials should be designed to assess its real value as a routine investigation before LC.
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Affiliation(s)
- Rami Rhaiem
- Department of Digestive and Hepatobiliary Surgery, Robert Debré University-Hospital, University Champagne-Ardennes, Reims, France
| | - Tullio Piardi
- Department of Digestive and Hepatobiliary Surgery, Robert Debré University-Hospital, University Champagne-Ardennes, Reims, France
| | - Yohann Renard
- Department of Digestive and Hepatobiliary Surgery, Robert Debré University-Hospital, University Champagne-Ardennes, Reims, France
| | - Mikael Chetboun
- Department of Digestive and Hepatobiliary Surgery, Robert Debré University-Hospital, University Champagne-Ardennes, Reims, France
| | - Arman Aghaei
- Department of Digestive and Hepatobiliary Surgery, Robert Debré University-Hospital, University Champagne-Ardennes, Reims, France
| | - Christine Hoeffel
- Department of Radiology, Robert Debré University-Hospital, University Champagne-Ardennes Reims, France
| | - Daniele Sommacale
- Department of Digestive and Hepatobiliary Surgery, Robert Debré University-Hospital, University Champagne-Ardennes, Reims, France
| | - Reza Kianmanesh
- Department of Digestive and Hepatobiliary Surgery, Robert Debré University-Hospital, University Champagne-Ardennes, Reims, France
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30
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Post cholecystectomy bile duct injury: early, intermediate or late repair with hepaticojejunostomy - an E-AHPBA multi-center study. HPB (Oxford) 2019; 21:1641-1647. [PMID: 31151812 DOI: 10.1016/j.hpb.2019.04.003] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2018] [Revised: 03/18/2019] [Accepted: 04/01/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Treatment of bile duct injuries (BDI) during cholecystectomy depends on the severity of injury and the timing of diagnosis. Standard of care for severe BDIs is hepaticojejunostomy. The aim of this retrospective multi-center study was to assess the optimal timing for repair of BDI with hepaticojejunostomy. METHODS Members of the European-African HepatoPancreatoBiliary Association were invited to report all consecutive patients with hepaticojejunostomy after BDI from January 2000 to June 2016. Patients were stratified according to the timing of biliary reconstruction with hepaticojejunostomy: early (day 0-7), intermediate (1-6 weeks) and late (6 weeks-6 months). Primary endpoint was re-intervention >90 days after the hepaticojejunostomy and secondary endpoints were severe 90-day complications and liver-related mortality. RESULTS In total 913 patients from 48 centers were included in the analysis. In 401 patients (44%) the bile duct injury was diagnosed intraoperatively, and 126 patients (14%) suffered from concomitant vascular injury. In multivariable analysis the timing of hepaticojejunostomy had no impact on postoperative complications, the need for re-intervention after 90 days nor liver-related mortality. The rate of re-intervention more than 90 days after the hepaticojejunostomy was significantly increased in male patients but decreased in older patients. Severe co-morbidity increased the risk for liver-related mortality (HR 3.439; CI 1.37-8.65; p = 0.009). CONCLUSION After BDI occurring during cholecystectomy, the timing of biliary reconstruction with hepaticojejunostomy did not have any impact on severe postoperative complications, the need for re-intervention or liver-related mortality. Individualised treatment after iatrogenic bile duct injury is still advisable.
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31
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Pekolj J, Drago J. Controversies in iatrogenic bile duct injuries. Role of video-assisted laparoscopy in the management of iatrogenic bile duct injuries. Cir Esp 2019; 98:61-63. [PMID: 31431255 DOI: 10.1016/j.ciresp.2019.06.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Revised: 06/05/2019] [Accepted: 06/05/2019] [Indexed: 10/26/2022]
Affiliation(s)
- Juan Pekolj
- Unidad de Trasplante Hepático, Servicio de Cirugía General, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina.
| | - Julián Drago
- Servicio de Cirugía General, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
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32
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Abstract
The incidence of biliary injury after laparoscopic cholecystectomy (LC) has shown a declining trend though it may still be twice that as with open cholecystectomy. Major biliary or vasculobiliary injury is associated with significant morbidity. As prevention is the best strategy, the concept of a culture of safe cholecystectomy has been recently introduced to educate surgeons and apprise them of basic tenets of safe performance of LC. Various aspects of safe cholecystectomy include: (1) thorough knowledge of relevant anatomy, various anatomical landmarks, and anatomical variations; (2) an understanding of the mechanisms involved in biliary/vascular injury, the most important being the misidentification injury; (3) identification of various preoperative and intraoperative predictors of difficult cholecystectomy; (4) proper gallbladder retraction; (5) safe use of various energy devices; (6) understanding the critical view of safety, including its doublet view and documentation; (7) awareness of various error traps (e.g., fundus first technique); (8) use of various bailout strategies (e.g., subtotal cholecystectomy) in difficult gallbladder cases; (9) use of intraoperative imaging techniques (e.g., intraoperative cholangiogram) to ascertain correct anatomy; and (10) understanding the concept of time-out. Surgeons should be facile with these aspects of this culture of safety in cholecystectomy in an attempt to reduce the incidence of biliary/vascular injury during LC.
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Affiliation(s)
- Vishal Gupta
- Department of Surgical Gastroenterology, Shatabdi Hospital Phase 1, King George's Medical University, Lucknow 226003, Uttar Pradesh, India.
| | - Gaurav Jain
- Transplant and HPB Surgery, the Iowa Clinic-Iowa Methodist Hospital, Des Moines, IA 50309, United States
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33
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Gupta V, Jain G. Safe laparoscopic cholecystectomy: Adoption of universal culture of safety in cholecystectomy. World J Gastrointest Surg 2019; 11:62-84. [PMID: 30842813 PMCID: PMC6397793 DOI: 10.4240/wjgs.v11.i2.62] [Citation(s) in RCA: 73] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2018] [Revised: 01/06/2019] [Accepted: 01/23/2019] [Indexed: 02/06/2023] Open
Abstract
The incidence of biliary injury after laparoscopic cholecystectomy (LC) has shown a declining trend though it may still be twice that as with open cholecystectomy. Major biliary or vasculobiliary injury is associated with significant morbidity. As prevention is the best strategy, the concept of a culture of safe cholecystectomy has been recently introduced to educate surgeons and apprise them of basic tenets of safe performance of LC. Various aspects of safe cholecystectomy include: (1) thorough knowledge of relevant anatomy, various anatomical landmarks, and anatomical variations; (2) an understanding of the mechanisms involved in biliary/vascular injury, the most important being the misidentification injury; (3) identification of various preoperative and intraoperative predictors of difficult cholecystectomy; (4) proper gallbladder retraction; (5) safe use of various energy devices; (6) understanding the critical view of safety, including its doublet view and documentation; (7) awareness of various error traps (e.g., fundus first technique); (8) use of various bailout strategies (e.g., subtotal cholecystectomy) in difficult gallbladder cases; (9) use of intraoperative imaging techniques (e.g., intraoperative cholangiogram) to ascertain correct anatomy; and (10) understanding the concept of time-out. Surgeons should be facile with these aspects of this culture of safety in cholecystectomy in an attempt to reduce the incidence of biliary/vascular injury during LC.
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Affiliation(s)
- Vishal Gupta
- Department of Surgical Gastroenterology, Shatabdi Hospital Phase 1, King George’s Medical University, Lucknow 226003, Uttar Pradesh, India
| | - Gaurav Jain
- Transplant and HPB Surgery, the Iowa Clinic-Iowa Methodist Hospital, Des Moines, IA 50309, United States
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34
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Serna JC, Patiño S, Buriticá M, Osorio E, Morales CH, Toro JP. Incidencia de lesión de vías biliares en un hospital universitario: análisis de más de 1.600 colecistectomías laparoscópicas. REVISTA COLOMBIANA DE CIRUGÍA 2019. [DOI: 10.30944/20117582.97] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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35
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Safe laparoscopic cholecystectomy: A systematic review of bile duct injury prevention. Int J Surg 2018; 60:164-172. [PMID: 30439536 DOI: 10.1016/j.ijsu.2018.11.006] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2018] [Revised: 10/14/2018] [Accepted: 11/04/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND Since the introduction of laparoscopic cholecystectomy (LC), a substantial increase in bile duct injury (BDI) incidence was noted. Multiple methods to prevent this complication have been developed and investigated. The most suitable method however is subject to debate. In this systematic review, the different modalities to aid in the safe performance of LC and prevent BDI are delineated. MATERIALS AND METHODS A systematic search for articles describing methods for the prevention of BDI in LC was conducted using EMBASE, Medline, Web of science, Cochrane CENTRAL and Google scholar databases from inception to 11 June 2018. RESULTS 90 studies were included in this systematic review. Overall, BDI preventive techniques can be categorized as dedicated surgical approaches (Critical View of Safety (CVS), fundus first, partial laparoscopic cholecystectomy), supporting imaging techniques (intraoperative radiologic cholangiography, intraoperative ultrasonography, fluorescence imaging) and others. Dedicated surgical approaches demonstrate promising results, yet limited research is provided. Intraoperative radiologic cholangiography and ultrasonography demonstrate beneficial effects in BDI prevention, however the available evidence is low. Fluorescence imaging is in its infancy, yet this technique is demonstrated to be feasible and larger trials are in preparation. CONCLUSION Given the low sample sizes and suboptimal study designs of the studies available, it is not possible to recommend a preferred method to prevent BDI. Surgeons should primarily focus on proper dissection techniques, of which CVS is most suitable. Additionally, recognition of hazardous circumstances and knowledge of alternative techniques is critical to complete surgery with minimal risk of injury to the patient.
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Rehman SFU, Ballance L, Rate A. Selective Antegrade Biliary Stenting Aids Emergency Laparoscopic Cholecystectomy. J Laparoendosc Adv Surg Tech A 2018; 28:1495-1502. [PMID: 29993317 DOI: 10.1089/lap.2018.0300] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Background: Symptomatic gall stone disease requires early emergency treatment to prevent complications. This early treatment is often delayed due to difficulty in the diagnosis and management of concomitant choledocholithiasis. Intervention with preoperative endoscopic retrograde cholangiopancreatography (ERCP) is associated with complications and known to be unnecessary in most cases. We follow a strategy of providing early cholecystectomy with selective utility of antegrade stent in cases of choledocholithiasis. Our main aim is to present our technique and results. Method: We conducted a 3-year (January 2014 to January 2017) review of a prospectively maintained database of our practice of performing routine intraoperative cholangiogram (IOC) during laparoscopic cholecystectomy (LC) and when choledocholithiasis is encountered on IOC; a transcystic antegrade biliary stent is inserted to decompress the common bile ducts (CBD) and facilitate postoperative ERCP at later date. Results: Of the 411 cholecystectomies performed, 77.3% were females with mean age of 48 years. Seventy-four patients were found to have CBD stones (CBDS) on IOC. Antegrade stents were successfully deployed in 69 cases. Even though Antegrade stents were done more frequently in emergency admissions (P = .001); this did not increase the length of hospital stay (LOHS) (P = .752) or the rate of complications (P = .171). However, doing a preoperative ERCP significantly increased LOHS (P = .001), and 67% of these needed two or more ERCP for complete clearance of CBD and had more complications. Nine (15.2%) out of 59 patients with pancreatitis had CBDS on IOC and were successfully managed with antegrade stent. Conclusion: This strategy can be followed by general surgeons, enabling them to perform LC in the presence of choledocholithiasis during acute admissions including pancreatitis. It does not require any specialist skills in CBD exploration and also eliminates unnecessary preoperative ERCP and avoids its potential complications.
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Affiliation(s)
- Sheik Fazal Ur Rehman
- Department of General Surgery, Royal Oldham Hospital, Oldham, Manchester, United Kingdom
| | - Laura Ballance
- Department of General Surgery, Royal Oldham Hospital, Oldham, Manchester, United Kingdom
| | - Anthony Rate
- Department of General Surgery, Royal Oldham Hospital, Oldham, Manchester, United Kingdom
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Giménez ME, Houghton EJ, Zeledón ME, Palermo M, Acquafresca P, Finger C, Serra E. THE CRITICAL VIEW OF SAFETY PREVENTS THE APPEARANCE OF BILIARY INJURIES? ANALYSIS OF A SURVEY. ARQUIVOS BRASILEIROS DE CIRURGIA DIGESTIVA : ABCD = BRAZILIAN ARCHIVES OF DIGESTIVE SURGERY 2018; 31:e1380. [PMID: 29972408 PMCID: PMC6044193 DOI: 10.1590/0102-672020180001e1380] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Accepted: 03/22/2018] [Indexed: 12/14/2022]
Abstract
BACKGROUND The risk of bile duct injury (BDI) during cholecystectomy remains a concern, despite efforts proposed for increasing safety. The Critical View of Safety (CVS) has been adopted promoting to reduce its risk. AIM To perform a survey to assess the awareness of the CVS, estimating the proportion of surgeons that correctly identified its elements and its relationship with BDI. METHODS An anonymous online survey was sent to 2096 surgeons inquiring on their common practices during cholecystectomy and their knowledge of the CVS. RESULTS A total of 446 surgeons responded the survey (21%). The percentage of surgeons that correctly identified the elements of CVS was 21.8% and 24.8% among surgeons claiming to know the CVS. The percentage of surgeons that reported BDI was higher among those that incorrectly identified the elements of the CVS (p=0.03). In the multivariate analysis, career length was the most significant factor related to BDI (p=0.002). CONCLUSIONS The percentage of surgeons that correctly identified the Critical View of Safety was low, even among those who claimed to know the CVS. The percentage of surgeons that reported BDI was higher among those that incorrectly identified the elements of the CVS.
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Affiliation(s)
| | - Eduardo Javier Houghton
- Mini-Invasive Surgery, Hospital Bernardino Rivadavia, University of Buenos Aires, Staff DAICIM Foundation
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Iranmanesh P, Tobler O, De Sousa S, Andres A, Frossard JL, Morel P, Toso C. Feasibility, benefit and risk of systematic intraoperative cholangiogram in patients undergoing emergency cholecystectomy. PLoS One 2018; 13:e0199147. [PMID: 29953458 PMCID: PMC6023227 DOI: 10.1371/journal.pone.0199147] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Accepted: 06/01/2018] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND The role of intraoperative cholangiogram (IOC) during cholecystectomy is debated. The aim of the present study was to evaluate the feasibility, benefit and risk of performing systematic IOC in patients undergoing cholecystectomy for acute gallstone-related disease. METHODS Between July 2013 and January 2015, all patients admitted for an acute gallstone-related condition and undergoing same-hospital-stay cholecystectomy were prospectively followed. IOC was systematically attempted and predictors of IOC failure were analyzed. RESULTS Among the 581 enrolled patients, IOC was deliberately not performed in 3 cases. IOC was successful in 509/578 patients (88.1%). The main predictors of IOC failure were age, body mass index, male gender and associated acute cholecystitis. Thirty-two patients with suspected common bile duct stone on IOC underwent 38 unnecessary negative postoperative common bile duct investigations (32/509, 6.3%). There was one IOC-related adverse outcome (mild pancreatitis, 1/578, 0.2%). CONCLUSIONS IOC can be successfully and safely performed in the majority of patients undergoing cholecystectomy for acute gallstone-related disease. Although its positive predictive value is suboptimal and results in a number of unnecessary postoperative common bile duct investigations, IOC accurately rules out common bile duct stones in patients with acute gallstone-related conditions.
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Affiliation(s)
- Pouya Iranmanesh
- Department of Digestive and Transplant Surgery, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
- * E-mail:
| | - Olivier Tobler
- Department of Digestive and Transplant Surgery, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Sandra De Sousa
- Department of Digestive and Transplant Surgery, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Axel Andres
- Department of Digestive and Transplant Surgery, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
- Hepato-Pancreato-Biliary Centre, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Jean-Louis Frossard
- Hepato-Pancreato-Biliary Centre, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
- Department of Gastroenterology, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Philippe Morel
- Department of Digestive and Transplant Surgery, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
- Hepato-Pancreato-Biliary Centre, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Christian Toso
- Department of Digestive and Transplant Surgery, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
- Hepato-Pancreato-Biliary Centre, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
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de Santibañes M, Glinka J, Pelegrini P, Alvarez FA, Elizondo C, Giunta D, Barcan L, Simoncini L, Dominguez NC, Ardiles V, Mazza O, Claria RS, de Santibañes E, Pekolj J. Extended antibiotic therapy versus placebo after laparoscopic cholecystectomy for mild and moderate acute calculous cholecystitis: A randomized double-blind clinical trial. Surgery 2018; 164:S0039-6060(18)30030-8. [PMID: 29506881 DOI: 10.1016/j.surg.2018.01.014] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Revised: 01/08/2018] [Accepted: 01/22/2018] [Indexed: 12/28/2022]
Abstract
BACKGROUND Acute calculous cholecystitis (ACC) is the most common complication of cholelithiasis. Laparoscopic cholecystectomy (LC) is the gold standard treatment in mild and moderate forms. Currently there is consensus for the use of antibiotics in the preoperative phase of ACC. However, the need for antibiotic therapy after surgery remains undefined with a low level of scientific evidence. METHODS The CHART (Cholecystectomy Antibiotic Randomised Trial) study is a single-center, prospective, double blind, and randomized trial. Patients with mild to moderate ACC operated by LC were randomly assigned to receive antibiotic (amoxicillin/clavulanic acid) or placebo treatment for 5 consecutive days. The primary endpoint was postoperative infectious complications. Secondary endpoints were as follows: (1) duration of hospital stay, (2) readmissions, (3) reintervention, and (4) overall mortality. RESULTS In the per-protocol analysis, 6 of 104 patients (5.8%) in the placebo arm and 6 of 91 patients (6.6%) in the antibiotic arm developed postoperative infectious complications (absolute difference 0.82 (95% confidence interval, -5.96 to 7.61, P = .81). The median hospital stay was 3 days. There was no mortality. There were no differences regarding readmissions and reoperations between the 2 groups. CONCLUSION Although this trial failed to show noninferiority of postoperative placebo compared to antibiotic treatment after LC for mild and moderate ACC within a noninferiority margin of 5%, the use of antibiotics in the postoperative period does not seem justified, because it was not associated with a decrease in the incidence of infectious and other types of morbidity in the present study.
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Affiliation(s)
- Martín de Santibañes
- Department of General Surgery, Hospital Italiano de Buenos Aires, Buenos,Aires, Argentina.
| | - Juan Glinka
- Department of General Surgery, Hospital Italiano de Buenos Aires, Buenos,Aires, Argentina
| | - Pablo Pelegrini
- Department of General Surgery, Hospital Italiano de Buenos Aires, Buenos,Aires, Argentina
| | - Fernando A Alvarez
- Department of General Surgery, Hospital Italiano de Buenos Aires, Buenos,Aires, Argentina
| | - Cristina Elizondo
- Department of Internal Medicine and Statistics, Hospital Italiano de Buenos, Aires, Buenos Aires, Argentina
| | - Diego Giunta
- Department of Internal Medicine and Statistics, Hospital Italiano de Buenos, Aires, Buenos Aires, Argentina
| | - Laura Barcan
- Department of Internal Medicine and Infectology, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Lionel Simoncini
- Department of Pharmacy & Pharmacology, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Nora Cáceres Dominguez
- Department of Pharmacy & Pharmacology, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Victoria Ardiles
- Department of General Surgery, Hospital Italiano de Buenos Aires, Buenos,Aires, Argentina
| | - Oscar Mazza
- Department of General Surgery, Hospital Italiano de Buenos Aires, Buenos,Aires, Argentina
| | - Rodrigo Sanchez Claria
- Department of General Surgery, Hospital Italiano de Buenos Aires, Buenos,Aires, Argentina
| | - Eduardo de Santibañes
- Department of General Surgery, Hospital Italiano de Buenos Aires, Buenos,Aires, Argentina
| | - Juan Pekolj
- Department of General Surgery, Hospital Italiano de Buenos Aires, Buenos,Aires, Argentina
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Rystedt JML, Tingstedt B, Montgomery F, Montgomery AK. Routine intraoperative cholangiography during cholecystectomy is a cost-effective approach when analysing the cost of iatrogenic bile duct injuries. HPB (Oxford) 2017; 19:881-888. [PMID: 28716508 DOI: 10.1016/j.hpb.2017.06.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2017] [Revised: 06/03/2017] [Accepted: 06/09/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND The total cost of bile duct injuries (BDIs) in an unselected national cohort of patients undergoing cholecystectomy are unknown. The aim was to evaluate costs associated with treatment of cholecystectomy-related BDIs and to calculate cost effectiveness of routine vs. on-demand intraoperative cholangiography (IOC). METHODS Data from Swedish patients suffering a BDI during a 5 year period were analysed. Questionnaires to investigate loss-of-production and health status (EQ-5D) were distributed to patients who suffered a BDI during cholecystectomy and who underwent uneventful cholecystectomy (matched control group). Costs per quality-adjusted-life-year (QALY) gained by intraoperative diagnosis were estimated for two strategies: routine versus on-demand IOC during cholecystectomy. RESULTS Intraoperative diagnosis, immediate intraoperative repair, and minor BDI were all associated with reduced direct treatment costs compared to postoperative diagnosis, delayed repair, and major BDI (all p < 0.001). No difference was noted in loss-of-production for minor versus major BDIs or between different treatment strategies. The cost per QALY gained with routine intraoperative cholangiography (ICER-incremental cost-effectiveness ratio) to achieve intraoperative diagnosis was €50,000. CONCLUSIONS Intraoperative detection and immediate intraoperative repair is the superior strategy with less than half the cost and superior functional patient outcomes than postoperative diagnosis and delayed repair. The cost per QALY gained (ICER) using routine IOC was considered reasonable.
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Affiliation(s)
| | - Bobby Tingstedt
- Department of Surgery, Clinical Sciences, Lund University, Sweden
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Altieri MS, Yang J, Obeid N, Zhu C, Talamini M, Pryor A. Increasing bile duct injury and decreasing utilization of intraoperative cholangiogram and common bile duct exploration over 14 years: an analysis of outcomes in New York State. Surg Endosc 2017; 32:667-674. [DOI: 10.1007/s00464-017-5719-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2017] [Accepted: 07/10/2017] [Indexed: 12/21/2022]
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Renz BW, Bösch F, Angele MK. Bile Duct Injury after Cholecystectomy: Surgical Therapy. Visc Med 2017; 33:184-190. [PMID: 28785565 PMCID: PMC5527188 DOI: 10.1159/000471818] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Iatrogenic bile duct injuries (IBDI) after laparoscopic cholecystectomy (LC), being one of the most common performed surgical procedures, remain a substantial problem in gastrointestinal surgery. The most important aspect regarding this issue is the prevention of IBDI during index cholecystectomy. Once it occurs, early and accurate diagnosis of IBDI is very important for surgeons and gastroenterologists, because unidentified IBDI may result in severe complications such as hepatic failure and death. Laboratory tests, radiological imaging, and endoscopy play an important role in the diagnosis of biliary injuries. METHODS This review summarizes and discusses the current literature on the management of IBDI after LC from a surgical point of view. RESULTS AND CONCLUSION In general, endoscopic techniques are recommended for the initial diagnosis and treatment of IBDI and are important to classify them correctly. In patients with complete dissection or obstruction of the bile duct, surgical management remains the only feasible option. Different surgical reconstructions are performed in patients with IBDI. According to the available literature, Roux-en-Y hepaticojejunostomy is the most frequent surgical reconstruction and is recommended by most authors. Long-term results are most important in the assessment of effectiveness of IBDI treatment. Apart from that, adequate diagnosis and treatment of IBDI may avoid many serious complications and improve the quality of life of our patients.
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Affiliation(s)
| | | | - Martin K. Angele
- Department of General, Visceral, Vascular and Transplantation Surgery, Ludwig-Maximilians-University (LMU) Munich, Munich, Germany
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SAGES clinical spotlight review: intraoperative cholangiography. Surg Endosc 2017; 31:2007-2016. [PMID: 28364147 DOI: 10.1007/s00464-016-5320-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2016] [Accepted: 10/31/2016] [Indexed: 12/19/2022]
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Rystedt JM, Montgomery AK. Quality-of-life after bile duct injury: intraoperative detection is crucial. A national case-control study. HPB (Oxford) 2016; 18:1010-1016. [PMID: 27773464 PMCID: PMC5144547 DOI: 10.1016/j.hpb.2016.09.003] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2016] [Revised: 09/05/2016] [Accepted: 09/05/2016] [Indexed: 12/12/2022]
Abstract
BACKGROUND Existing reports on quality-of-life (QoL) after bile duct injury (BDI) are conflicting. METHODS Case-control study were QoL assessment was performed using SF-36 (36-item short Form health survey). Patients with BDI were compared to a matched control group (1:2) subject to cholecystectomy. RESULTS In total 168 BDIs (0.3%) were eligible for participation and 64% returned SF-36. Median follow-up was 4.3 years. Intraoperative cholangiography was performed/attempted in 93% of BDI patients and 92% were diagnosed intraoperatively. Lesions <5 mm dominated (59%) and QoL was comparable for BDIs and controls (physical composite score PCS; p = 0.052 and mental composite score MCS; p = 0.478). Patients with an immediate intraoperative repair reported a better PCS than patients subjected to a later repair and/or referral (p = 0.002). No difference in SF-36 was detected when the BDI was repaired by the index compared to non-index surgeon (PCS p = 0.446, MCS p = 0.525). CONCLUSION QoL after bile duct injury is comparable to uneventful cholecystectomy, as long as the injury is diagnosed intraoperatively. Immediate repair, in this cohort of mainly minor injuries, also performed by the index surgeon, resulted in similar QoL as in the control group. We suggest liberal use of cholangiography for early detection of BDI, and intraoperative repair whenever possible.
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Affiliation(s)
- Jenny M.L. Rystedt
- Correspondence Jenny M.L. Rystedt, Department of Surgery, Skåne University Hospital, 221 85 Lund, Sweden. Tel: +46 46171899.Department of SurgerySkåne University HospitalLund221 85Sweden
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Elective laparoscopic cholecystectomy without intraoperative cholangiography: role of preoperative magnetic resonance cholangiopancreatography - a retrospective cohort study. BMC Surg 2016; 16:45. [PMID: 27411676 PMCID: PMC4944431 DOI: 10.1186/s12893-016-0159-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2016] [Accepted: 06/13/2016] [Indexed: 12/19/2022] Open
Abstract
Background Laparoscopic cholecystectomy (LC) is the standard treatment for gallbladder diseases. Intraoperative cholangiography (IOC) can reduce biliary complications of LC; however, with the emergence of magnetic resonance cholangiopancreatography (MRCP), IOC nowadays is faced with unprecedented challenge. The purpose of this study is to evaluate whether preoperative MRCP can safely replace IOC during elective LC in terms of retained common bile duct (CBD) stones and bile duct injury (BDI). Methods A retrospective study on candidates for elective LC who underwent IOC or preoperative MRCP between January 2009 and December 2014 was conducted. Results In the IOC group, 1972 patients underwent LC and 213 required IOC. In the MRCP group, 2268 patients underwent LC and 257 required MRCP. In the IOC group, the rate of retained CBD stones was 0.45 % without IOC and 1.41 % with IOC. In five of 157 patients who underwent IOC, endoscopic retrograde cholangiopancreatography or laparoscopic CBD exploration showed no evidence of CBD stones. In the MRCP group, the rate of retained CBD stones was 0.45 % without MRCP. No patients with normal MRCP findings returned with symptomatic CBD stones during 1-year follow-up. The rate of BDIs was 0.20 % in the IOC group and 0.13 % in the MRCP group. Conclusions Selective use of preoperative MRCP is an effective and safe strategy when conducting elective LC to treat gallstones. LC resorting to preoperative MRCP can be performed safely without IOC, with an acceptable rate of retained CBD stones and BDIs.
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Lammert F, Gurusamy K, Ko CW, Miquel JF, Méndez-Sánchez N, Portincasa P, van Erpecum KJ, van Laarhoven CJ, Wang DQH. Gallstones. Nat Rev Dis Primers 2016; 2:16024. [PMID: 27121416 DOI: 10.1038/nrdp.2016.24] [Citation(s) in RCA: 348] [Impact Index Per Article: 43.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Gallstones grow inside the gallbladder or biliary tract. These stones can be asymptomatic or symptomatic; only gallstones with symptoms or complications are defined as gallstone disease. Based on their composition, gallstones are classified into cholesterol gallstones, which represent the predominant entity, and bilirubin ('pigment') stones. Black pigment stones can be caused by chronic haemolysis; brown pigment stones typically develop in obstructed and infected bile ducts. For treatment, localization of the gallstones in the biliary tract is more relevant than composition. Overall, up to 20% of adults develop gallstones and >20% of those develop symptoms or complications. Risk factors for gallstones are female sex, age, pregnancy, physical inactivity, obesity and overnutrition. Factors involved in metabolic syndrome increase the risk of developing gallstones and form the basis of primary prevention by lifestyle changes. Common mutations in the hepatic cholesterol transporter ABCG8 confer most of the genetic risk of developing gallstones, which accounts for ∼25% of the total risk. Diagnosis is mainly based on clinical symptoms, abdominal ultrasonography and liver biochemistry tests. Symptoms often precede the onset of the three common and potentially life-threatening complications of gallstones (acute cholecystitis, acute cholangitis and biliary pancreatitis). Although our knowledge on the genetics and pathophysiology of gallstones has expanded recently, current treatment algorithms remain predominantly invasive and are based on surgery. Hence, our future efforts should focus on novel preventive strategies to overcome the onset of gallstones in at-risk patients in particular, but also in the population in general.
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Affiliation(s)
- Frank Lammert
- Department of Medicine II, Saarland University Medical Center, Saarland University, Kirrberger Str. 100, 66424 Hamburg, Germany
| | - Kurinchi Gurusamy
- Royal Free Campus, University College London Medical School, 9th Floor, Royal Free Hospital, Rowland Hill Street, London NW3 2PF, UK
| | - Cynthia W Ko
- Department of Medicine, Division of Gastroenterology, University of Washington, Seattle, Washington, USA
| | - Juan-Francisco Miquel
- Department of Gastroenterology, Faculty of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | | | - Piero Portincasa
- Department of Biomedical Sciences and Human Oncology, Clinica Medica "A. Murri", University of Bari Medical School, Bari, Italy
| | - Karel J van Erpecum
- Department of Gastroenterology and Hepatology, University Medical Center, Utrecht, The Netherlands
| | - Cees J van Laarhoven
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - David Q-H Wang
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Saint Louis University School of Medicine, Saint Louis, Missouri, USA
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Impact of intraoperative cholangiography on postoperative morbidity and readmission: analysis of the NSQIP database. Surg Endosc 2016; 30:5395-5403. [PMID: 27105616 DOI: 10.1007/s00464-016-4896-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2015] [Accepted: 03/26/2016] [Indexed: 12/12/2022]
Abstract
BACKGROUND The debate regarding the merits of routine use of intraoperative cholangiography (IOC) during laparoscopic cholecystectomy (LC) continues to rage. We aim to analyze the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database to identify patterns of utilization of cholangiography during LC as well as its impact on patient outcomes. STUDY DESIGN This is a retrospective cohort study of patients undergoing LC with or without IOC in the 2012 and 2013 ACS NSQIP database. Only patients without any preoperative biochemical evidence of the CBD stone were included in the analysis. Comparison between two groups and data analysis focused on the following primary outcomes: 30-day mortality, readmission, return to operating room and NSQIP collected morbidity. RESULTS Twenty-one percentage of patients undergoing LC without any biochemical abnormality are undergoing IOC. There were no statistically significant differences in thirty-day outcomes between two patient populations with regard to mortality, morbidity, cardiac, central nervous system, wound, deep vein thrombosis, sepsis, respiratory and urinary tract complications. Patients undergoing LC plus IOC were found to have statistically significant reduction in the rate of readmission related to the first operation (adjusted odds ratio 0.80, 95 % CI 0.70-0.92; P value = 0.002). Readmissions related to biliary complications including retained CBD following cholecystectomy were 1.61 times more likely in patients who underwent LC without cholangiography. CONCLUSION The use of IOC at the time of LC appears to be associated with a statistically significant decrease in re-admission rates, especially readmissions related to biliary complications.
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Boni L, Fingerhut A. Toward 0% Bile Duct Injury During Laparoscopic Cholecystectomy? Surg Innov 2016; 23:113-114. [DOI: 10.1177/1553350616628685] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Affiliation(s)
| | - Abe Fingerhut
- Department of Surgical Research, University Hospital, Graz, Austria
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El-Dhuwaib Y, Slavin J, Corless DJ, Begaj I, Durkin D, Deakin M. Bile duct reconstruction following laparoscopic cholecystectomy in England. Surg Endosc 2016; 30:3516-25. [PMID: 26830413 PMCID: PMC4956705 DOI: 10.1007/s00464-015-4641-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2015] [Accepted: 10/22/2015] [Indexed: 12/16/2022]
Abstract
Objectives To determine the incidence of bile duct reconstruction (BDR) following laparoscopic cholecystectomy (LC) and to identify associated risk factors. Background Major bile duct injury (BDI) requiring reconstruction is a serious complication of cholecystectomy. Methods All LC and attempted LC operations in England between April 2001 and March 2013 were identified. Patients with malignancy, a stone in bile duct or those who underwent bile duct exploration were excluded. This cohort of patients was followed for 1 year to identify those who underwent BDR as a surrogate marker for major BDI. Logistic regression was used to identify factors associated with the need for reconstruction. Results In total, 572,223 LC and attempted LC were performed in England between April 2001 and March 2013. Five hundred (0.09 %) of these patients underwent BDR. The risk of BDR is lower in patient that do not have acute cholecystitis [odds ratio (OR) 0.48 (95 % CI 0.30–0.76)]. The regular use of on-table cholangiography (OTC) [OR 0.69 (0.54–0.88)] and high consultant caseload >80 LC/year [OR 0.56 (0.39–0.54)] reduced the risk of BDR. Patients who underwent BDR were 10 times more likely to die within a year than those who did not require further surgery (6 vs. 0.6 %). Conclusions The rate of BDR following laparoscopic cholecystectomy in England is low (0.09 %). The study suggests that OTC should be used more widely and provides further evidence in support of the provision of LC services by specialised teams with an adequate caseload (>80).
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Affiliation(s)
- Y El-Dhuwaib
- The Institute for Science and Technology in Medicine, Keele University, Stoke-on-Trent, UK
| | - J Slavin
- The Institute for Science and Technology in Medicine, Keele University, Stoke-on-Trent, UK.,Department of Surgery, Mid Cheshire Hospitals NHS Foundation Trust, Crewe, UK
| | - D J Corless
- Department of Surgery, Mid Cheshire Hospitals NHS Foundation Trust, Crewe, UK
| | - I Begaj
- Health Informatics Department, University Hospitals Birmingham, Birmingham, UK
| | - D Durkin
- Department of Surgery, Royal Stoke University Hospital, Stoke-on-Trent, ST4 6RG, UK
| | - M Deakin
- The Institute for Science and Technology in Medicine, Keele University, Stoke-on-Trent, UK. .,Department of Surgery, Royal Stoke University Hospital, Stoke-on-Trent, ST4 6RG, UK.
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50
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Ozkan OV, Yagmurkaya O, Sahin MF, Gurler AS, Kucuker H. Visualizing biliary tracts with isosulphan blue to prevent injury during laparoscopic cholecystectomy: a preliminary cadaveric study. Surg Radiol Anat 2015; 37:1233-7. [PMID: 26040402 DOI: 10.1007/s00276-015-1502-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2015] [Accepted: 05/29/2015] [Indexed: 12/16/2022]
Abstract
BACKGROUND Bile duct injury (BDI) as a complication of laparoscopic cholecystectomy may result in biliary cirrhosis with a high morbidity-mortality rate. Recurrent invasive procedures may be required for the optimum management. The most frequent causative factor in BDI is anatomical misidentification, particularly by inexperienced surgeons. Direct coloration of the cystic duct, bile duct, and gallbladder may decrease biliary tract injury. METHODS This study was conducted during 10 standard, fresh cadaver autopsies at the Council of Forensic Medicine, Istanbul. Following needle puncture of the gallbladder fundus and aspiration of the bile content, identical quantities of isosulphan blue were injected into the gallbladder to visualize the biliary tract. RESULTS Of the ten fresh cadavers, three were males and seven were females; the mean age at death was 43 years (range 22-76 years). Successful visualization of the colored biliary tract, encompassing the gallbladder, cystic duct, and bile duct, was achieved in all of the cadavers. CONCLUSIONS Visualization of the biliary tract may reduce the risk associated with dissection of Calot's triangle. Surgical BDI risk following anatomical misidentification could be reduced by intraoperative injection of isosulphan blue; further studies are required to validate the clinical utility of this technique.
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Affiliation(s)
- Orhan Veli Ozkan
- Department of General Surgery, Faculty of Medicine, Sakarya University, Adnan Menderes Caddesi, Saglik Sokak No:193, 54100, Sakarya, Turkey.
| | - Orhan Yagmurkaya
- Department of General Surgery, Research and Educational Hospital, Sakarya University, 54100, Sakarya, Turkey
| | | | | | - Hudaverdi Kucuker
- Department of Forensic Medicine, Faculty of Medicine, Dumlupınar University, 43266, Sakarya, Turkey
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