Major biliary complications in 2,714 cases of laparoscopic cholecystectomy without intraoperative cholangiography: a multicenter retrospective study

Comparison of laparoscopic cholecystectomy in children at paediatric centres and adult centres: a systematic review and meta-analysis

INTRODUCTION

Paediatric laparoscopic cholecystectomy (LC) is performed by both paediatric and adult surgeons. The aim of this review was to compare outcomes at paediatric centres (PCs) and adult centres (ACs).

METHODS

A literature search was conducted, in accordance with PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines, for papers published between January 2000 and December 2020. Statistical analysis was performed using Stata® version 16 (StataCorp, College Station, TX, US).

RESULTS

A total of 92 studies involving 74,852 paediatric LCs met the inclusion criteria. Over half (59%) of the LCs were performed at ACs. No significant differences were noted in the male-to-female ratio, mean age or mean body mass index between PCs and ACs. The main indications were cholelithiasis (34.1% vs 34.4% respectively, p=0.83) and biliary dyskinesia (17.0% vs 23.5% respectively, p<0.01). There was no significant difference in the median inpatient stay (2.52 vs 2.44 days respectively, p=0.89). Bile duct injury was a major complication (0.80% vs 0.37% respectively, p<0.01). Reoperation rates (2.37% vs 0.74% respectively, p<0.01) and conversion to open surgery (1.97% vs 4.74% respectively, p<0.01) were also significantly different. Meta-analysis showed no significant difference in overall complications (p=0.92).

CONCLUSIONS

The number of LCs performed, intraoperative cholangiography use and conversion rates were higher at ACs whereas bile duct injury and reoperation rates were higher at PCs. Despite a higher incidence of bile duct injury at PCs, the incidence at both PCs and ACs was <1%. In complex cases, a joint operation by both paediatric and adult surgeons might be a better approach to further improve outcomes. Overall, LC was found to be a safe operation with comparable outcomes at PCs and ACs.

Near-infrared fluorescence cholangiography in dogs: A pilot study

OBJECTIVE

To determine the effect of indocyanine green (ICG) dose and timing of administration on near-infrared fluorescence (NIRF) imaging of the normal canine biliary tree.

STUDY DESIGN

Preclinical prospective study.

ANIMALS

Eight purpose-bred beagles.

METHODS

The dogs were randomized to receive two of four intravenous ICG dose (low [L]:0.05 mg/kg or high [H]:0.25 mg/kg)/time (0 and 3 h prior to NIRF) combinations. NIRF images were collected every 10 min for 120 min. Target (cystic duct)-to-background (liver) ratios were calculated for all timepoints and compared.

RESULTS

ICG cholangiography was successful in all dogs. The contrast ratio was above 1 in the L0 group by 20 min and reached its peak at 100 min. In the H0 group, the ratio was above 1 by 60 min and reached its peak at 90 min. Contrast ratios above 2 (fluorescence twice as bright in the cystic duct compared to the liver) were maintained from 180 to 300 min for L3 and H3 and was achieved after 80 min for L0.

CONCLUSION

Low dose ICG provided better ratios early after injection compared to the high dose which remained highly concentrated in the liver tissue after injection. Both doses provided excellent visualization of the biliary tree at 3 h post injection, low dose ICG provided better ratios from 3 to 5 h post injection. Based on these results, 0.05 mg/kg of ICG administered at anesthetic premedication, or as early as 3 h prior to laparoscopic surgery should yield optimal fluorescence images.

CLINICAL SIGNIFICANCE

This study provides guidelines for NIRF cholangiography in clinically normal dogs.

Impact of fundus-first laparoscopic cholecystectomy for severe cholecystitis

BACKGROUND

The Tokyo Guidelines 2018 proposed fundus-first laparoscopic cholecystectomy (FFLC) as a bailout surgery. This study investigated the clinical impact of FFLC for severe cholecystitis.

METHODS

This study reviewed 772 patients who underwent laparoscopic cholecystectomy (LC) between 2015 and 2018. Of these patients, 171 patients were diagnosed with severe cholecystitis according to our difficulty scoring system. FFLC was not prevalent in our faculty for the first 2 years [early period group (EG)], whereas FFLC was predominantly used for the last 2 years [late period group (LG)]. There were 81 patients (47%) belonging to the EG and 90 patients (53%) in the LG. The clinical data and the surgical outcomes of these patients were retrospectively analyzed.

RESULTS

The difficulty score did not differ between the two groups (11 vs. 11 points, p = 0.846). Patients underwent FFLC significantly more frequently in the LG (63% vs. 12%, p = 0.020). Laparoscopic subtotal cholecystectomy (LSC) was done in 10 patients (11%) of the LG, which was significantly low compared to that in the EG (n = 20, 25%) (p = 0.020). In all patients, LC was safely achieved without bile duct injury or conversion to laparotomy. The incidence of choledocholithiasis was significantly low in the LG (0 vs. 4, p = 0.048). The median postoperative hospital stay was significantly shorter in the LG (6 vs. 4 days, p < 0.001).

CONCLUSION

After the introduction of FFLC, there were significant improvements in the surgical outcomes of LC for severe cholecystitis, including the rate of LSC, incidence of choledocholithiasis, and duration of postoperative hospital stay.

Application of Intraoperative Fluorescence Imaging with Indocyanine Green in the Difficult Gallbladder: A Comparative Study between Indocyanine Green-Guided Fluorescence Cholangiography and Conventional Surgery

Background: In the difficult gallbladder, the rate of bile duct injury (BDI) remains high. To lessen iatrogenic biliary injury, we attempted to utilize indocyanine green (ICG)-guided fluorescence cholangiography during surgery to illuminate the extrahepatic biliary tract. Materials and Methods: According to admission criteria, 38 patients were diagnosed with difficult gallbladder and underwent percutaneous transhepatic gallbladder drainage (PTGBD). Consecutive patients who underwent ICG-assisted laparoscopic biliary surgery (n = 18, ICG group) or conventional laparoscopic biliary surgery (n = 20, white light [WL group) were enrolled in this study. ICG group received ICG fluorescent cholangiography via PTGBD tube during operation; 16 cases of laparoscopic cholecystectomy (LC) and 2 cases of LC plus laparoscopic common bile duct exploration (LC+LCBDE) were performed by fluorescent laparoscopy. In the WL group, 16 cases of LC, 1 case of laparoscopic subtotal cholecystectomy (LSC), and 3 cases of LC+LCBDE were performed under white light without ICG. Result: The biliary system was successfully established in the ICG group. Compared with the WL group, the anatomy of the Calot's triangle with severe abdominal adhesion or local inflammatory edema was more clearly displayed by fluorescence. Laparoscopic surgery was completed in both groups without conversion to laparotomy. There were no significant differences in surgery-related complications (P = .232) and postoperative hospital stay (P = .074) between the two groups. However, compared with the WL group, the ICG group had less intraoperative blood loss (P = .002) and shorter operation duration (P = .006). Conclusion: ICG fluorescence cholangiography has good clinical application value in the difficult gallbladder, which can avoid iatrogenic BDI, reduce surgery-related complications and intraoperative blood loss, and shorten the duration of surgery.

Intraoperative cholangiography 2020: Quo vadis? A systematic review of the literature

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.

A meta-analysis of the use of intraoperative cholangiography; time to revisit our approach to cholecystectomy?

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.

Routine versus selective intraoperative cholangiography during cholecystectomy: systematic review, meta-analysis and health economic model analysis of iatrogenic bile duct injury

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.

Dual common bile duct examination with transcystic choledochoscopy and cholangiography in laparoscopic cholecystectomy for suspected choledocholithiasis: a prospective study

BACKGROUND

Detection of common bile duct (CBD) stones is a major objective of intraoperative cholangiography (IOC) in laparoscopic cholecystectomy (LC). We evaluated the feasibility and safety of the routine use of transcystic choledochoscopy following IOC (dual common bile duct examination: DCBDE), which may improve the diagnostic accuracy of CBD stones and facilitate one-stage clearance, in LC for suspected choledocholithiasis.

METHODS

Between May 2017 and November 2018, 38 patients with suspected choledocholithiasis were prospectively enrolled in this study, regardless of whether they underwent endoscopic sphincterotomy. Transcystic choledochoscopy was routinely attempted following IOC in LC.

RESULTS

Five cases were excluded due to cholecystitis, bile duct anomaly, or liver cirrhosis. DCBDE was performed in the remaining 33 patients. The biliary tree was delineated by IOC in all patients. Subsequently, choledochosope was performed in 32 patients except for one who was found to have pancreaticobiliary malunion in IOC. The scope was successfully passed into the CBD in 25 (78.1%) patients. Choledochoscopy detected 3 (9.4%) cases of cystic duct stones and 4 (12.5%) cases of CBD stones which were not identified by IOC. All those stones were removed via cystic duct. There were no intra- and postoperative complications, except for two cases of wound infection and one case of a transient increase in serum amylase.

CONCLUSIONS

DCBDE in LC is a safe and promising approach for intraoperative diagnosis and one-stage treatment of suspected choledocholithasis.

Natural Orifice Transluminal Endoscopic Surgery: Long-Term Experience with Hybrid Transvaginal Cholecystectomies

Objective. To assess outcome and safety of 571 hybrid natural orifice transluminal endoscopic surgery (NOTES) cholecystectomies. Methods. We retrospectively analyzed all consecutive NOTES cholecystectomies performed at our center between June 2009 and January 2018. All procedures were performed using a hybrid transvaginal technique, including an umbilical small-size trocar. End points, calculated at discharge, 30 and up to 90 days postoperatively, included intra- and postoperative morbidity assessed by the validated Clavien-Dindo classification and the Comprehensive Complication Index (CCI). Special focus was held on outcome and necessity of pre- and postoperative gynecological examinations. Results. We performed 571 hybrid NOTES cholecystectomies within 9 years. The vast majority were elective, 9.6% were emergency cholecystectomies. 6.7% of patients developed at least one complication until discharge, most of them minor (≤grade II). 30- and 90-day complication rates were 10.7% and 11%, respectively. Mean CCI at discharge and postoperative days 30 and 90 was 1.45 (±6.4), 2.3 (±7.7), and 2.4 (±7.8), respectively. Major complications (≥grade IIIa) occurred in 1.6% of patients, and 4 patients required emergency reoperation. No mortality was observed. In 9.8%, an additional abdominal trocar was placed. All patients underwent routine gynecological examination, whereof only 5 were rejected for transvaginal access preoperatively. In no case transvaginal access was discontinued intraoperatively due to gynecological disease. Conclusion. Hybrid NOTES transvaginal cholecystectomy represents a safe and feasible alternative to standard laparoscopic cholecystectomy. Preoperative gynecological examination is no longer routinely necessary, as intraoperative assessment is adequate.

Risk factors for complications after cholecystectomy for common bile duct stones: An EAST multicenter study

BACKGROUND

We sought to prospectively identify risk factors for biliary complications and 30-day readmission after cholecystectomy for choledocholithiasis and gallstone pancreatitis across multiple US hospitals.

METHODS

We performed a prospective, observational study of patients who underwent same admission cholecystectomy for choledocholithiasis and gallstone pancreatitis between 2016 and 2019 at 12 US centers. Patients with prior history of endoscopic retrograde cholangiopancreatography or diagnosis of cholangitis were excluded. We used logistic regression to determine associations between preoperative demographics, labs, and imaging on primary outcomes: postoperative biliary complications and 30-day readmission.

RESULTS

There were 989 patients in the cohort. There were 16 (1.6%) patients with postoperative biliary complications, including intra-abdominal abscesses, endoscopic retrograde cholangiopancreatography-induced pancreatitis, and biliary leaks. Increasing operative time (odds ratio 1.01, 95% confidence interval 1.00-1.01, P = .02), worsening leukocytosis (odds ratio 1.16, 95% confidence interval 1.07-1.25, P = .0002), and jaundice (odds ratio 3.25, 95% confidence interval 1.01-10.42, P = .04) were associated with postoperative biliary complications. There were 36 (3.6%) patients readmitted within 30 days owing to a surgical complication. A prior postoperative biliary complication (odds ratio 7.8, 95% confidence interval 1.63-37.27, P = .01), male sex (odds ratio 2.42, 95% confidence interval 1.2-4.87, P = .01), and index operative duration (odds ratio 1.01, 95% confidence interval 1.00-1.01, P = .03) were associated with 30-day readmission.

CONCLUSION

Among patients undergoing cholecystectomy for common bile duct stones, jaundice, worsening leukocytosis, and longer operations are associated with postoperative biliary complications. A prior biliary complication is also predictive of a 30-day readmission. Surgeons should recognize these factors and avoid prematurely discharging at-risk patients given their propensity to develop complications and require readmission.

Safe laparoscopic subtotal cholecystectomy in the face of severe inflammation in the cystohepatic triangle: a retrospective review and proposed management strategy for the difficult gallbladder

Background

Laparoscopic subtotal cholecystectomy (LSC) can be employed when extensive fibrosis or inflammation of the cystohepatic triangle prohibits safe dissection of the cystic duct and artery. The purpose of this study was to compare postoperative outcomes in patients with severe cholecystitis who underwent laparoscopic cholecystectomy (LC) or LSC.

Methods

In this retrospective study, we compared the postoperative outcomes of patients with severe cholecystitis who underwent LC or LSC between July 2010 and July 2016 at St. Joseph’s Health Centre, Toronto. We further stratified LSC cases on the basis of the extent of gallbladder (GB) dissection and GB remnant closure.

Results

A total of 105 patients who underwent LC and 46 who underwent LSC were included in the study. There were 4 bile duct injuries in the LC group and 0 in the LSC group. Bile leaks (relative risk [RR] 3.4, 95% confidence interval [CI] 1.01–11.5) and subphrenic collections (RR 3.1, 95% CI 1.3–8.0) were more common in the LSC group. Overall postoperative morbidity did not differ significantly between the 2 groups. Postoperative endoscopic retrograde cholangiopancreatography (ERCP) (RR 3.2, 95% CI 1.1–9.5) and biliary stent insertion (RR 4.6, 95% CI 1.2–17.5) were more common in the LSC group. Bile leaks appeared to be more prominent with open GB remnants but all cases of leak were successfully managed with ERCP and biliary stenting.

Conclusion

LSC may mitigate the risk of bile duct injury when dissection into the cystohepatic triangle is unsafe. There were more bile leaks in patients who underwent LSC; however, they were readily managed with endoscopic stents. Long-term biliary fistulae were not observed. LSC should be considered early as a means of completing difficult cholecystectomies safely without the need for cholecystostomy tube or conversion to laparotomy.

Laparoscopic end-to-end biliary reconstruction with T-tube for transected bile duct injury during laparoscopic cholecystectomy

Purpose

This report describes the laparoscopic end-to-end biliary reconstruction with T-tube for transected bile duct injury (BDI) during laparoscopic cholecystectomy.

Methods

We performed a retrospective descriptive analysis for all patients with a transected BDI at a single institution. We collected and analyzed data for injury site and type, reconstruction methods, conversion rate, previous intervention, and outcomes.

Results

Between January 2014 and December 2017, 2,901 patients underwent laparoscopic cholecystectomy at a single institution. Among them, 8 patients experienced a transected BDI during laparoscopic cholecystectomy, so the surgeon performed laparoscopic end-to-end biliary reconstruction with T-tube. Our patient series consisted of 6 women (75%) and 2 men (25%) with a mean age of 48.3 years (median, 49 years; range, 29–77 years). Two cases were converted to open surgery. The most common injured site was the common bile duct (5 of 8, 62.5%). The most common injury type, using Bismuth's classification system, was type I (3 of 8, 37.5%). The mean operating time was 136.8 minutes (median, 135.0 minutes; range, 0–180.0 minutes). The mean hospital stay was 7.0 days (median, 4.5 days, range: 3.0–21.0 days). The mean follow-up was 36.4 months (median, 34.0 months; range, 16.0–63.0 months). We observed one postoperative complication during the follow-up period. The patient had an anastomosis site leakage and was cured after reoperation.

Conclusion

Laparoscopic end-to-end biliary reconstruction with T-tube for transected BDI during laparoscopic cholecystectomy seems to be safe and feasible in selected patients. However, long-term follow-up to identify complications from bile duct stricture remains important.

An Update on Iatrogenic Biliary Injuries: Identification, Classification, and Management

Common bile duct injury is a feared complication of cholecystectomy, with an incidence of 0.1% to 0.6%. A majority of injuries go unnoticed at index operation, and postoperative diagnosis can be difficult. Patient presentation can vary from vague abdominal pain to uncontrolled sepsis and peritonitis. Diagnostic evaluation typically begins with ultrasound or CT scan in the acute setting, and source control is paramount at time of presentation. In a stable patient, hepatobiliary iminodiacetic acid scan can be useful in identifying an ongoing bile leak, which requires intervention. A variety of diagnostic techniques define biliary anatomy. Treatment often requires a multidisciplinary approach.

Hepatic Pedicle Occlusion with the Pringle Maneuver During Difficult Laparoscopic Cholecystectomy Reduces the Conversion Rate

BACKGROUND

In the presence of cholecystitis or portal hypertension, hemorrhage is common during laparoscopic cholecystectomy (LC) because the vessels of Calot's triangle are fragile and tortuous. Bleeding can obstruct surgical field visibility and increase conversion rates and risk of common bile duct injury. The Pringle maneuver is a simple occlusion approach that could limit blood flow from the hepatic pedicle, thus controlling bleeding to provide a clear surgical field to reduce conversion rate. In this study, we aimed to investigate the feasibility, effectiveness and safety of hepatic pedicle occlusion with the Pringle maneuver during difficult LC.

METHODS

From 2011 to 2015, LC with hepatic pedicle occlusion by the Pringle maneuver was performed in 67 patients (Pringle group). Another group of 67 cases with matched clinical parameters where LC was performed without the Pringle maneuver (non-Pringle group) was retrieved from a database to serve as the control group.

RESULTS

The Pringle group had a significantly lower conversion rate (1.49% vs. 11.9%; P = 0.038), less blood loss (37.5 ± 24.1 mL vs. 94.5 ± 67.8 mL; P = 0.002), shorter postoperative hospitalization (2.5 ± 1.4 days vs. 3.5 ± 2.5 days; P = 0.005), and lower cost ($1343 ± $751 USD vs. $1674 ± $609 USD; P = 0.024) than non-Pringle group. There was one case each of bile duct injury and readmission within 30 days because of bile leakage in the non-Pringle group, but none in the Pringle group.

CONCLUSIONS

Hepatic pedicle occlusion could provide a clear surgical field and enable the recognition of structures during LC. The Pringle maneuver offers a feasible and safe approach to lower conversion rates in difficult LC.

Bile duct injuries (BDI) in the advanced laparoscopic cholecystectomy era

BACKGROUND

Laparoscopic cholecystectomy is the most commonly performed laparoscopic procedure. It is superior in nearly every regard compared to open cholecystectomies. The one significant aspect where the laparoscopic approach is inferior regards the association with bile duct injuries (BDI). The BDI rate with laparoscopic cholecystectomy is approximately 0.5%; nearly triple the rate compared to the open approach. We propose that 0.5% BDI rate with the laparoscopic approach is no longer accurate.

METHODS

The National Surgical Quality Improvement Program (NSQIP) registry was retrospectively reviewed. All laparoscopic cholecystectomies performed between 2012 and 2016 were extracted. A total of 217,774 cases meeting inclusion criteria were analyzed. The primary data points were the overall BDI incidence rate and time of diagnosis. BDI were identified by ICD-9 and ICD-10 codes. Secondary data points were variables associated with BDI.

RESULTS

The BDI rate was 0.19%. 77% of cases were diagnosed after the index surgical admission. Intra-operative cholangiography (IOC) use was associated with a higher BDI rate and higher identification rate of a BDI intraoperatively (P value < 0.0001). Resident teaching cases were protective with a RR score of 0.56 (P value < 0.0001). The presence of cholecystitis increased the risk of a BDI with a RR score of 1.20 (P value < 0.0001). There was a low conversion rate of 0.04% however converted cases had a nearly hundredfold increase in BDI at 15% (P value < 0.0001).

CONCLUSIONS

The performance of laparoscopic cholecystectomies in North America is no longer associated with higher BDI rates compared to open. IOC use still is not protective against BDI, and cholecystitis continues to be a risk factor for BDI. When a cholecystectomy requires conversion from a laparoscopic to an open approach the BDI increases a hundredfold; which may raise the concern if this approach is still a safe bailout method for a difficult laparoscopic dissection.

Bile duct injury and morbidity following cholecystectomy: a need for improvement

BACKGROUND

Bile duct injury (BDI) remains the most dreaded complication following cholecystectomy with serious repercussions for the surgeon, patient and entire healthcare system. In the absence of registries, the true incidence of BDI in the United States remains unknown. We aim to identify the incidence of BDI requiring operative intervention and overall complications after cholecystectomy.

METHODS

Utilizing the Truven Marketscan^® research database, 554,806 patients who underwent cholecystectomy in calendar years 2011-2014 were identified using ICD-9 procedure and diagnosis codes. The final study population consisted of 319,184 patients with at least 1 year of continuous enrollment and who met inclusion criteria. Patients were tracked for BDI and other complications. Hospital cost information was obtained from 2015 Premier data.

RESULTS

Of the 319,184 patients who were included in the study, there were a total of 741 (0.23%) BDI identified requiring operative intervention. The majority of injuries were identified at the time of the index procedure (n = 533, 72.9%), with 102 (13.8%) identified within 30-days of surgery and the remainder (n = 106, 14.3%) between 31 and 365 days. The operative cumulative complication rate within 30 days of surgery was 9.84%. The most common complications occurring at the index procedure were intestinal disorders (1.2%), infectious (1%), and shock (0.8%). The most common complications identified within 30-days of surgery included infection (1.5%), intestinal disorders (0.7%) and systemic inflammatory response syndrome (SIRS) (0.7%) for cumulative rates of infection, intestinal disorders, shock, and SIRS of 2.0, 1.9, 1.0, and 0.8%, respectively.

CONCLUSION

BDI rate requiring operative intervention have plateaued and remains at 0.23% despite increased experience with laparoscopy. Moreover, cholecystectomy is associated with a 9.84% 30-day morbidity rate. A clear opportunity is identified to improve the quality and safety of this operation. Continued attention to educational programs and techniques aimed at reducing patient harm and improving surgeon skill are imperative.

Laparoscopic Exploration Can Salvage Recurrent Common Bile Duct Stone after Cholecystectomy

Conventionally, patients suffered from recurrent common bile duct (CBD) stone after cholecystectomy are suggested to be treated with endoscopic retrograde cholangiopancreaticography. This study was designed to explore the feasibility of laparoscopic common bile duct exploration (LCBDE) as a salvage procedure for recurrent CBD calculi after cholecystectomy. A retrospective review was conducted of data from 65 patients who underwent LCBDE for recurrent CBD calculi after cholecystectomy from January 2011 to July 2015. LCBDE was successfully carried out in 61 cases, with a successful rate of 93.8 per cent. Three cases required open conversion because of serious abdominal adhesion, and one case for intraoperative bleeding. Postoperative bile leakage occurred in two cases, and bile peritonitis developed in one case; all these three patients with complications were fully cured by conservative treatment. A postoperative retained CBD stone was found in one patient, which was extracted with endoscopic sphincterotomy. Furthermore, it was found that the mean operative time and length of postoperative hospital stay were much shorter in primary closure group (n = 49) than in T-tube drainage group (n = 12), and the hospital expense was also lower in primary closure group. We suggest that LCBDE could be a novel approach as a salvage procedure for the recurrent CBD stone after cholecystectomy, and we prefer to intraoperative primary closure of CBD if possible.

Laparoscopic Repair of Post-cholecystectomy Bile Duct Injury: an Advance in Surgical Management

Despite widespread advances in laparoscopic surgery, laparoscopic repair of post-cholecystectomy bile duct injury (BDI) has rarely been reported related mainly to technical difficulty. We describe three cases of BDI treated laparoscopically with one illustrated by a video. With our gained experience in hepatic pedicle dissection during laparoscopic pancreaticoduodenectomy, we decided to perform laparoscopic repair of BDI in patients with an intact biliary confluence without vascular injury. Three patients were operated including two women: one was re-operated by subcostal incision for peritonitis and two had undergone cholecystectomy without conversion. Surgical technique is detailed in the manuscript and the video. Laparoscopic repair was performed between 45 and 300 days after cholecystectomy. Surgery lasted between 250 and 270 min with no conversion and no transfusion. The postoperative course was uneventful with a hospital stay ranging from 7 to 9 days. After a mean follow-up of 9-33 months, patients were symptom free with normal liver function tests. The laparoscopic approach can be safely and effectively proposed to a subgroup of patients with BDI. This approach has the advantages of the laparoscopic approach and represents the main new surgical advancement in the management of this complication.

Elective laparoscopic cholecystectomy without intraoperative cholangiography: role of preoperative magnetic resonance cholangiopancreatography - a retrospective cohort study

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.

Gallstones

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.

The Hepaticojejunostomy Technique with Intra-Anastomotic Stent in Biliary Diseases and Its Evolution throughout the Years: A Technical Analysis

Roux-en-Y hepaticojejunostomy (RYHJ) is currently considered as the definitive treatment for iatrogenic bile duct injuries and the principal representative of biliary diversion procedures. This technique has met many milestones of extensive evolution, particularly the last years of concomitant technological evolution (laparoscopic/robotic approach). Anastomotic strictures and leaks, which may have deleterious effects on the survival and quality of life of a patient with biliary obstruction of any cause, made the need of the development of a safe and efficient RYHJ compulsory. The aim of this technical analysis and the juxtaposed discussions is to elucidate with the most important milestones and technical tips and tricks all aspects of a feasible and reliable RYHJ technique that is performed in our center for the last 25 years in around 400 patients.

Beyond the learning curve: incidence of bile duct injuries following laparoscopic cholecystectomy normalize to open in the modern era

BACKGROUND

Early reports of higher complication rates, specifically bile duct injuries, raised concerns over the safety of laparoscopy over open cholecystectomy. This study aims to ascertain the rate, management, and perioperative outcomes of bile duct injury in an era beyond the laparoscopic learning curve.

METHODS

The New York State (NYS) Planning and Research Cooperative System longitudinal administrative database was used to identify patients. From 2005 to 2010, 156,315 patients were identified who had undergone laparoscopic cholecystectomy for symptomatic cholelithiasis or acute or chronic cholecystitis. Patients were then tracked with unique identifiers for common bile duct injury. Common bile duct injury was identified by ICD-9 and CPT diagnosis and procedure codes for patients who subsequently underwent hepatectomy, hepaticojejunostomy, or other bile duct surgery.

RESULTS

From 2005 to 2010, 156,958 patients were identified who had undergone laparoscopic cholecystectomy for symptomatic cholelithiasis or acute or chronic cholecystitis. Of the total patients, 149 patients underwent a biliary duct procedure within a year. Twenty-four of them were diagnosed with gallbladder cancer and excluded, leaving 125 for further analysis. The biliary injuries were identified at a rate of 0.080 %. Thirty-one of those patients (24.8 %) underwent hepatectomy, 40 patients (32.0 %) underwent hepaticoenterostomy, and 54 patients (43.2 %) underwent primary repair of the bile duct. Thirty-two (26 %) patients were repaired on the same day of their initial procedure. Of the remaining 93 patients, 38 (30 %) were repaired within 10 days, seven (6 %) repaired between 11 and 20 days, and 48 (38 %) patients over 21 days from injury.

CONCLUSION

In NYS, the rate of bile duct injury has now decreased to 0.08 % and mirrors the historical figures quoted for open cholecystectomy. This improvement likely reflects increased experience, improved instrumentation, and movement beyond the "learning curve."

Use of floseal hemostatic matrix for control of hemostasis during laparoscopic cholecystectomy for acute cholecystitis: a multicenter historical control group comparison (the GLA study gelatin matrix for acute cholecystitis)

BACKGROUND

In patients with acute cholecystitis undergoing laparoscopic cholecystectomy, bleeding is a common complication that can reduce procedural visibility and worsen outcome. Insufficient hemostasis can also lead to postoperative bleeding that can, in rare cases, be fatal. Topical hemostatic agents are used to ensure adequate hemostasis during laparoscopic cholecystectomy.

SUBJECTS AND METHODS

This prospective, open-label, nonrandomized, historical control group study investigated the use of Floseal(®) (Baxter International, Inc., Deerfield, IL) hemostatic matrix as an adjunct to surgical techniques to achieve hemostasis of the resected areas in patients undergoing laparoscopic cholecystectomy for acute cholecystitis. The primary end point was the rate of complete hemostasis 10 minutes after laparoscopic application of Floseal to the gallbladder bed. Secondary end points included complete hemostasis rates at 2, 4, and 6 minutes, surgery time, laparoscopic procedure to open laparotomy conversion rate, postoperative bleeding rate, and mortality and safety outcomes over the entire follow-up period.

RESULTS

From April to November 2011, 101 consecutive patients were enrolled (51 men; mean age, 61.5±6.2 years). The historical control group of 100 age- and gender-matched patients with acute cholecystitis had undergone laparoscopic cholecystectomy without hemostatic agent. In the Floseal group, bleeding ceased within 10 minutes after laparoscopic application of the hemostatic agent to the gallbladder bed in all patients. The conversion rate was significantly lower in the Floseal group than in the control group (4 versus 12 patients, P<.05).

CONCLUSIONS

Floseal in acute cholecystitis is safe, is effective in controlling bleeding, and results in a lower conversion rate compared with cholecystectomy without hemostatic agents.

Comparing Near-Infrared Imaging with Indocyanine Green to Conventional Imaging During Laparoscopic Cholecystectomy: A Prospective Crossover Study

BACKGROUND

The aim of this study was to test and validate a novel noninvasive method for intraoperative visualization of extrahepatic bile ducts during laparoscopic cholecystectomy. Injury to the common bile duct (CBD) is a rare but major complication of laparoscopic cholecystectomy. Most injuries occur when anatomy is unclear due to the presence of anatomic variations, acute inflammation, or adhesions.

PATIENTS AND METHODS

Thirty patients were included, and each received an intravenous injection of 0.05 mg/kg of indocyanine green (ICG) (ICG-Pulsion(®); PULSION Medical Systems AG, Munich, Germany) prior to the start of surgery. Laparoscopic cholecystectomy was performed according to standard procedures. The CBD and cystic duct (CD) were visualized before and during dissection of the liver hilus using a conventional laparoscopic camera and a recently developed near-infrared (NIR) camera (Olympus, Tokyo, Japan).

RESULTS

Using ICG-NIR, the CBD and CD could be visualized 11 minutes (P=.008) and 8.6 minutes (P=.001) earlier than with a conventional camera. Both early (20/30 patients) and late (26/30 patients) identification of the CBD with ICG-NIR was significantly more frequent compared with conventional images (2/30 and 10/30, respectively; P<.001). One postoperative bilioma required re-admission and endoscopic retrograde cholangiopancreatography with stent placement.

CONCLUSIONS

Identification of the CBD and CD using a low dose of ICG and the NIR camera was both faster and more frequent compared with conventional laparoscopic images during elective laparoscopic cholecystectomy.

Early or Delayed Intervention for Bile Duct Injuries following Laparoscopic Cholecystectomy? A Dilemma Looking for an Answer

Background. To evaluate the effect of timing of management and intervention on outcomes of bile duct injury. Materials and Methods. We retrospectively analyzed 92 patients between 1991 and 2011. Data concerned patient's demographic characteristics, type of injury (according to Strasberg classification), time to referral, diagnostic procedures, timing of surgical management, and final outcome. The endpoint was the comparison of postoperative morbidity (stricture, recurrent cholangitis, required interventions/dilations, and redo reconstruction) and mortality between early (less than 2 weeks) and late (over 12 weeks) surgical reconstruction. Results. Three patients were treated conservatively, two patients were treated with percutaneous drainage, and 13 patients underwent PTC or ERCP. In total 74 patients were operated on in our unit. 58 of them underwent surgical reconstruction by end-to-side Roux-en-Y hepaticojejunostomy, 11 underwent primary bile duct repair, and the remaining 5 underwent more complex procedures. Of the 56 patients, 34 patients were submitted to early reconstruction, while 22 patients were submitted to late reconstruction. After a median follow-up of 93 months, there were two deaths associated with BDI after LC. Outcomes after early repairs were equal to outcomes after late repairs when performed by specialists. Conclusions. Early repair after BDI results in equal outcomes compared with late repair. BDI patients should be referred to centers of expertise and experience.

Association between cholecystectomy with vs without intraoperative cholangiography and risk of common duct injury

IMPORTANCE

Significant controversy exists regarding routine intraoperative cholangiography in preventing common duct injury during cholecystectomy.

OBJECTIVE

To investigate the association between intraoperative cholangiography use during cholecystectomy and common duct injury.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective cohort study of all Texas Medicare claims data from 2000 through 2009. We identified Medicare beneficiaries 66 years or older who underwent inpatient or outpatient cholecystectomy for biliary colic or biliary dyskinesia, acute cholecystitis, or chronic cholecystitis. We compared results from multilevel logistic regression models to the instrumental variable analyses.

INTERVENTIONS

Intraoperative cholangiography use during cholecystectomy was determined at the level of the patients (yes/no), hospitals (percentage intraoperative cholangiography use for all cholecystectomies at the hospital), and surgeons (percentage use for all cholecystectomies performed by the surgeon). Percentage of use at the hospital and percentage of use by surgeon were the instrumental variables.

MAIN OUTCOMES AND MEASURES

Patients with claims for common duct repair operations within 1 year of cholecystectomy were considered as having major common duct injury.

RESULTS

Of 92,932 patients undergoing cholecystectomy, 37,533 (40.4%) underwent concurrent intraoperative cholangiography and 280 (0.30%) had a common duct injury. The common duct injury rate was 0.21% among patients with intraoperative cholangiography and 0.36% among patients without it. In a logistic regression model controlling for patient, surgeon, and hospital characteristics, the odds of common duct injury for cholecystectomies performed without intraoperative cholangiography were increased compared with those performed with it (OR, 1.79 [95% CI, 1.35-2.36]; P < .001). When confounding was controlled with instrumental variable analysis, the association between cholecystectomy performed without intraoperative cholangiography and duct injury was no longer significant (OR, 1.26 [95% CI, 0.81-1.96]; P = .31).

CONCLUSIONS AND RELEVANCE

When confounders were controlled with instrumental variable analysis, there was no statistically significant association between intraoperative cholangiography and common duct injury. Intraoperative cholangiography is not effective as a preventive strategy against common duct injury during cholecystectomy.

Intraoperative management and repair of bile duct injuries sustained during 10,123 laparoscopic cholecystectomies in a high-volume referral center

BACKGROUND

Bile duct injury (BDI) remains the most serious complication of laparoscopic cholecystectomy (LC). The best strategy in terms of timing of repair is still controversial. The purpose of the current study is to review the experience in the intraoperative repair of bile duct injuries sustained during LC at a high-volume referral center.

STUDY DESIGN

Single-institution retrospective analysis of a prospectively collected database. Patients with diagnosis of BDI sustained during LC between October 1991 and November 2010 were extracted.

RESULTS

Among 10,123 LC performed during the study period, 19 patients had a BDI sustained during the procedure. Intraoperative cholangiography was routinely used. Bile duct injury was diagnosed intraoperatively in 17 patients (89.4%). Mean age was 56.4 years (range 18 to 81 years) and 15 patients were women (88%). According to the Strasberg classification of BDI, there were 3 type C lesions, 12 type D lesions, and 2 type E2 lesions. There were no associated vascular injuries. Twelve cases (71%) were converted to open surgery. The repairs included 10 primary biliary closures, 4 Roux-en-Y hepaticojejunostomies, 2 end to end anastomosis, and 1 laparoscopic transpapillary drainage. Postoperative complications occurred in 5 patients (29.4%). During the follow-up period, early biliary strictures developed in 2 patients (11.7%) and were treated by percutaneous dilation and a Roux-en-Y hepaticojejunostomy with satisfactory long-term results.

CONCLUSIONS

The current series represents one of the largest single-center experiences in terms of intraoperative repair of BDI sustained during LC. The results suggest that a high level of intraoperative diagnosis is possible, where intraoperative cholangiography is a useful tool. The intraoperative repair of BDI sustained during LC by experienced hepatobiliary surgeons either by open or laparoscopic approach appears of paramount importance to assure optimal results.

Is routine intraoperative cholangiogram necessary in the twenty-first century? A national view

INTRODUCTION

Intraoperative cholangiogram (IOC) can define biliary ductal anatomy. Routine IOC has been proposed previously. However, current surgeon IOC utilization practice patterns and outcomes are unclear.

METHODS

Nationwide Inpatient Sample 2004-2009 was queried for patients with acute biliary disease undergoing cholecystectomy (CCY). Analyses only included surgeons performing ≥10 CCY/year. We dichotomized surgeons into a routine IOC group vs. selective. Outcomes included bile duct injury, complications, mortality, length of stay, and cost.

RESULTS

Of the nonweighted patients, 111,815 underwent CCY. A total of 4,740 actual surgeon yearly volumes were examined. On average, each surgeon performed 23.6 CCYs and 7.9 IOCs annually, using IOC in 33 % of cases. The routine IOC group used IOC for 96 % of cases, whereas selective IOC group used IOC ∼25 % of the time. Routine IOC surgeons had no difference in mortality (0.4 %) or rate of bile duct injury (0.25 vs. 0.26 %), but higher overall complications (7.3 vs. 6.8 %, p = 0.04). Patients of routine IOC surgeons received more additional procedures and incurred higher costs.

CONCLUSION

Routine IOC does not decrease the rate of bile duct injury, but is associated with significant added cost. Surgeons' routine use of IOC is correlated with increased rates of postsurgical procedures, and is associated with increased overall complications. These data suggest routine IOC may not improve outcomes.

Evidence-based current surgical practice: calculous gallbladder disease

BACKGROUND

Gallbladder disease is common and, if managed incorrectly, can lead to high rates of morbidity, mortality, and extraneous costs. The most common complications of gallstones include biliary colic, acute cholecystitis, common bile duct stones, and gallstone pancreatitis. Ultrasound is the initial imaging modality of choice. Additional diagnostic and therapeutic studies including computed tomography, magnetic resonance imaging, magnetic resonance cholangiopancreatography, endoscopic ultrasound, and endoscopic retrograde cholangiopancreatography are not routinely required but may play a role in specific situations.

DISCUSSION

Biliary colic and acute cholecystitis are best treated with early laparoscopic cholecystectomy. Patients with common bile duct stones should be managed with cholecystectomy, either after or concurrent with endoscopic or surgical relief of obstruction and clearance of stones from the bile duct. Mild gallstone pancreatitis should be treated with cholecystectomy during the initial hospitalization to prevent recurrence. Emerging techniques for cholecystectomy include single-incision laparoscopic surgery and natural orifice transluminal endoscopic surgery. Early results in highly selected patients demonstrate the safety of these techniques. The management of complications of the gallbladder should be timely and evidence-based, and choice of procedures, particularly for common bile duct stones, is largely influenced by facility and surgeon factors.

Bile duct injury during laparoscopic cholecystectomy without intraoperative cholangiography: a retrospective study on 1,100 selected patients

BACKGROUND

Whether to routinely or selectively use intraoperative cholangiography (IOC) during laparoscopic cholecystectomy (LC) has been a controversial issue for many years. Many authors maintain that IOC decreases the rate of biliary complications such as bile duct injuries, biliary leak, and missed common bile duct (CBD) stones. However, in contrast to these claims, many centers have opted to perform LC without IOC. In this retrospective study, the results of a series of 1,100 LCs, all of which involved major biliary complications and which were performed without the use of IOC, were reviewed.

METHODS

Data from 1,100 selected patients (728 females and 372 males) undergoing LC without the use of IOC from January 2003 to November 2011 were analyzed. One hundred and seventy LCs were performed by young surgeons during the learning curve, and 930 by surgeons with over 10 years of experience. Two techniques were used to create pneumoperitoneum: the Veress technique in 319 cases (29%) and the Hasson technique in the remaining 781 cases (71%). Patients with a suspicion of CBD stones were excluded from the study.

RESULTS

Two CBD injuries (0.18%) and three biliary leaks (0.27%) were detected among this group. Thirty-three patients (3%) needed conversion to open cholecystectomy. Missed CBD stones were reported in 4 cases (0.36%). There was no postoperative mortality.

CONCLUSION

LC can be performed safely without the use of IOC and with acceptable low rates of biliary complications. An accurate preoperative evaluation of clinical risk factors, precise operative procedures, and conversion to an open approach in doubtful cases are important measures which must be taken to prevent CBD injury.

Variation in the use of intraoperative cholangiography during cholecystectomy

BACKGROUND

The role of intraoperative cholangiography (IOC) in prevention of common bile duct (CBD) injuries and the management of CBD stones is controversial, and current variation in use of IOC has not been well described.

STUDY DESIGN

Multilevel hierarchical models using data from the Texas Hospital Inpatient Discharge Public Use data files (2001 to 2008) were used to evaluate the percentage of variance in the use of IOC that was attributable to patient, surgeon, and hospital factors.

RESULTS

A total of 176,981 cholecystectomies were performed in 212 hospitals in Texas. There was wide variation in IOC use, ranging from 2.4% to 98.4% of cases among surgeons and 3.7% to 94.8% of cases among hospitals, even after adjusting for case mix differences. The percentage of variance in IOC use attributable to the surgeon was 20.7% and an additional 25.7% was attributable to the hospital. IOC use was associated with increased age, gallstone pancreatitis or CBD stones, Hispanic race, decreased illness severity, insurance, and later year of cholecystectomy. ERCP (24.0% vs 14.9%, p < 0.0001) and CBD exploration (1.63% vs 0.42%, p < 0.0001) were more commonly performed in patients undergoing IOC.

CONCLUSIONS

Uncertainty regarding the benefit of IOC leads to wide variation in use across surgeons and hospitals. The surgeon and hospital are more important determinants of IOC use than measured patient characteristics. Our study highlights the need for further evaluation of comparative effectiveness of IOC in the prevention of CBD injuries and retained stones, taking into account patient risk factors, surgeon skill, cost, and availability of local expertise.

Laparoscopic cholecystectomy as a teaching operation: comparison of outcome between residents and attending surgeons in 1,747 patients

PURPOSE

Standardized surgical training is increasingly confronted with the public demand for high quality of surgical care in modern teaching hospitals. The aim of this study was to compare the results of laparoscopic cholecystectomy (LC) performed by resident surgeons (RS) and attending surgeons (AS).

METHODS

In this retrospective review of prospectively collected data 1,747 LC were performed in a community hospital between 1999 and 2009. Seven hundred seventy operations were performed by RS. Parameters analysed included the duration of operation and length of hospital stay, intraoperative complications, 30-day morbidity and mortality.

RESULTS

Duration of operation was 88 (25-245) min for RS vs. 75 (30-190) min by AS (p = 0.001). Elective operations were shorter when performed by AS (70 (30-190) [AS] vs. 85 (25-240) [RS] min, p = 0.001). Length of hospital stay was shorter in patients treated by RS (4 (1-49) days [RS] vs. 5 (1-83) days [AS], p = 0.1). Intraoperative complications showed no differences between the groups (1.0% [RS] vs. 1.3% [AS], p = 0.6), whereas 30-day morbidity was lower in patients treated by RS (3.8% [RS] vs. 6.2% [AS], p = 0.02). Overall mortality was 0.6% and independent of surgical expertise (0.5% [RS] vs. 0.8% [AS], p = 0.5).

CONCLUSIONS

Provided adequate training, supervision and patient selection, surgical residents are able to perform LC with results comparable to those of experienced surgeons.