The Cost and the Effectiveness of Cholangiography for the Diagnosis and Treatment of a Bile Duct Injury After Difficult Identification of the Cystic Duct

Medical error: From a legal framework to an approach based on surgical risk management

The legal concept of medical error is focused on the liability of professionals and healthcare establishments in the event of patient harm. Encompassing medical hazard and loss of chance, this approach is aimed at determining indemnification for harm following a medical accident occurring in a patient. Risk management associated with an adverse event strives to prevent errors and to minimize their deleterious consequences. Search for medical accident avoidability is the main concept characterizing this approach. Analysis by feedback from operational experience allows professionals to anonymously and non-punitively learn from their mistakes, the key objective being to improve their practices. The objective of the present study was to consider medical or surgical error first in a legal framework and then from a risk management standpoint, thereby enabling the surgeon to better understand the specificities of these approaches with their different purposes and to expressly integrate them in his practice, in such a way as to promote patient and professional safety.

SAGES SAFE CHOLE program changes surgeons practice in France-results of the FCVD implementation of SAFE CHOLE in France

BACKGROUND

With the Society of Gastrointestinal and Endoscopic Surgeons supervision, the Safe Cholecystectomy Task Force (SAFE CHOLE) was translated into French by the the Federation of Visceral and Digestive Surgery (FCVD) and adopted to run on its national e-learning platform for surgical continuing medical education (CME). The objective of this study was to assess the impact of the SAFE CHOLE (SF) program on the knowledge and practice of French surgeons performing cholecystectomy and participating in the FCVD lead CME activity.

METHODS

To obtain CME certification, each participant must fill out three FCVD validated questionnaires regarding (1) the participants' routine practice for cholecystectomy, (2) the participants' knowledge and practice after successful completion of the program, and (3) the educational value of the SC program.

RESULTS

From 2021 to 2022, 481 surgeons completed the program. The overall satisfaction rate for the program was 81%, and 53% of the surgeons were practicing routine cholangiography before the SC program. Eighty percent declared having acquired new knowledge. Fifty-six percent reported a change in their practice of cholecystectomy. Of those, 46% started routinely using the critical view of safety, 12% used a time-out prior transection of vital structures, and 11% adopted routine intraoperative cholangiography. Sixty-seven percent reported performing a sub-total cholecystectomy in case the CVS was unobtainable. If faced with BDI, 45% would transfer to a higher level of care, 33% would seek help from a colleague, and 10% would proceed with a repair. Ninety percent recommended adoption of SC by all general surgeons and 98% reported improvement of patient safety.

CONCLUSIONS

Large-scale implementation of the SC program in France is feasible within a broad group of diverse specialty surgeons and appears to have a significant impact on their practice. These data should encourage other surgeons and health systems to engage in this program.

Selective intraoperative cholangiography should be considered over routine intraoperative cholangiography during cholecystectomy: a systematic review and meta-analysis

BACKGROUND

Decades of debate surround the use of intraoperative cholangiography (IOC) during cholecystectomy. To the present day, the role of IOC is controversial as regards decreasing the rate of bile duct injury (BDI). We aimed to review and analyse the available literature on the benefits of IOC during cholecystectomy.

METHODS

A systematic literature search was performed until 19 October 2020 in five databases using the following search keys: cholangiogra* and cholecystectomy. The primary outcomes were BDI and retained stone rate. To investigate the differences between the groups (routine IOC vs selective IOC and IOC vs no IOC), we calculated weighted mean differences (WMD) for continuous outcomes and relative risks (RR) for dichotomous outcomes, with 95% confidence intervals (CI).

RESULTS

Of the 19,863 articles, 38 were selected and 32 were included in the quantitative synthesis. Routine IOC showed no superiority compared to selective IOC in decreasing BDI (RR = 0.91, 95% CI 0.66; 1.24). Comparing IOC and no IOC, no statistically significant differences were found in the case of BDI, retained stone rate, readmission rate, and length of hospital stay. We found an increased risk of conversion rate to open surgery in the no IOC group (RR = 0.64, CI 0.51; 0.78). The operation time was significantly longer in the IOC group compared to the no IOC group (WMD = 11.25 min, 95% CI 6.57; 15.93).

CONCLUSION

Our findings suggest that IOC may not be indicated in every case, however, the evidence is very uncertain. Further good quality research is required to address this question.