Major bile duct injuries associated with laparoscopic cholecystectomy: effect of surgical repair on quality of life

The difficult laparoscopic cholecystectomy: a narrative review

BACKGROUND/PURPOSE

Laparoscopic cholecystectomy is one of the most commonly performed general surgical procedures. Difficult laparoscopic cholecystectomy is associated with increased operative time, hospital stay, complication rates, open conversion, treatment costs, and mortality. This study aimed to provide a comprehensive literature review on difficult laparoscopic cholecystectomy.

METHODS

A literature search was conducted for articles published in English up to June 2024 using common databases including PubMed/MIDLINE, Web of Science, Google Scholar, and ScienceDirect. Keywords included "safe laparoscopic cholecystectomy", "difficult laparoscopic cholecystectomy", "acute cholecystitis", "prevention of bile duct injuries", "intraoperative cholangiography," "bailout procedure," and "subtotal cholecystectomy". Only clinical trials, systematic reviews/meta-analyses, and review articles were included. Studies involving children, robotic cholecystectomy, single incision laparoscopic cholecystectomy, open cholecystectomy, and cholecystectomy for indications other than gallstone disease were excluded.

RESULTS/DISCUSSION

Emergency laparoscopic cholecystectomy for acute cholecystitis is ideally performed within 72 h of symptom onset, with a maximum window of 7-10 days. Intraoperative cholangiography can help clarify unclear biliary anatomy and detect bile duct injuries. In the "impossible gallbladder", laparoscopic cholecystostomy or gallbladder aspiration may be considered. When dissection of Calot's triangle is deemed hazardous or impossible, the fundus-first approach allows for completion of the procedure with either total cholecystectomy or subtotal cholecystectomy. Subtotal cholecystectomy is effective in preventing bile duct injuries, can be performed laparoscopically, and is currently the best available bailout approach for difficult laparoscopic cholecystectomy.

CONCLUSION

Difficult laparoscopic cholecystectomy is a common clinical scenario that requires a judicious approach by experienced surgeons in appropriate settings. When difficult laparoscopic cholecystectomy is encountered, various bailout strategies are available. Currently, subtotal cholecystectomy is likely the most effective bailout approach.

Clinical and patient-reported outcomes following subtotal cholecystectomy: 10-year single-institution experience

OBJECTIVE

Subtotal cholecystectomy provides a safe, bail-out alternative for difficult gallbladders. However, long-term outcomes comparing fenestrating and reconstituting subtotal cholecystectomy subtypes remain underexplored.

METHODS

This retrospective cohort included patients who underwent subtotal cholecystectomy between 2010 and 2020 within a single hospital system. Subtotal cholecystectomy was identified by parsing operative notes for keywords. Demographic and clinical variables were collected by manual review. Patient-reported outcomes were collected via phone using an abbreviated Gastrointestinal Quality-of-Life Index.

RESULTS

We identified 218 subtotal cholecystectomies, with 113 (51.8%) fenestrating subtotal cholecystectomy and 105 (48.2%) reconstituting subtotal cholecystectomy and a median follow-up of 63 months (interquartile range 27-106). Rates of bile duct injury (0.9% vs 1.0%; P > .99), bile leak (10.6% vs 9.5%; P > .99), and 30-day readmission (7.6% vs 8.0%; P > .99) did not differ between fenestrating and reconstituting subtotal cholecystectomy. For fenestrating subtotal cholecystectomy, the postoperative bile leak rate decreased fourfold when cystic duct closure was achieved (6.0% vs 24.1%; P = .012). Subtotal cholecystectomies completed laparoscopically had fewer postoperative bile leaks (2.9% vs 16.8%; P = .001), fewer wound complications (4.8% vs 13.3%; P = .035), and decreased length of stay (7.00 ± 9.07 vs 10.15 ± 13.50 days; P < .001) compared with open operations. The survey response rate was 38.9% (n = 51/131); 47 patients (92.2%) did not report recurrent biliary pain or postprandial nausea or vomiting, but 19 patients (37.2%) reported dietary restriction. Long-term completion cholecystectomy rate was 0.9%.

CONCLUSION

Given no notable difference in postoperative or quality of life outcomes between subtotal cholecystectomy subtypes, consideration of technique depends on intraoperative conditions. Cystic duct closure during fenestrating subtotal cholecystectomy and laparoscopic completion of subtotal cholecystectomy are associated with improved postoperative outcomes.

Selective vs Routine Cholangiography Across a Health Care Enterprise

Importance

There is sparse literature on whether routine cholangiography (RC) vs selective cholangiography (SC) during cholecystectomy is associated with improved perioperative outcomes, regardless of whether an intraoperative cholangiogram (IOC) is performed.

Objective

To compare perioperative outcomes of cholecystectomy between surgeons who routinely vs selectively perform IOC.

Design, Setting, and Participants

This retrospective cohort study was conducted from January 2015 through June 2023 and took place within the Cleveland Clinic Enterprise, which includes 18 hospitals and 9 ambulatory surgery centers in 2 states (Ohio and Florida). Participants included adult patients who underwent cholecystectomy for benign biliary disease. Data analysis was conducted between July 2023 and August 2024.

Exposure

Routine cholangiography, defined as more than 70% of cholecystectomies performed with IOC per surgeon over the study period.

Main Outcome(s) and Measure(s)

The primary outcome was major bile duct injury (BDI). Hierarchical mixed-effects models with patients nested in hospitals adjusted for individual- and surgeon-level characteristics were used to assess the odds of major BDI and secondary outcomes (minor BDI, operative duration, and perioperative endoscopic retrograde cholangiopancreatography [ERCP]).

Results

A total of 134 surgeons performed 28 212 cholecystectomies with 10 244 in the RC cohort (mean age, 52.71 [SD, 17.78] years; 7102 female participants [69.33%]) and 17 968 in the SC cohort (mean age, 52.33 [SD, 17.72] years; 12 135 female participants [67.54%]). Overall, 26 major BDIs (0.09%) and 105 minor BDIs (0.34%) were identified. Controlling for patient and surgeon characteristics nested in hospitals, RC was associated with decreased odds of major BDI (odds ratio [OR], 0.16; 95% CI, 0.15-0.18) and minor BDI (OR, 0.83; 95% CI, 0.77-0.89) compared with SC. Major BDIs were recognized intraoperatively more often in the RC cohort than the SC cohort (76.9% vs 23.0%; difference, 53.8%; 95% CI, 15.9%-80.2%). Lastly, RC was not significantly associated with increased perioperative ERCP utilization (OR, 1.01; 95% CI, 0.90-1.14) or negative ERCP rate (RC, 27 of 844 [3.2%] vs SC, 57 of 1570 [3.6%]; difference, -0.3%; 95% CI, -1.9% to 1.0%).

Conclusions and Relevance

In this study, RC was associated with decreased odds of major and minor BDI, as well as increased intraoperative recognition of major BDI when it occurred. RC could be considered as a health systems strategy to minimize BDI, acknowledging the overall low prevalence but high morbidity from these injuries.

Development of an artificial intelligence system to indicate intraoperative findings of scarring in laparoscopic cholecystectomy for cholecystitis

BACKGROUND

The surgical difficulty of laparoscopic cholecystectomy (LC) for acute cholecystitis (AC) and the risk of bile duct injury (BDI) depend on the degree of fibrosis and scarring caused by inflammation; therefore, understanding these intraoperative findings is crucial to preventing BDI. Scarring makes it particularly difficult to perform safely and increases the BDI risk. This study aimed to develop an artificial intelligence (AI) system to indicate intraoperative findings of scarring in LC for AC.

MATERIALS AND METHODS

An AI system was developed to detect scarred areas using an algorithm for semantic segmentation based on deep learning. The training dataset consisted of 2025 images extracted from LC videos of 21 cases with AC. External evaluation committees (EEC) evaluated the AI system on 20 cases of untrained data from other centers. EECs evaluated the accuracy in identifying the scarred area and the usefulness of the AI system, which were assessed based on annotation and a 5-point Likert-scale questionnaire.

RESULTS

The average DICE coefficient for scarred areas between AI detection and EEC annotation was 0.612. The EEC's average detection accuracy on the Likert scale was 3.98 ± 0.76. AI systems were rated as relatively useful for both clinical and educational applications.

CONCLUSION

We developed an AI system to detect scarred areas in LC for AC. Since scarring increases the surgical difficulty, this AI system has the potential to reduce BDI.

Magnetic compression anastomosis for the treatment of complete biliary obstruction after cholecystectomy

BACKGROUND AND AIMS

Post-cholecystectomy biliary strictures can be treated surgically or nonsurgically. Although endoscopic or percutaneous treatments are the preferred approaches, these methods are not feasible in cases in which complete stricture occlusion prevents the successful passage of a guidewire. The utility of magnetic compression anastomosis (MCA) in patients with post-cholecystectomy complete biliary obstruction that cannot be treated conventionally was evaluated.

METHODS

MCA was performed in 10 patients with post-cholecystectomy biliary strictures that did not resolve with conventional endoscopic or percutaneous treatment. One magnet was delivered through the percutaneous transhepatic biliary drainage tract, and another was advanced via ERCP of the common bile duct. After magnet approximation and recanalization, a fully covered self-expandable metal stent (FCSEMS) was placed for 3 months and then replaced for an additional 3 months. Stricture resolution was evaluated after FCSEMS removal.

RESULTS

Among the 10 patients who underwent MCA for post-cholecystectomy biliary stricture, the biliary injury was Strasberg type B in 2, type C in 3, and type E in 5. Recanalization was successful in all patients (technical success rate, 100%). The mean follow-up period after recanalization was 50.2 months (range, 13.2-116.8 months). Partial restenosis after MCA occurred in 2 patients at 24.1 and 1.6 months after stent removal. ERCP with FCSEMS placement resolved the recurrent stenosis in both patients.

CONCLUSIONS

MCA is a useful nonsurgical alternative treatment for complete biliary obstruction after cholecystectomy that cannot be resolved by use of conventional methods.

Critical View of Safety Assessment in Laparoscopic Cholecystectomy via Segment Anything Model

Laparoscopic Cholecystectomy (LC) is a minimally invasive surgery for the removal of diseased gallbladders. Compared to traditional open cholecystectomy, LC procedures is associated with significantly shorter recovery period, but has an increased chance of bile duct injuries (BDIs). Critical view of safety (CVS) is an important validation method and safety protocol which has a set of conditions that can be visually identified during LC surgeries. In this paper, we approach the problem of automated CVS prediction by combining state-of-the-art object detection methods and prompting the Segment Anything model to achieve more accurate localization of anatomical structures and classification of CVS conditions. When evaluated on our dataset of 5,750 frames with CVS annotations, our method achieved competitive results on frame-level CVS condition prediction, and around 20% improvement on video-level CVS assessment compared to previous SoTA LG-CVS.

Application of 3-Step Laparoscopic Cholecystectomy in Acute Difficult Cholecystitis

BACKGROUND

With the aging of the global population, the incidence rate of acute cholecystitis is increasing. Laparoscopic cholecystectomy is considered as the first choice to treat acute cholecystitis. How to effectively avoid serious intraoperative complications such as bile duct and blood vessel injury is still a difficult problem that puzzles surgeons. This paper introduces the application of laparoscopic cholecystectomy, a new surgical concept, in acute difficult cholecystitis.

METHODS

This retrospective analysis was carried out from January 2019 to January 2021. A total of 36 patients with acute difficult cholecystitis underwent 3-step laparoscopic cholecystectomy. The general information, clinical features, surgical methods, surgical results, and postoperative complications of the patients were analyzed.

RESULTS

All patients successfully completed the surgery, one of them was converted to laparotomy, and the other 35 cases were treated with 3-step laparoscopic cholecystectomy. Postoperative bile leakage occurred in 2 cases (5.56%), secondary choledocholithiasis in 1 case (2.78%), and hepatic effusion in 1 case (2.78%). No postoperative bleeding, septal infection, and other complications occurred, and no postoperative colon injury, gastroduodenal injury, liver injury, bile duct injury, vascular injury, and other surgery-related complications occurred. All 36 patients were discharged from hospital after successful recovery. No one died 30 days after surgery, and there was no abnormality in outpatient follow-up for 3 months after surgery.

CONCLUSIONS

Three-step laparoscopic cholecystectomy seems to be safer and more feasible for acute difficult cholecystitis patients. Compared with traditional laparoscopic cholecystectomy or partial cholecystectomy, 3-step laparoscopic cholecystectomy has the advantages of safe surgery and less complications, which is worth trying by clinicians.

Development of an artificial intelligence system for real-time intraoperative assessment of the Critical View of Safety in laparoscopic cholecystectomy

BACKGROUND

The Critical View of Safety (CVS) was proposed in 1995 to prevent bile duct injury during laparoscopic cholecystectomy (LC). The achievement of CVS was evaluated subjectively. This study aimed to develop an artificial intelligence (AI) system to evaluate CVS scores in LC.

MATERIALS AND METHODS

AI software was developed to evaluate the achievement of CVS using an algorithm for image classification based on a deep convolutional neural network. Short clips of hepatocystic triangle dissection were converted from 72 LC videos, and 23,793 images were labeled for training data. The learning models were examined using metrics commonly used in machine learning.

RESULTS

The mean values of precision, recall, F-measure, specificity, and overall accuracy for all the criteria of the best model were 0.971, 0.737, 0.832, 0.966, and 0.834, respectively. It took approximately 6 fps to obtain scores for a single image.

CONCLUSIONS

Using the AI system, we successfully evaluated the achievement of the CVS criteria using still images and videos of hepatocystic triangle dissection in LC. This encourages surgeons to be aware of CVS and is expected to improve surgical safety.

Fluorescence cholangiography for laparoscopic cholecystectomy: how, when, and why? A single-center preliminary study

INTRODUCTION

Bile duct injuries avoidance is a key goal of biliary surgery. In this prospective study we evaluate the safety and feasibility of ICG fluorescent cholangiography during laparoscopic cholecystectomy (LC) focusing on the optimization of timing and dose administration.

MATERIAL AND METHODS

From February to December 2022 fifty-four LC were performed with fluorescence imaging in our surgical department. 2.5 mg ICG were administered intravenously between 5 h and 24 h before surgery. Near-infrared fluorescent cholangiography (NIRF-C) was performed. Adequate fluorescence was evaluated by comparing agent accumulation in the gallbladder and the extrahepatic duct and the background of liver parenchyma.

RESULTS

Biliary anatomy was identified in all cases. Median time of ICG administration was 11 h previous surgery and three groups of patients were identified: group A receiving ICG 5-9 h, group B 10-14 h, group C 15-24 h before surgery. Peak contrast was gained in group B, with minimal fluorescence of liver parenchyma and more intense visibility of the biliary tract. Intraoperative cholangiogram was unnecessary in all cases.

CONCLUSION

Fluorescent cholangiography during LC is safe and feasible overcoming the limits of other techniques available. 2.5 mg ICG administered 10-14 h before surgery produces optimal outcomes for near-infrared (NIR) fluorescent cholangiography.

Implications of routine cholangiography during laparoscopic cholecystectomy on postoperative testing: Review of more than 2,300 cases in a community-based practice

BACKGROUND

We hypothesized that routine cholangiography during laparoscopic cholecystectomy may increase use of postoperative imaging and invasive testing.

METHODS

A retrospective review was performed of laparoscopic cholecystectomy cases at 6 community hospitals from 2017 through 2020. For surgeons performing routine vs selective cholangiography, we compared primary outcomes of operative time, 30-day complications, and postoperative imaging or procedures.

RESULTS

In total, 2359 laparoscopic cholecystectomy procedures were performed. Eighteen surgeons performed routine cholangiography (1125 cases), and 13 performed selective (1234 cases). Mean operative time was longer in the routine group (125.3 vs 98.7 min, P < .001). Between groups, 30-day complications were similar. Two common bile duct injuries were identified in the routine group. Postoperatively, the routine group underwent 2.5 times more imaging and invasive testing (P < .001).

CONCLUSIONS

In community hospitals, laparoscopic cholecystectomy can be performed safely by surgeons using cholangiography routinely or selectively. Routine cholangiography resulted in more postoperative imaging and invasive testing.

Post-cholecystectomy major bile duct injury: ideal time to repair based on a multicentre randomized controlled trial with promising results

BACKGROUND

Bile duct injury (BDI) is one of the serious complications of cholecystectomy procedures, which has a disastrous impact on long-term survival, health-related quality of life (QoL), healthcare costs as well as high rates of litigation. The standard treatment of major BDI is hepaticojejunostomy (HJ). Surgical outcomes depend on many factors, including the severity of the injury, the surgeons' experiences, the patient's condition, and the reconstruction time. The authors aimed to assess the impact of reconstruction time and abdominal sepsis control on the reconstruction success rate.

METHODS

This is a multicenter, multi-arm, parallel-group, randomized trial that included all consecutive patients treated with HJ for major post-cholecystectomy BDI from February 2014 to January 2022. Patients were randomized according to the time of reconstruction by HJ and abdominal sepsis control into group A (early reconstruction without sepsis control), group B (early reconstruction with sepsis control), and group C (delayed reconstruction). The primary outcome was successful reconstruction rate, while blood loss, HJ diameter, operative time, drainage amount, drain and stent duration, postoperative liver function tests, morbidity and mortality, number of admissions and interventions, hospital stay, total cost, and patient QoL were considered secondary outcomes.

RESULTS

Three hundred twenty one patients from three centres were randomized into three groups. Forty-four patients were excluded from the analysis, leaving 277 patients for intention to treat analysis. With univariate analysis, older age, male gender, laparoscopic cholecystectomy, conversion to open cholecystectomy, failure of intraoperative BDI recognition, Strasberg E4 classification, uncontrolled abdominal sepsis, secondary repair, end-to-side anastomosis, diameter of HJ (< 8 mm), non-stented anastomosis, and major complications were risk factors for successful reconstruction. With multivariate analysis, conversion to open cholecystectomy, uncontrolled sepsis, secondary repair, the small diameter of HJ, and non-stented anastomosis were the independent risk factors for the successful reconstruction. Also, group B patients showed decreased admission and intervention rates, decreased hospital stay, decreased total cost, and early improved patient QoL.

CONCLUSION

Early reconstruction after abdominal sepsis control can be done safely at any time with comparable results for delayed reconstruction in addition to decreased total cost and improved patient QoL.

How much is the long-term quality of life impaired in cholecystectomy-related biliary tract injury?

Objectives

Iatrogenic bile duct injury (IBDI) is a serious complication of cholecystectomy that may crucially affect long-term quality of life and have major morbidities. Furthermore, even after reconstructive surgical treatment, such injuries still reduce the long-term quality of life. Therefore, there remains a need to investigate long-term quality of life of the patients since it is considered that there is a long-term decrease in both physical and mental quality of life. Accordingly, this study aimed to investigate the clinical evaluations and long-term quality of life of the patients who had undergone reconstructive surgery for iatrogenic bile duct injury.

Material and Methods

This clinical study included 49 patients (38 females/11 males) with cholecystectomy-associated bile duct injury and who underwent reconstruction surgery. Several parameters, including the type of bile duct injury, reconstructive surgical procedures, length of hospital stay, and complications were evaluated. Moreover, the effects of reconstructive surgical timing (perioperative, early postoperative, late postoperative) on quality of life were assessed. Long term quality of life (LTQL) levels were evaluated using the SF-36 questionnaire in patients whose follow-ups ranged from two to nine years. The SF-36 questionnaire scores were compared to the average SF-36 norm values of the healthy Turkish population.

Results

Our results showed that 73.5% of biliary tract injuries occurred after a laparoscopic surgery while 26.5% after open cholecystectomy. Of the injuries, 32.7% developed in patients with acute cholecystitis. Thirty of the patients were treated with hepaticojejunostomy. When SF-36 questionnaire scores of the study were compared to those of the healthy Turkish population, energy-vitality was found to be lower significantly in male patients (p= 0.041). However, there was no significant deterioration in female patients. Although general health perception was better in hepaticojejunostomy according to the type of reconstructive surgery performed, no significant difference was observed in the quality of life. Mental health, energy-vitality (p= 0.019), and general health perception (p= 0.026) were found to be lower in women who had E¹ -E² injuries. Only seven of the injuries were detected perioperatively. Physical function (p= 0.033) and general health perception (p= 0.035) were found to be lower in the early postoperative treatment group in male patients in terms of the time of reconstructive surgery.

Conclusion

IBDIs cause serious morbidity. Furthermore, even after reconstructive surgical treatment, such injuries still reduce LTQL. Our results suggest that LTQL is lower, especially in male patients undergoing postoperative early biliary repair for Strasberg E³ -E⁴ type injuries.

Sex Differences in Presentation and Surgical Outcomes From a Prospective Multicenter Chronic Rhinosinusitis Study

OBJECTIVE

Despite extensive research into chronic rhinosinusitis (CRS) epidemiology, presentation, and outcomes, there is scant knowledge on sex-specific differences. The objective of this study was to identify differences between male and female patients with CRS in baseline disease severity at presentation, choice for surgery vs continued medical treatment, and postoperative response.

STUDY DESIGN

We evaluated data on demographic and health characteristics, clinical objective disease measures, and sinus-specific and general health patient-reported outcome measures.

SETTING

Secondary analysis of prospective multicenter outcome study.

METHODS

Comparison of cohort characteristics and baseline and postoperative measures was performed with a t test, chi-square test of independence, or Fisher exact test. Within-subject improvement was compared between sexes with a linear mixed model.

RESULTS

Females reported worse quality of life on presentation and postsurgery, despite experiencing less severe disease by standard clinical measures. Overall, females and males showed similar within-subject improvement after surgery. However, certain quality of life domains and disease measures showed sex-specific improvement. Females demonstrated greater within-subject improvement in SF6D-derived health utility and the SNOT-22 ear and facial, psychological, and sleep subdomains, although this did not reach statistical significance for the overall cohort.

CONCLUSION

Incorporating data on sex-specific differences may be important to personalize CRS treatment decision making. The discordance between patient-reported and clinical measures in CRS has been demonstrated in other pathologies and appears to be exaggerated by sex. Biological and psychological bases for sex-specific differences in CRS manifestations are an intriguing topic for further research.

Bile duct injury following cholecystectomy: delayed referral to a tertiary care center is strongly associated with malpractice litigation

BACKGROUND

Bile duct injury (BDI) following cholecystectomy is associated with malpractice litigation. Aim of this study was to evaluate risk factors for litigation in patients with BDI referred in a tertiary care center.

METHODS

Patients treated for BDI between 1994 and 2016. Stabilized inverse probability therapy weighting was used and multivariable logistic regression analysis identified risk factors for malpractice litigation.

RESULTS

Of the 211 treated patients, 98 met the inclusion criteria: early-referral group (<20 days; 51.0%), late-referral (≥20 days; 49.0%). 36 patients (36.7%) initiated malpractice litigation with verdict in favor of plaintiff in 86.7% of cases (median payment = €90 500, up to €600 000). Attempts at surgical and endoscopic repair before referral were significantly higher in late-referral group. Failed postoperative management (delayed referral, attempts at repair before referral) was one of the strongest predictors for litigation. Risk of litigation progressively increased from 23.8%, when referral time was within 19 days, to 54.5% (61-120 days), to 60.0% (121-210 days) and to 65.1% (211-365 days).

DISCUSSION

Litigation rate after BDI was 37%. Delayed referral to tertiary care center was one of the strongest predictors for litigation. Prompt referral to tertiary experienced centers without any attempt at repair may reduce the risk of litigation.

Simultaneous early surgical repair of post-cholecystectomy major bile duct injury and complex abdominal evisceration: A case report

BACKGROUND

Major bile duct injuries (BDIs) are hazardous complications during 0.4%-0.6% of laparoscopic cholecystectomies. Major BDIs usually require surgical repair, ideally either immediately or at least six weeks after the damage. The complexity of our case lies in the coexistence of early BDI followed by 2-week biliary peritonitis with massive midline evisceration which, in combination, has over 40% mortality risk.

METHODS & CASE REPORT

We describe the case of a 65-year-old male, transferred to our tertiary HPB service on day 14 after common bile duct complete transection during cholecystectomy and postoperative laparotomy. The patient presented with biliary peritonitis along with full wound dehiscence and extensive evisceration. During emergency peritoneal wash-out surgery we deemed immediate BDI repair feasible by primary Roux-en-Y hepaticojejunostomy (HJ), with multi-stage abdominal closure. In the following days we performed progressive abdominal wall closure in multiple sessions under general anesthesia, aided by vacuum-assisted wound closure and intraperitoneal mesh-mediated fascial traction-approximation (VAWCM) with permeable mesh. An expected late incisional hernia was eventually repaired through component separation and biological mesh.

DISCUSSION & CONCLUSION

The simultaneous use of Roux-en-Y HJ and VAWCM has proven safe and effective in the treatment of BDI and 2-week biliary peritonitis with massive midline evisceration.

Subtotal Cholecystectomy After Failed Critical View of Safety Is an Effective and Safe Bail Out Strategy

BACKGROUND

Bile duct injury (BDI) is accompanied by significant morbidity and long-term impact in quality of life. Subtotal cholecystectomy (STC) is an alternative to prevent this outcome but is associated with other complications. The aim of this work is to demonstrate that BDI associated morbidity exceeds STC associated morbidity, underscoring STC as a reasonable bail out strategy.

METHODS

We compared 115 patients who underwent STC with 293 patients who were referred to our center with BDI type E1-E3 and underwent surgical repair. The groups were comparable because in both instances the surgeon had the opportunity to decide not to perform a total cholecystectomy once critical view of safety (CVS) was not achieved.

RESULTS

Bile leakage was found in 21% of the STC group with only one BDI (0.9%). More Accordion ≥ 4 were found in the STC group (10.4% vs 4.8%, p = 0.035); however, reoperations were more frequent in the BDI group (8.2% vs 0.9%, p = 0.006). No patient in the STC group required reintervention for completion cholecystectomy. After 3.8 years follow-up, 2.4% of patients had secondary biliary cirrhosis in the BDI group; none in the STC group.

CONCLUSIONS

Despite complications of STC, morbidity associated with BDI is much higher due to high long-term reoperation rate, in addition to secondary biliary cirrhosis. STC is a safe alternative that can prevent BDI if properly and timely performed in the context of difficult cholecystectomy.

Intraoperative Time-Out to Promote the Implementation of the Critical View of Safety in Laparoscopic Cholecystectomy: A Video-Based Assessment of 343 Procedures

BACKGROUND

The critical view of safety (CVS) is poorly adopted in surgical practices although it is ubiquitously recommended to prevent major bile duct injuries during laparoscopic cholecystectomy (LC). This study aims to investigate whether performing a short intraoperative time out can improve CVS implementation.

STUDY DESIGN

In this before versus after study, surgeons performing LCs at an academic center were invited to use a 5-second long time out to verify CVS before dividing the cystic duct (5-second rule). The primary aim was to compare the rate of CVS achievement for LCs performed in the year before versus the year after implementation of the 5-second rule. The CVS achievement rate was computed after exclusion of bailout procedures using a mediated video-based assessment made by two independent reviewers. Clinical outcomes, LC workflows, and postoperative reports were also compared.

RESULTS

343 of the 381 LCs performed between December 2017 and November 2019 (171 before and 172 after implementation of the 5-second rule) were analyzed. The 5-second rule was associated with a significantly increased rate of CVS achievement (15.9 vs. 44.1% before vs. after the 5-second rule, respectively; P<0.001). Significant differences were also observed with respect to the rate of bailout procedures (8.2 vs. 15.7%; P=0.04), the median [IQR] time to clip the cystic duct or artery (00:17:26 [00:11:48, 00:28:35] vs. 00:23:12 [00:14:29, 00:31:45] duration; P=0.007), and the rate of postoperative CVS reporting (1.3 vs. 28.8%; P<0.001). Postoperative morbidity was comparable (1.8 vs. 2.3%; P=0.68).

CONCLUSION

Performing a short intraoperative time out was associated with an improved CVS achievement rate. Systematic intraoperative cognitive aids should be studied to sustain the uptake of guidelines.

Development of a novel intraoperative difficulty score for minimally invasive cholecystectomy

BACKGROUND

The rate of biliary injuries from minimally invasive cholecystectomy has remained high for over two decades. To improve outcomes there are multiple bail-out methods described, including aborting the procedure, converting to open, or performing a sub-total cholecystectomy. However, the intraoperative difficulty threshold for when a bail-out method should be implemented is poorly understood.

METHODS

From 1/2014 to 2/2019 cholecystectomy videos were collected, de-identified, edited to include the 2-3 minutes when the gallbladder was first visualized, and accelerated. They were then rated on a 5-point difficulty scale. Inter-coder reliability was evaluated using Krippendorff's alpha and regression models were used to evaluate the scores ability to predict the need for a bail-out technique.

RESULTS

62 videos were analyzed with a median length after editing of 37.5 (29.0-43.3) seconds. A median time of 46.2 (38.3-53.4) seconds was required for grading. The bail-out rate was 42.9%. The inter-coder reliability between 2 surgeons and 8 non-clinical reviewers was 0.675 with an average difficulty score of 3.0 (SD = 1.01). Regression models showed that the scale was able to significantly predict conversion (β=0.56,p<.01).

CONCLUSION

This novel difficulty score was able to predict conversion to a bail-out technique early in the course of minimally invasive cholecystectomy.

Is subtotal cholecystectomy safe and feasible? Short- and long-term results

BACKGROUND

Cholecystectomy is one of the most commonly performed surgical procedures. However, it may result in some unpleasant conditions such as bile duct injury (BDI), bile leak, and vessel injury. Subtotal cholecystectomy (SC), which has been introduced as an alternative method for reducing the complication rates, has been reported to have lower risk of BDI when compared to total cholecystectomy. This study aimed to evaluate the indications for SC, its early and late complications and their management, and the risk factors affecting the bile leak.

METHODS

Fifty-seven patients who underwent SC were included in the study, and their medical records were retrospectively reviewed.

RESULTS

Thirty-three patients were male (57.9%) and the mean age was 64.84 ± 11.35 (range: 29-86). All patients had at least one episode of cholecystitis. Forty-seven (82.5%) patients underwent surgery under emergency conditions. Postoperative bile leak/fistula, surgical site infection, and fluid collection were developed in 12 (21.1%), eight (14%), and six (10.5%) patients, respectively. Leaving the remnant tissue pouch open, presence of comorbidity and emergency operative condition were found to increase the risk of leak development (P < .001). During the average follow-up of 49 months (range: 13-98), symptomatic choledocholithiasis, symptomatic gallstones in the remnant tissue, and incisional hernia were detected within the first year of surgery in three (5.3%), four (7%), and seven (12.3%) patients, respectively.

CONCLUSIONS

Although SC is not an equivalent to total cholecystectomy, its vital benefit of lowering the risk of BDI should be considered in difficult cases.

Impact of iatrogenic biliary injury during laparoscopic cholecystectomy on surgeon's mental distress: a nationwide survey from China

BACKGROUND

Iatrogenic biliary injury (IBI) following laparoscopic cholecystectomy (LC) is the most serious iatrogenic complications. Little is known whether LC-IBI would lead to surgeon's severe mental distress (SMD).

METHODS

A cross-sectional survey in the form of electronic questionnaire was conducted among Chinese general surgeons who have caused LC-IBI. The six collected clinical features relating to mental distress included: 1) feeling burnout, anxiety, or depression, 2) avoiding performing LC, 3) having physical reactions when recalling the incidence, 4) having the urge to quit surgery, 5) taking psychiatric medications, and 6) seeking professional psychological counseling. Univariable and multivariable analyses were performed to identify risk factors of SMD, which was defined as meeting ≥3 of the above-mentioned clinical features.

RESULTS

Among 1466 surveyed surgeons, 1236 (84.3%) experienced mental distress following LC-IBI, and nearly half (49.7%, 614/1236) had SMD. Multivariable analyses demonstrated that surgeons from non-university affiliated hospitals (OR:1.873), patients who required multiple repair operations (OR:4.075), patients who required hepaticojejunostomy/partial hepatectomy (OR:1.859), existing lawsuit litigation (OR:10.491), existing violent doctor-patient conflicts (OR:4.995), needing surgeons' personal compensation (OR:2.531), and additional administrative punishment by hospitals (OR:2.324) were independent risk factors of surgeon's SMD.

CONCLUSION

Four out of five surgeons experienced mental distress following LC-IBI, and nearly half had SMD. Several independent risk factors of SMD were identified, which could help to make strategies to improve surgeons' mental well-being.

Factors influencing the occurrence of biliary stricture above the confluence in major bile ducts injuries: Analysis of a case series

Background

bile duct injury is a complication that occurs mainly after cholecystectomy. Outcomes of biliary repair surgery are worse when the stricture level is above the biliary confluence.

Method

A single centred retrospective study was carried out on patients operated in our department for biliary stricture after a major bile duct injury over the period from January 2010 to May 2018. Only patients operated for biliary stricture were included. This study aimed to determine the independent factors influencing the occurrence of a stricture above de biliary confluence. Univariate and multivariate binary regression was used for data analysis.

Results

Fifty-three patients were included, they were 43 women and 10 men, sex-ratio was 0.23. Thirty-one patients had Grade E3-E4-E5 stricture (58,5%), and patients who had a failure of a previous repair surgery accounted for 36% (n = 19) of our patients.After univariate and multivariate analysis, only laparoscopic cholecystectomy (OR = 7.58, CI = [1.47-38, 91], P = 0.015) and failure of anterior biliary repair surgery (OR = 7, 12, CI = [1.29-39.42], P = 0.025) were independent factors associated with more frequent occurrence of biliary strictures above the confluence.

Conclusion

Failure of biliary repair surgery makes the pre-existing biliary stricture progress and compromises subsequent surgery's outcomes. It is important to refer all cases of bile duct injury to specialized centers to increase the chances of success of the first biliary repair surgery.

Quality-of-life after bile duct injury repaired by hepaticojejunostomy: a national cohort study

OBJECTIVES

Reports on quality-of-life (QoL) after bile duct injury (BDI) show conflicting results. The aim of this cohort study was to evaluate QoL stratified according to type of treatment.

METHODS

QoL assessment using the SF-36 (36-item short form health survey) questionnaire. Patients with post-cholecystectomy BDI needing hepaticojejunostomy (HJ) were compared to all other treatments (BDI repair) and to patients without BDI at cholecystectomy (controls).

RESULTS

Patients needing a HJ after BDI reported reduced long-term QoL irrespective of time for diagnosis and repair in both the physical (PCS; p < .001) and mental (MCS; p < .001) domain compared to both controls and patients with less severe BDI. QoL was comparable for BDI repair (n = 86) and controls (n = 192) in both PCS (p = .171) and MCS (p = .654). As a group, patients with BDI (n = 155) reported worse QoL than controls, in both the PCS (p < .001) and MCS (p = .012). Patients with a BDI detected intraoperatively (n = 124) reported better QoL than patients with a postoperative diagnosis. Patients with an immediate intraoperative repair (n = 99), including HJ, reported a better long-term QoL compared to patients subjected to a later procedure (n = 54).

CONCLUSIONS

Patients with postoperative diagnosis and patients with BDIs needing biliary reconstruction with HJ both reported reduced long-term QoL.

Safe Cholecystectomy Multi-society Practice Guideline and State of the Art Consensus Conference on Prevention of Bile Duct Injury During Cholecystectomy

BACKGROUND

BDI is the most common serious complication of laparoscopic cholecystectomy. To address this problem, a multi-society consensus conference was held to develop evidenced-based recommendations for safe cholecystectomy and prevention of BDI.

METHODS

Literature reviews were conducted for 18 key questions across 6 broad topics around cholecystectomy directed by a steering group and subject experts from 5 surgical societies (Society of Gastrointestinal and Endoscopic Surgeons, Americas Hepato-Pancreato-Biliary Association, International Hepato-Pancreato-Biliary Association, Society for Surgery of the Alimentary Tract, and European Association for Endoscopic Surgery). Evidence-based recommendations were formulated using the grading of recommendations assessment, development, and evaluation methodology. When evidence-based recommendations could not be made, expert opinion was documented. A number of recommendations for future research were also documented. Recommendations were presented at a consensus meeting in October 2018 and were voted on by an international panel of 25 experts with greater than 80% agreement considered consensus.

RESULTS

Consensus was reached on 17 of 18 questions by the guideline development group and expert panel with high concordance from audience participation. Most recommendations were conditional due to low certainty of evidence. Strong recommendations were made for (1) use of intraoperative biliary imaging for uncertainty of anatomy or suspicion of biliary injury; and (2) referral of patients with confirmed or suspected BDI to an experienced surgeon/multispecialty hepatobiliary team.

CONCLUSIONS

These consensus recommendations should provide guidance to surgeons, training programs, hospitals, and professional societies for strategies that have the potential to reduce BDIs and positively impact patient outcomes. Development of clinical and educational research initiatives based on these recommendations may drive further improvement in the quality of surgical care for patients undergoing cholecystectomy.

Safe cholecystectomy multi-society practice guideline and state-of-the-art consensus conference on prevention of bile duct injury during cholecystectomy

BACKGROUND

Bile duct injury (BDI) is the most common serious complication of laparoscopic cholecystectomy. To address this problem, a multi-society consensus conference was held to develop evidenced-based recommendations for safe cholecystectomy and prevention of BDI.

METHODS

Literature reviews were conducted for 18 key questions across six broad topics around cholecystectomy directed by a steering group and subject experts from five surgical societies (SAGES, AHPBA IHPBA, SSAT, and EAES). Evidence-based recommendations were formulated using the GRADE methodology. When evidence-based recommendations could not be made, expert opinion was documented. A number of recommendations for future research were also documented. Recommendations were presented at a consensus meeting in October 2018 and were voted on by an international panel of 25 experts with greater than 80% agreement considered consensus.

RESULTS

Consensus was reached on 17 of 18 questions by the Guideline Development Group (GDG) and expert panel with high concordance from audience participation. Most recommendations were conditional due to low certainty of evidence. Strong recommendations were made for (1) use of intraoperative biliary imaging for uncertainty of anatomy or suspicion of biliary injury; and (2) referral of patients with confirmed or suspected BDI to an experienced surgeon/multispecialty hepatobiliary team.

CONCLUSION

These consensus recommendations should provide guidance to surgeons, training programs, hospitals, and professional societies for strategies that have the potential to reduce BDIs and positively impact patient outcomes. Development of clinical and educational research initiatives based on these recommendations may drive further improvement in the quality of surgical care for patients undergoing cholecystectomy.

Does non-operative management of iatrogenic bile duct injury result in impaired quality of life? A systematic review

BACKGROUND

Several studies have reported the effect of bile duct injury (BDI) on health-related quality of life (HRQOL) with conflicting results. This systematic review aims to study the impact of patient and treatment factors on HRQOL after BDI.

METHODS

A search of the PubMed database was performed and studies were reviewed as per the PRISMA guidelines. Selected studies (n = 11) were then divided into two subgroups depending on whether they found HRQOL to be similar or worse between BDI and control groups. Pooled rates of surgical repair and major BDI were calculated for each of these subgroups.

RESULTS

Surgical repair rates were 99% (95% CI: 96%-99%) in studies where the BDI patients had similar outcomes to controls, compared to 78% (40%-100%) where their outcomes were significantly worse (p = 0.091). The major BDI rate was 51% (95% CI: 42%-61%) in studies where the BDI patients had similar outcomes to controls, compared to 72% (41%-94%) where their outcomes were significantly worse (p = 0.322). Considerable heterogeneity was present within the two subgroups (I²: 68-99%).

DISCUSSION

HRQOL may be adversely affected amongst patients with BDI who do not undergo surgical repair. Significant heterogeneity of data suggests the need for standardised HRQOL tools and injury severity systems when assessing outcomes after BDI.

Patients support transfer of care for unexpected findings in laparoscopic cholecystectomy

INTRODUCTION

Surgeons often assume patients may be dissatisfied if their operations were stopped due to suspicious intraoperative findings requiring transfer of care. We sought to assess patient opinions regarding transfer of care for unexpected intraoperative findings during laparoscopic cholecystectomy with and without bile duct injury (BDI).

METHODS AND PROCEDURES

The investigators developed two clinical scenarios comparing transfer of care for unexpected intraoperative findings during elective laparoscopic cholecystectomy: without BDI and with BDI requiring open repair. A multi-institutional structured telephone interview process was conducted with patients ≥ 18 years of age who had an outpatient, uncomplicated laparoscopic cholecystectomy within the last year. The first scenario presented a case of suspicious findings prompting the surgeon to stop and transfer for specialized care; whereas the second case was a BDI requiring transfer of care. Textual and thematic analysis as well as descriptive statistics was used for analysis, with significance set at p < 0.05.

RESULTS

Forty-five patients completed the survey. Satisfaction with transfer of care for unexpected intraoperative findings without BDI was 69%, and over 95% of respondents were satisfied their surgeon stopped the procedure to initiate transfer due to safety concerns; 64% of patients would return to that surgeon for postoperative care; and 78% would see that surgeon again. In the scenario with BDI requiring open repair, 86% were satisfied with their surgeon's decision to stop the operation; 91% of patients were satisfied with transfer of care; and 32% would see their first surgeon again. Themes of prioritizing safety and transparency were frequently cited.

CONCLUSIONS

Patients prioritize safety and are satisfied with halting a procedure to facilitate transfer of care for suspicious intraoperative findings during routine laparoscopic cholecystectomy.

Long-term Impact of Bile Duct Injury on Morbidity, Mortality, Quality of Life, and Work Related Limitations

OBJECTIVE

Assessment of long-term comprehensive outcome of multimodality treatment of bile duct injury (BDI) in terms of morbidity, mortality, quality of life (QoL), survival, and work related limitations.

BACKGROUND

The impact of BDI on work ability is scarcely investigated.

METHODS

BDI patients referred to a tertiary center after BDI were included (n = 800). QoL and work related limitations (HLQ) were compared with 175 control patients after uncomplicated laparoscopic cholecystectomy.

RESULTS

The mean survival after BDI was 17.6 years (95% confidence interval, CI, 17.2-18.0 years). BDI related mortality was 3.5% (28/800). Corrected for sex, ASA classification, treatment and type of injury, survival is worse in male patients (hazard ratio, HR 1.50, 95% CI 1.01-2.33) and progressively worse with higher ASA classification (ASA2: 5.25 (2.94-9.37), ASA3: 18.1 (9.79-33.3). Patients treated surgically had a significantly better survival (HR: 0.45 (95% CI: 0.25-0.80). BDI patients reported a significantly worse physical QoL compared with the control group and worse disease specific QoL. Loss of productivity of work was significantly higher among BDI patients. There also was a significant hindrance in unpaid work. A higher number of bile duct injury patients were receiving disability benefits after long-term follow-up (34.9% vs 19.6%, P = 0.004).

CONCLUSIONS

Reconstructive surgery in BDI patients is associated with improved survival. Although the clinical outcome of multidisciplinary treatment of bile duct injury is good, it is associated with a significant decrease in QoL, loss of productivity in both paid and unpaid work and high rates of disability benefits use.

A three-step conceptual roadmap for avoiding bile duct injury in laparoscopic cholecystectomy: an invited perspective review

Bile duct injuries are the most common serious complication of cholecystectomy. Avoidance of bile duct injury is a key aim of biliary surgery. The purpose of this paper is to describe laparoscopic cholecystectomy from the viewpoint of three conceptual goals. Three conceptual goals of cholecystectomy are: (1) getting secure anatomical identification of key structures; (2) making the right decision not to perform a total cholecystectomy when conditions are too dangerous to get secure identification - the "inflection point"; and (3) finishing the operation safely when secure anatomical identification of cystic structures is not possible. The Critical View of Safety (CVS) has been shown to be a good way of getting secure anatomical identification. Conceptually, CVS is a method of target identification, the targets being the two cystic structures. Sometimes, anatomic identification is not possible because the risk of biliary injury is judged to be too great. Then a decision is made to abandon the attempt to do a complete cholecystectomy - and instead to "bail-out". This "inflection point" is defined as the moment at which the decision is made to halt the attempt to perform a total cholecystectomy laparoscopically and to finish the operation by a different method. Currently the best bail-out procedure seems to be subtotal fenestrating cholecystectomy. Application of conceptual goals of cholecystectomy can help the surgeon to avoid biliary injury.

A Memorable Moment During Laparoscopic Cholecystectomy: A Case Report

Common bile duct (CBD) stones are encountered in 14%-15% of patients with symptomatic gall stone disease. Endoscopic retrograde cholangiopancreatography (ERCP) is a primary modality for the management of pancreaticobiliary disorders. We present a case of unintentional stent placement into the gall bladder discovered during surgery.

Bile duct injury: to err is human; to refer is divine

A 42-year-old woman sustained complete transection of common hepatic duct during routine laparoscopic cholecystectomy. The surgery was being performed at a rural setting, and the injury was identified intraoperatively. The surgeon sought the opinion of an expert biliary surgeon via telephone and discussed the possibility of an immediate end-to-end bile duct repair. Since he lacked the experience of doing biliary-enteric anastomosis, he was advised to place a subhepatic drain and transfer the patient to the hepatobiliary centre for definitive surgery. At the referral centre, the patient was evaluated and planned an immediate biliary repair. On exploration, she was found to have a major type, Strasberg E5 injury. The transected ducts were small in calibre and required double Roux-en-Y hepaticojejunostomy over transanastomotic stents. The postoperative recovery was uneventful. Transanastomotic stents were removed after 6 months, and the patient remained perfectly well at a follow-up of 1 year.

A New Era of Bile Duct Repair: Robotic-Assisted Versus Laparoscopic Hepaticojejunostomy

BACKGROUND

Despite scientific evidence of the safety, efficacy, and in some cases superiority of minimally invasive surgery in hepato-pancreato-biliary procedures, there are scarce publications about bile duct repairs. The aim of this study was to compare the outcomes of robotic-assisted surgery versus laparoscopic surgery on bile duct repair in patients with post-cholecystectomy bile duct injury.

METHODS

This is a retrospective comparative study of our prospectively collected database of patients with bile duct injury who underwent robotic or laparoscopic hepaticojejunostomy.

RESULTS

Seventy-five bile duct repairs (40 by laparoscopic and 35 by robotic-assisted surgery) were treated from 2012 to 2018. Injury types were as follows: E1 (7.5% vs. 14.3%), E2 (22.5% vs. 14.3%), E3 (40% vs. 42.9%), E4 (22.5% vs. 28.6%), and E5 (7.5% vs. 0), for laparoscopic hepaticojejunostomy (LHJ) and robotic-assisted hepaticojejunostomy (RHJ) respectively. The overall morbidity rate was similar (LHJ 27.5% vs. RHJ 22.8%, P = 0.644), during an overall median follow-up of 28 (14-50) months. In the LHJ group, the actuarial primary patency rate was 92.5% during a median follow-up of 49 (43.2-56.8) months. While in the RHJ group, the actuarial primary patency rate was 100%, during a median follow-up of 16 (12-22) months. The overall primary patency rate was 96% (LHJ 92.5% vs. RHJ 100%, log-rank P = 0.617).

CONCLUSION

Our results showed that the robotic approach is similar to the laparoscopic regarding safety and efficacy in attaining primary patency for bile duct repair.

Long-Term Impact of Iatrogenic Bile Duct Injury

BACKGROUND

Bile duct injury (BDI) is a devastating complication following cholecystectomy. After initial management of BDI, patients stay at risk for late complications including anastomotic strictures, recurrent cholangitis, and secondary biliary cirrhosis.

METHODS

We provide a comprehensive overview of current literature on the long-term outcome of BDI. Considering the availability of only limited data regarding treatment of anastomotic strictures in literature, we also retrospectively analyzed patients with anastomotic strictures following a hepaticojejunostomy (HJ) from a prospectively maintained database of 836 BDI patients.

RESULTS

Although clinical outcomes of endoscopic, radiologic, and surgical treatment of BDI are good with success rates of around 90%, quality of life (QoL) may be impaired even after "clinically successful" treatment. Following surgical treatment, the incidence of anastomotic strictures varies from 5 to 69%, with most studies reporting incidences around 10-20%. The median time to stricture formation varies between 11 and 30 months. Long-term BDI-related mortality varies between 1.8 and 4.6%. Of 91 patients treated in our center for anastomotic strictures after HJ, 81 (89%) were treated by percutaneous balloon dilatation, with a long-term success rate of 77%. Twenty-four patients primarily or secondarily underwent surgical revision, with recurrent strictures occurring in 21%.

CONCLUSIONS

The long-term impact of BDI is considerable, both in terms of clinical outcomes and QoL. Treatment should be performed in tertiary expert centers to optimize outcomes. Patients require a long-term follow-up to detect anastomotic strictures. Strictures should initially be managed by percutaneous dilatation, with surgical revision as a next step in treatment.

Quality of Life in Patients with Background of Iatrogenic Bile Duct Injury

BACKGROUND

There are only a few reports regarding the quality of life of patients who underwent a complicated cholecystectomy with an iatrogenic bile duct injury (IBDI); the results have been heterogeneous and realized with unspecific measures.

METHODS

The objective was to determine whether the quality of life of the subjects with a history of IBDI repaired with bilioenteric derivation is modified in the long term with respect to a control group, for which a group of patients with a history of IBDI (group A) was compared with a group of patients with a history of uncomplicated cholecystectomy (group B). Two different measures were used: on the one hand, the SF-12 questionnaire and on the other hand, a questionnaire was implemented where the patient could determine by himself which variables define his quality of life.

RESULTS

A total of 46 patients were included in group A and 51 in group B. The analysis of the SF-12 questionnaire showed a statistical significant reduction in 4 of 8 of the evaluated parameters (general health, physical functioning, physical role and social functioning) in group A in comparison with group B. If a more specific questionnaire is used, the results are similar, with a statistically significant reduction in the quality of life within the group A (0.03).

CONCLUSIONS

We conclude that the quality of life of patients with a history of bilioenteric derivation due to an IBDI decreases significantly compared to patients with uncomplicated cholecystectomy.

Long-term effects and quality of life following definitive bile duct reconstruction

The study covered a cohort of 236 patients with transection of hepatic duct. It aimed to assess the long-term outcome of the reconstruction and a patient's quality of life.The literature contains many controversies over timing of biliary reconstruction and who ought to repair the injury but just few reports on the long-term outcomes and patient's quality of life.The bile duct system was reconstructed by hepaticojejunostomy in 236 patients. Of these, 139 patients were initially repaired at a public hospital and referred because of stricture (Group A, N = 59) or of an anastomosis dehiscence (Group B, N = 80); 97 were unrepaired and referred because of a surgical clip occluding the duct (Group C, N = 39) or bile leakage from an open duct (Group D, N = 58). All patients were surveyed in 2015 for quality of life using WHOQOL-BREF.The mean time of follow-up was 150 months. The time without symptoms amounted to >5 years in 78.6% of patients. The mean time before anastomosis renewal ranged from 8.9 to 4.7 years (P < .04). Multivariate analysis showed infection, failure of reconstruction in public hospital, and female sex as factors responsible for poor long-term outcome.Patients in Group C had better quality of life than the others (P < .001) with respect to physical health (median 67.85) and psychological condition (median 79.16). The overall mortality was 15.2%.The long-term result of reconstruction depends on the cause of referral which, in turn, arises from subsequent intervention taken in local hospitals.

Evolution of the Konyang Standard Method for single incision laparoscopic cholecystectomy: the result from a thousand case of a single center experience

Purpose

Single incision laparoscopic cholecystectomy (SILC) is increasingly performed worldwide. Accordingly, the Konyang Standard Method (KSM) for SILC has been developed over the past 6 years. We report the outcomes of our procedures.

Methods

Between April 2010 and December 2016, 1,005 patients underwent SILC at Konyang University Hospital. Initially 3-channel SILC with KSM was changed to 4-channel SILC using a modified technique with a snake retractor for exposure of Calot triangle; we called this a modified KSM (mKSM). Recently, we have used a commercial 4-channel (Glove) port for simplicity.

Results

SILC was performed in 323 patients with the KSM, in 645 with the mKSM, and in 37 with the commercial 4-channel port. Age was not significantly different between the 3 groups (P = 0.942). The postoperative hospital days (P = 0.051), operative time (P < 0.001) and intraoperative bleeding volume (P < 0.001) were significantly improved in the 3 groups. Drain insertion (P = 0.214), additional port insertion (P = 0.639), and postoperative complications (P = 0.608) were not significantly different in all groups. Postoperative complications were evaluated with the Clavien-Dindo classification. There were 3 cases (0.9%) over grade IIIb (bile duct injury, incisional hernia, duodenal perforation, or small bowel injury) with KSM and 3 (0.5%) with mKSM.

Conclusion

We evaluated the evolution of the KSM for SILC. The use of the mKSM with a commercial 4-channel port may be the safest and most effective method for SILC.

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.

Quality of Life and Medico-Legal Implications Following Iatrogenic Bile Duct Injuries

In this review we aimed to evaluate quality of life after bile duct injury and the consequent medico-legal implications. A comprehensive English language literature search was performed on MEDLINE, Embase, Science Citation Index and Google™ Scholar databases for articles published between January 2000 and April 2016. The last date of search was 11 April 2016. Key search words included bile duct injury, iatrogenic, cholecystectomy, prevention, risks, outcomes, quality of life, litigation and were used in combination with the Boolean operators AND, OR and NOT. Long-term survival after bile duct injury is significantly impaired (all-cause long-term mortality approximately 21 %) along with the quality of life (especially psychological/mental state remains affected). Bile duct injury is associated with high rates of litigation. Monetary compensation varied from £2500 to £216,000 in the UK, €9826-€55,301 in the Netherlands and $628,138-$2,891,421 in the USA. Bile duct injuries have profound implications for patients, medical personnel and healthcare providers as they cause significant morbidity and mortality, high rates of litigation and raised healthcare expenditure.

The Difficult Gallbladder: A Safe Approach to a Dangerous Problem

Laparoscopic cholecystectomy is a common surgical procedure, and remains the gold standard for the management of benign gallbladder and biliary disease. While this procedure can be technically straightforward, it can also represent one of the most challenging operations facing surgeons. This dichotomy of a routine operation performed so commonly that poses such a hidden risk of severe complications, such as bile duct injury, must keep surgeons steadfast in the pursuit of safety. The "difficult gallbladder" requires strict adherence to the Culture of Safety in Cholecystectomy, which promotes safety first and assists surgeons in managing or avoiding difficult operative situations. This review will discuss the management of the difficult gallbladder and propose the use of subtotal fenestrating cholecystectomy as a definitive option during this dangerous situation.

Iatrogenic, blunt, and penetrating trauma to the biliary tract

Iatrogenic and traumatic bile leaks are uncommon. However, given the overall increase in number of hepatobiliary surgeries and the paradigm shift toward nonoperative management of patients with liver trauma, they have become more prevalent in recent years. Imaging is essential to establishing early diagnosis and guiding treatment as the clinical signs and symptoms of bile leaks are nonspecific, and a delay in recognition of bile leaks portends a high morbidity and mortality rate. Findings suspicious for a bile leak at computed tomography or ultrasonography include free or contained peri- or intrahepatic low density fluid in the setting of recent trauma or hepatobiliary surgery. Hepatobiliary scintigraphy and magnetic resonance cholangiopancreatography (MRCP) with hepatobiliary contrast agents can be used to detect active or contained bile leak. MRCP with hepatobiliary contrast agents has the unique ability to reveal the exact location of bile leak, which often governs whether endoscopic management or surgical management is warranted. Percutaneous transhepatic cholangiography and fluoroscopy via an indwelling catheter that is placed either percutaneously or surgically are useful modalities to guide percutaneous transhepatic biliary drain placement which can provide biliary drainage and/or diversion in the setting of traumatic biliary injury. Surgical treatment of a bile duct injury with Roux-en-Y hepaticojejunostomy is warranted if definitive treatment cannot be accomplished through percutaneous or endoscopic means.

Repair of a common bile duct defect with a decellularized ureteral graft

AIM

To evaluate the feasibility of repairing a common bile duct defect with a decellularized ureteral graft in a porcine model.

METHODS

Eighteen pigs were randomly divided into three groups. An approximately 1 cm segment of the common bile duct was excised from all the pigs. The defect was repaired using a 2 cm long decellularized ureteral graft over a T-tube (T-tube group, n = 6) or a silicone stent (stent group, n = 6). Six pigs underwent bile duct reconstruction with a graft alone (stentless group). The surviving animals were euthanized at 3 mo. Specimens of the common bile ducts were obtained for histological analysis.

RESULTS

The animals in the T-tube and stent groups survived until sacrifice. The blood test results were normal in both groups. The histology results showed a biliary epithelial layer covering the neo-bile duct. In contrast, all the animals in the stentless group died due to biliary peritonitis and cholangitis within two months post-surgery. Neither biliary epithelial cells nor accessory glands were observed at the graft sites in the stentless group.

CONCLUSION

Repair of a common bile duct defect with a decellularized ureteral graft appears to be feasible. A T-tube or intraluminal stent was necessary to reduce postoperative complications.

Quality-of-life after bile duct injury: intraoperative detection is crucial. A national case-control study

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.

Iatrogenic common bile duct injuries: Increasing complexity in the laparoscopic era: A prospective cohort study

PURPOSE

Iatrogenic bile duct injury (BDI) is the most significant associated complication to laparoscopic cholecystectomy (LC). Little is known about the evolution of the pattern of BDI in the era of laparoscopy. The aim of the study is to assess the pattern of post-LC BDIs managed in a tertiary referral centre.

METHODS

Post-LC BDI referred over two decades were studied. Demographic data, type of BDI (classified using the Strasberg System), clinical symptoms, diagnostic investigations, timing of referral, post-referral management and morbidity were analysed. The pattern of injury, associated vascular injuries rate and their management were compared over two time periods (1992-2004,2005-2014).

RESULTS

78 BDIs were referred. During the second time period Strasberg A injuries decreased from 14% to 0 and Strasberg E1increased from 4% to 23%, the rate of associated vascular injury was six time higher (3.6% versus 22.7%), more patients had an attempted repair at the index hospital (16% versus 35%) sand fewer patients could be managed without surgical intervention at the referral hospital (28% versus 4%).

CONCLUSION

Complexity of referred BDIs and rate of associated vascular injuries have increased over time. These findings led to more patients managed requiring surgical intervention at the referral hospital.

Innovative Approach to a Frozen Calot's Triangle During Laparoscopic Cholecystectomy

The laparoscopic cholecystectomy is now the "gold standard." In around 2 % of cases, there is a need to convert because of the difficult dissection encountered in the Calot's Triangle, a "frozen Calot's triangle." There is no consensus among surgeons about how to tackle this situation. To lower the conversion rate, there is a continuous attempt made to innovate. The authors present their rationale and experience in 100 difficult cases by creating a retro-gallbladder tunnel and encircling the gallbladder by a gauze for maneuvering.

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.