Lower Rate of Major Bile Duct Injury and Increased Intraoperative Management of Common Bile Duct Stones after Implementation of Routine Intraoperative Cholangiography

Abstract

Our university medical center is the only center in The Netherlands that has adopted a policy of routine intraoperative cholangiography (IOC) during cholecystectomy. This study aimed to describe the rate of bile duct injury (BDI) and management of common bile duct (CBD) stones before and after implementation of a routine IOC policy. Medical records were reviewed of all patients undergoing cholecystectomy in the 3 years before implementation of routine IOC and 3 years after. Dissection with the goal to achieve the critical view of safety was the standard operative technique during the entire study period. Four hundred and twenty-one patients underwent cholecystectomy with selective IOC and 435 patients with routine IOC. Groups were similar in age, sex, comorbidity, indication for surgery, and surgical approach. IOC was attempted in 5.9% in the selective IOC group and 59.8% in the routine IOC group (p < 0.001). The rate of major BDI was 1.9% in the selective IOC group and 0% in the routine IOC group (p = 0.004). The injuries consisted of 5 type B and 3 type D injuries, according to the Amsterdam classification. The rate of minor BDI did not differ substantially among the groups. More CBD stones were detected in the routine IOC group (4.8% versus 1.0%; p = 0.001) and they were managed intraoperatively more frequently (2.8% versus 0.7%; p = 0.023). There was a trend toward fewer preoperative and postoperative ERCPs and other interventions for CBD stones (19.1% versus 24.2%; p = 0.067). Implementation of routine IOC policy was followed by fewer major BDIs and higher rates of intraoperative CBD stone management.