Incidence Of Bile Duct Injury Research Articles

Bile duct injuries after laparoscopic cholecystectomy: 11-year experience in a tertiary center

Incidence of bile duct injuries (BDI) is low but remains a dramatic complication after laparoscopic cholecystectomy (LC). This study aimed to assess BDI incidence and management strategies. All patients treated in our institution for BDI after LC between 2000 and 2011 were retrospectively analyzed. Patients referred from others centers were excluded. Strasberg classification was used to determine the type of lesion. Thirteen patients presented iatrogenic BDI among 2,840 consecutive cholecystectomies performed (0.46%). Four cases were classified Strasberg type A, 4 type D, and 5 type E. Injury was recognized intraoperatively in 6 cases (46%). Three of these 6 required conversions to open surgery and all but one were primary sutured on a drain; the remaining patient required immediate biliodigestive anastomosis. In 7 patients, the injury was discovered postoperatively (54%). Among them, one was treated by direct closure of a cystic leak through immediate re-laparoscopy. Six underwent initially main bile duct stenting, but 4 required delayed secondary surgery (mean time 115 days), 2 to improve bile duct drainage and 2 for biliodigestive derivation. BDI incidence remains low but management depends on the time of diagnosis. BDI are complex and require tailored treatment usually in a tertiary center for a multidisciplinary approach.

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

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. 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. 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 10days, seven (6%) repaired between 11 and 20days, and 48 (38%) patients over 21days from injury. 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."

Laparoscopic hepaticojejunostomy after bile duct injury.

The incidence of bile duct injuries (BDI) after cholecystectomy, which is a life-threatening condition that has several medical and legal implications, currently stands at about 0.6%. The aim of this study is to describe our experience as the first center to use a laparoscopic approach for BDI repair. A prospective study between June 2012 and September 2014 was developed. Twenty-nine consecutive patients with BDI secondary to cholecystectomy were included. Demographics, comorbidities, presenting symptoms, details of index surgery, type of lesion, preoperative and postoperative diagnostic work-up, and therapeutic interventions were registered. Videos and details of laparoscopic hepaticojejunostomy (LHJ) were recorded. Injuries were staged using Strasberg classification. A side-to-side anastomosis with Roux-en-Y reconstruction was always used. In patients with E4 and some E3 injuries, a segment 4b or 5 section was done to build a wide anastomosis. In E4 injuries, a neo-confluence was performed. Complications, mortality, and long-term evolution were recorded. Twenty-nine patients with BDI were operated. Women represented 82.7% of the cases. The median age was 42 years (range 21-74). Injuries at or above the confluence occurred in 62%, and primary repair at our institution was performed at 93.1% of the cases. Eight neo-confluences were performed in all E4 injuries (27.5%). The median operative time was 240 min (range 120-585) and bleeding 200 mL (range 50-1100). Oral intake was started in the first 48 h. Bile leak occurred in 5 cases (17.2%). Two patients required re-intervention (6.8%). No mortality was recorded. The maximum follow-up was 36 months (range 2-36). One patient with E4 injury developed a hepaticojejunostomy (HJ) stenosis after 15 months. This was solved with endoscopic dilatation. The benefits of minimally invasive approaches in BDI seem to be feasible and safe, even when this is a complex and catastrophic scenario.

Infundibulinės laparoskopinės cholecistektomijos metodika turi kokybiškai atsinaujinti: 18 metų 13 274 cholecistektomijų analizė, 45 jatrogeninių tulžies latakų sužalojimų aptarimas ir įvertinimas

ĮžangaAtliktas Respublikinės Vilniaus universitetinės ligoninės 1996–2013 metų tulžies pūslės chirurgijos retrospektyvusis auditas, apibendrinantis 18 metų operacijų patirtį. Svarbiausias tyrimo tikslas – apibūdinti su laparoskopine cholecistektomija (LC) siejamą tulžies latakų sužalojimo riziką.MetodaiLC metu, siekdami identifikuoti tulžies pūslės lataką ir jos arteriją, laikėmės infundibulinės metodikos principų. Jatrogeniniai tulžies latakų sužalojimai susisteminti į penkias klases pagal Bismutho ir Strasbergo klasifikaciją. Siekdami nustatyti Lietuvos gydytojų publikacijas, kuriose analizuojamos laparoskopinės cholecistektomijos komplikacijos, naudojomės http://scholar.google.co.uk paieškos sistema. Taikyti standartiniai vienfaktoriai ir daugiafaktoriai statistinės analizės būdai.RezultataiAtliktos 13 274 cholecistektomijos, iš jų LC – 11 189 kartus (84,29 %). 5241 (39,48 %) pacientas laparoskopiškai operuotas dėl ūminio, 8033 (60,52 %) – dėl lėtinio cholecistito. Tulžies latakai sužaloti 45 ligoniams, iš jų 42 sužalojimai siejami su LC. Laparoskopinės operacijos metu tulžies latakai buvo sužaloti 2,7 karto dažniau nei per atvirąją (0,38 % vs 0,14 %, ŠS = 2,6149, 95 % PI 0,8097–8,4442, z = 1,607, p = 0,1080). Operuojant pacientus dėl ūminio cholecistito, jatrogeninių tulžies latakų sužalojimų pasitaikė du kartus dažniau (0,5 % vs 0,24 %, ŠS = 2,1029, 95 % PI 1,1627–3,8034, z = 2,459, p = 0,0140). Su LC siejamų jatrogeninių tulžies latakų sužalojimų rizika yra 1:261. 2010–2013 metais jų padaugėjo. Tulžies pūslės latako nesandarumo rizika po LC yra 1:323 (tai didele dalimi atspindi specifinę technologijos problemą). Pagrindinių šoninių tulžies latakų sužalojimų rizika yra 1:247 (tai chirurginės technikos problema). E klasės sužalojimo rizika 1:1243. 2000–2013 metais su LC siejama 40 % (17/42) jatrogeninių tulžies latakų sužalojimų. Hospitalinis mirštamumas nuo tulžies latakų sužalojimo buvo 11 % (5/45).IšvadosJatrogeniniai tulžies latakų sužalojimai yra nedažni, bet pavojingi. Tyrimas išryškino koncepcinius, sisteminius ir techninius LC trūkumus. Kadangi laparoskopinės cholecistektomijos kultūra prasideda nuo operacijai tinkamų pacientų atrankos, išsamiai infomuoto paciento sutikimo, šiuolaikinių pripažintų technologinių ir techninių priklausinių bei racionalių, pacientų saugumą užtikrinančių sprendimų, ji turi keistis. Ir ne tik įstaigoje, kurioje buvo atliktas šis klinikinis tyrimas, bet ir visose kitose geografinio regiono gydymo įstaigose, jeigu jose praktikuojama tokia pati arba metodologiškai panaši tulžies pūslės chirurgija.

The Clinical Analysis of Bile Duct Injury during Laparoscopic Cholecystectomy

The study was to improve surgical safety and reduce the incidence of bile duct injury (BDI) during laparoscopic cholecystectomy. The clinical information of 31 cases with bile duct injury during Laparoscopic Cholecystectomy (LC) was analyzed retrospectively. Thirty patients with bile duct injury were divided into 5 types according to Bismuth typing, including: type I 9 cases, type II 12 cases, type III 4 cases, type IV 3 cases, type V 3 cases. After median follow-up of 48 months, 30 (97%) patients are alive and 29 (94%) remain in good general condition with normal liver function. One patient died from acute obstructive suppurative cholangitis (AOSC). One patient appeared to have pain under the xiphoid that was resolved after 3 months. Recurrent strictures following repair have developed in two (6%) patients with high injuries combined with right hepatic arterial injury. Appropriate surgical indications, handling Calot triangle carefully and correctly, and conversion to open surgery at the right moment are the keys of prevention and treatment of bile duct injury during LC.

Safety of transvaginal hybrid NOTES cholecystectomy: a systematic review and meta-analysis.

Despite increasing data regarding clinical outcomes following transvaginal hybrid NOTES cholecystectomy (TVC), a consensus regarding safety based on comparative studies has yet to be reached. The aim of this systematic review and meta-analysis was to compare safety and clinical outcomes of TVC with conventional laparoscopic cholecystectomy (CLC) for the treatment of benign gallstone disease. A comprehensive search for published studies comparing TVC and CLC was performed. Review of each study was conducted and data were extracted. All pooled outcome measures were determined using random-effects models. Data were retrieved from 14 studies describing 1,145 patients. There was no difference in total complications (POR = 0.68; 95 % CI 0.40-1.14; P = 0.14), incidence of bile duct injury (POR = 1.33; 95 % CI 0.31-5.66; P = 0.70), Clavien-Dindo Grade II (POR = 0.48; 95 % CI 0.14-1.60; P = 0.23) or Grade III (POR = 0.63; 95 % CI 0.24-1.65; P = 0.34) complications between TCV and CLC. Time of return to normal activities was significantly reduced in the TVC group (WMD = -4.86 days; 95 % CI -9.33 to -0.39; P = 0.03), and there was a non-significant reduction in postoperative pain on days 1 (WMD = -0.80; 95 % CI -1.60 to 0.01; P = 0.05) and 3 (WMD = -0.89; 95 % CI -1.77 to -0.01; P = 0.05). TVC is safe when performed by appropriately trained surgeons and may be associated with a faster return to normal activities and decreased postoperative pain.

Strategies to decrease bile duct injuries during laparoscopic cholecystectomy.

Laparoscopic cholecystectomy (LC) has been performed clinically for more than 20 years. However, the incidence of bile duct injury (BDI) remains high despite attempts to prevent and reduce it. The aim of this study was to use an intraoperative unfavorable factors ratings system to identify unfavorable intraoperative factors and evaluate the effectiveness of application of the system in reducing BDI during LC. Between January 2009 and December 2010, 780 patients who underwent LC were reviewed retrospectively, including 384 LC patients without graded treatment of intraoperative unfavorable factors (GTIUF) during 2009 and 396 LC patients with routine GTIUF during 2010. BDI was decreased significantly after routine GTIUF (5 cases without GTIUF versus 0 cases with routine GTIUF; P=.029). There was no significant difference in postoperative morbidity and mortality between the two groups. The mean operation duration of the routine GTIUF group was prolonged significantly (P<.0001). Laparoscopic cholecystitis grading, GTIUF, and doctor's experience were important factors affecting the duration of operation (P<.0001, P<.0001, and P<.0001, respectively). GTIUF is an effective method that emphasizes identification of the course of the extrahepatic bile duct and reduces the occurrence of BDI, especially for inexperienced operators.

Threefold increased bile duct injury rate is associated with less surgeon experience in an insurance claims database: more rigorous training in biliary surgery may be needed.

Bile duct injury (BDI) remains the dreaded complication of laparoscopic cholecystectomy (LC) over the last two decades. Although the Fundamentals of Laparoscopic Surgery (FLS) certification is now required for new applicants by the American Board of Surgery, the impact of FLS on procedure-specific outcomes is unknown. Moreover, the FLS content centers on fundamental education and not procedure-specific complication reduction such as BDI, magnifying the importance of understanding the educational impact of FLS on specific case types. This study reviewed the impact of FLS certification and other factors on the incidence of bile duct injury in a large insurance claims database. In total, 53,632 LCs were reviewed from July 2009 to December 2010 from a large private payer claims database. Surgeon National Provider Identifier (NPI), FLS certification status, International Classification of Diseases, Ninth Revision (ICD-9) and Current Procedural Terminology (CPT) were available for each event. Each record was analyzed for evidence of any bile duct injury based on associated CPT or ICD-9 data in the claim record. Characteristics of the FLS+ and FLS- surgeon groups were analyzed by a separate reviewer blinded to clinical outcome on a large scale. A total of 53,632 LCs were reviewed; 1748 LC were performed by 441 FLS+ surgeons; and 58,870 LCs by 10,851 FLS- surgeons. (Some procedures involved more than one surgeon). Eighty-two BDIs were identified: 8 in the FLS+ and 74 in the FLS- group. The FLS+ group had a higher rate of BDI than the FLS- group (0.47 vs. 0.14 %, p = 0.0013); however, the FLS+ group was also younger (mean age 38.2 FLS+ vs. 50.4 years) and had significantly fewer years in practice (FLS+ = 6.1 vs. FLS- = 20.7, p = 0.0012). No other complications showed differences between the groups. NPI can be used as a linking intermediary between skills certification and outcomes on claims databases. FLS certification was not associated with a reduction in bile duct injury in this analysis, but FLS+ surgeons were also younger and less experienced overall. Since FLS lacks content specific to BDI, large-scale validated training and assessment programs targeted at BDI prevention are needed to impact the rate of this complication during cholecystectomy.

Impact of routine intraoperative cholangiography during laparoscopic cholecystectomy on bile duct injury

The role of intraoperative cholangiography (IOC) in the diagnosis, prevention and management of bile duct injury (BDI) remains controversial. The aim of the present study was to determine the value of routine IOC in the diagnosis and management of BDI sustained during laparoscopic cholecystectomy (LC) at a high-volume centre. A retrospective analysis of a single-institution database was performed. Patients who underwent LC with routine IOC between October 1991 and May 2012 were included. Among 11,423 consecutive LCs IOC was performed successfully in 95.7 per cent of patients. No patient had IOC-related complications. Twenty patients (0.17 per cent) sustained a BDI during LC, and the diagnosis was made during surgery in 18 patients. Most BDIs were type D according to the Strasberg classification. The sensitivity of IOC for the detection of BDI was 79 per cent; specificity was 100 per cent. All injuries diagnosed during surgery were repaired during the same surgical procedure. Two patients developed early biliary strictures that were treated by percutaneous dilatation and a Roux-en-Y hepaticojejunostomy with satisfactory long-term results. The routine use of IOC during LC in a high-volume teaching centre was associated with a low incidence of BDI, and facilitated detection and repair during the same surgical procedure with a good outcome.

Remains of the day: Biliary complications related to single-port laparoscopic cholecystectomy

To assess the rate of bile duct injuries (BDI) and overall biliary complications during single-port laparoscopic cholecystectomy (SPLC) compared to conventional laparoscopic cholecystectomy (CLC). SPLC has recently been proposed as an innovative surgical approach for gallbladder surgery. So far, its safety with respect to bile duct injuries has not been specifically evaluated. A systematic review of the literature published between January 1990 and November 2012 was performed. Randomized controlled trials (RCT) comparing SPLC versus CLC reporting BDI rate and overall biliary complications were included. The quality of RCT was assessed using the Jadad score. Analysis was made by performing a meta-analysis, using Review Manager 5.2. This study was based on the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. A retrospective study including all retrospective reports on SPLC was also performed alongside. From 496 publications, 11 RCT including 898 patients were selected for meta-analysis. No studies were rated as high quality (Jadad score ≥ 4). Operative indications included benign gallbladder disease operated in an elective setting in all studies, excluding all emergency cases and acute cholecystitis. The median follow-up was 1 mo (range 0.03-18 mo). The incidence of BDI was 0.4% for SPLC and 0% for CLC; the difference was not statistically different (P = 0.36). The incidence of overall biliary complication was 1.6% for SPLC and 0.5% for CLC, the difference did not reached statistically significance (P = 0.21, 95%CI: 0.66-15). Sixty non-randomized trials including 3599 patients were also analysed. The incidence of BDI reported then was 0.7%. The safety of SPLC cannot be assumed, based on the current evidence. Hence, this new technology cannot be recommended as standard technique for laparoscopic cholecystectomy.

Bipartite Laparoscopic Cholecystectomy: New Technique for Avoiding Bile Duct Injury in Difficult Cases

The incidence of bile duct injury in laparoscopic cholecystectomy (LC) is still two times greater compared to classic open surgery. This study offers new procedure to avoid this complication during LC. The gall bladder was divided into two parts above the Hartmann pouch and all contents were aspirated. Then, the distal part was dissected for short distance. The proximal part was dissected dome down until reaching to cystic duct which was tied or clipped and cut. J-vac drain was put in peritoneal cavity. Between September 2012 and October 2013, overall 77 patients (53 females and 24 males) with mean age of 49 years (between 23 and 67 years) underwent bipartite laparoscopic cholecystectomy. The mean operative time was 60 minutes (between 40 and 90 minutes). The dissection of both parts of gall bladder was safe and easy as close as possible from its wall. No biliary tract injuries were recorded during or after procedure and also at follow-up period (20 months). Bipartite laparoscopic cholecystectomy is safe, easy to do, and can avoid all complications especially bile duct injuries in difficult cases.

Management of bile duct leaks

The cause of bile duct leaks can be either iatrogenic or more rarely, traumatic. The most common cause is related to laparoscopic cholecystectomy. While surgical repair has been the standard for many years, management in these often morbid and complex situations must currently be multidisciplinary incorporating the talents of interventional radiologists and endoscopists. Based on the literature and in particular the recent recommendations of the European Society of Gastrointestinal Endoscopy (ESGE), this review aims to update the management strategy. The incidence of these complications decreases with surgeon experience attesting to the value of training to prevent these injuries. Bile duct injuries must be categorized and their mapping detailed by magnetic resonance cholangiography MRCP or endoscopic cholangiography (ERCP) when endoscopic therapy is considered. Endoscopic management should be preferred in the absence of complete circumferential interruption of the common bile duct. The ESGE recommends insertion of a plastic stent for 4 to 8 weeks without routine sphincterotomy. For complete circumferential injuries, hepaticojejunostomy is usually necessary. In conclusion, adequate training of surgeons is essential for prevention since the incidence of bile duct injury decreases with experience. Faced with a bile duct injury, a multidisciplinary team approach, involving radiologists, endoscopists and surgeons improves patient outcome.

Congenital Absence of the Cystic Duct: A Rare but Significant Anomaly

Cholecystectomy is the most common digestive tract surgery performed worldwide and injury to the bile duct leads to both acute and chronic sequelae. The incidence of bile duct injury is increased in the presence of severe inflammation and is compounded by congenital abnormalities of the biliary tract. Congenitally absent cystic duct is one such rare anomaly with significant surgical implications. So far only nine clear cases of congenitally absent cystic duct have been reported. In this report we describe two additional cases of a congenitally absent cystic duct and provide a comprehensive discussion of the clinical significance, and appropriate surgical management of this anomaly.

TG13 surgical management of acute cholecystitis

Laparoscopic cholecystectomy is now accepted as a surgical procedure for acute cholecystitis when it is performed by an expert surgeon. There are several lines of strong evidence, such as randomized controlled trials (RCTs) and meta-analyses, supporting the introduction of laparoscopic cholecystectomy for patients with acute cholecystitis. The updated Tokyo Guidelines 2013 (TG13) describe the surgical treatment for acute cholecystitis according to the grade of severity, the timing, and the procedure used for cholecystitis in a question-and-answer format using the evidence concerning surgical management of acute cholecystitis. Forty-eight publications were selected for a careful examination of their full texts, and the types of surgical management of acute cholecystitis were investigated using this evidence. The items concerning the surgical management of acute cholecystitis were the optimal surgical treatment for acute cholecystitis according to the grade of severity, optimal timing for the cholecystectomy, surgical procedure used for cholecystectomy, optimal timing of the conversion of cholecystectomy from laparoscopic to open surgery, and the complications of laparoscopic cholecystectomy. There were eight RCTs and four meta-analyses concerning the optimal timing of the cholecystectomy. Consequently, it was found that cholecystectomy is preferable early after admission. There were three RCTs and two meta-analyses concerning the surgical procedure, which concluded that laparoscopic cholecystectomy is preferable to open procedures. Literature concerning the surgical treatment according to the grade of severity could not be quoted, because there have been no publications on this topic. Therefore, the treatment was determined based on the general opinions of professionals. Surgical management of acute cholecystitis in the updated TG13 is fundamentally the same as in the Tokyo Guidelines 2007 (TG07), and the concept of a critical view of safety and the existence of extreme vasculobiliary injury are added in the text to call the surgeon's attention to the need to reduce the incidence of bile duct injury. Free full-text articles and a mobile application of TG13 are available via http://www.jshbps.jp/en/guideline/tg13.html.

Bile duct injuries following laparoscopic cholecystectomy and repair involving lowering of the hilar plate

Background: Laparoscopic cholecystectomy (LC) is the standard of care for symptomatic cholelithiasis, but is associated with a higher incidence of bile duct injuries than the open approach. We evaluated a multidisciplinary approach for managing these injuries after LC. Materials and Methods: From April 2006 to August 2011, all patients who developed bile duct injury after LC and were treated by the hepatobiliary team of Al-Hada Armed Forces Hospital, Taif, Saudi Arabia were included in our study. If an injury was suspected intraoperatively, intraoperative cholangiography was performed; thereafter, if the injury was confirmed, immediate laparotomy and primary repair or hepaticojejunostomy (H-J) involving lowering of the hilar plate were performed. Injuries occurring postoperatively were treated by endoscopic cholangiopancreatography (ERCP) to diagnose the type of Strasberg injury. Strasberg type A injuries were managed endoscopically, and more advanced cases underwent open surgery. Results: Of 30 females and 18 males (mean age, 45 years; range, 18-90 years), 6 cases of bile duct injuries were discovered intraoperatively. Of these, two were classified as type C and underwent primary repair with internal stenting. The other four were classified as type E and were treated by Roux-en-Y H-J reconstruction. Forty-two cases of bile duct injuries presented postoperatively, including 18 Strasberg type A and 24 Strasberg type E injuries. Type A injuries were treated with ERCP and stenting, and six with endoscopic removal of a retained stone. Of the 28 patients who underwent H-J, 20 underwent the technique involving lowering of the hilar plate. Of these, three subsequently developed anastomotic strictures and were treated with percutaneous transhepatic balloon dilatation. There were no mortalities. The mean follow-up was for 36 months. Conclusion: Early referral to a specialized surgeon and a multidisciplinary approach help manage bile duct injury after LC in all patients with an acceptable low stricture rate.

Effect of intended intraoperative cholangiography and early detection of bile duct injury on survival after cholecystectomy: population based cohort study

Objectives To determine whether the routine use of intraoperative cholangiography can improve survival from complications related to bile duct injuries.Design Population based cohort study.Setting Prospectively collected data from the Swedish...

Single Incision Laparoscopic Cholecystectomy Is Associated With a Higher Bile Duct Injury Rate

To compare the incidence of bile duct injuries during single incision laparoscopic cholecystectomy (SILC) in relation to the accepted historic rate of 0.4% to 0.5% for standard laparoscopic cholecystectomy (SLC). Technically, SILC is more challenging than SLC. The role and benefit of SILC in patient care has yet to be defined. Bile duct injuries have been reported in several series of SILC. A comprehensive database search of MEDLINE, EMBASE, CINAHL, and PubMed Central was performed to generate all reported cases of SILC to present. The search was limited to reports of 20 or more patients based on current literature of existing SILC learning curves. Data were analyzed using the Student t test and χ analyses where appropriate. A total of 76 candidate studies were identified; 45 studies met inclusion criteria for an aggregate total of 2626 patients. Most SILCs were performed in the absence of acute cholecystitis (90.6%). The aggregate complication rate was 4.2%, and complications were graded according to the Dindo-Clavien Classification System. Nineteen bile duct injuries were identified for a SILC-associated bile duct injury rate of 0.72%. There seems to be an increase in the rate of bile duct injuries during SILC when compared with historic rates during SLC. Because most SILCs are performed in optimal conditions, such as lack of acute inflammation, we urge caution in applying this technique to inflamed gallbladder pathology. Controlled trials are needed before conclusions are made regarding safety of SILC.

Referral Pattern, Management, and Long-Term Results of Laparoscopic Bile Duct Injuries: A Case Series of 44 Patients

The incidence of bile duct injuries (BDIs) after laparoscopic cholecystectomy (LC) is higher than after open cholecystectomy, and the management of these lesions is still controversial. This study analyzed diagnostic and management strategies as well as long-term outcomes after BDI. A prospective database of patients with BDIs at the Clinic of Surgery was maintained during the 8-year period (2000-2007). The long-term results were evaluated during 2008-2010, after 36- to 120-month follow-up (median, 84 months). In our series, 21 patients (48%) presented with minor and 23 (52%) with major BDIs. The overall incidence of BDIs was 0.24%. In 92% of cases in the minor BDI group, endoscopic stenting resulted in a good outcome. Major BDIs were treated by immediate, early, or delayed surgery depending on the timeliness of diagnosis and presence of biliary sepsis and/or cholangitis. The mean estimated time to failure after the initial treatment in the minor BDI group was significantly longer when compared with the major BDI group (114.3 vs. 81.8 months, log-rank test P=0.048). The hazard ratio of initial treatment failure after major versus minor BDIs was 6.06 (95% CI, 1.01-17.59). The mean estimated time to develop a biliary stricture after immediate, early, and delayed reconstructions was not different (P>0.05 in pairwise comparisons by log-rank test). Minor BDIs are best served by endoscopy, while surgical repair may be an efficient option when injury is diagnosed intraoperatively. The timing of reconstruction after major BDIs does not portend a different outcome; consequently, every attempt to achieve infection control should be warranted. Referral to a tertiary care center should be encouraged to facilitate a proper classification of preoperative injuries and multidisciplinary approach.

Surgical management of acute cholecystitis: results of a 2-year prospective multicenter survey in Belgium

Laparoscopic cholecystectomy is considered nowadays as the standard management of acute cholecystitis (AC). However, results from multicentric studies in the general surgical community are still lacking. A prospective multicenter survey of surgical management of AC patients was conducted over a 2-year period in Belgium. Operative features and patients' clinical outcome were recorded. The impact of independent predictive factors on the choice of surgical approach, the risk of conversion, and the occurrence of postoperative complications was studied by multivariate logistic regression analysis. Fifty-three surgeons consecutively and anonymously included 1,089 patients in this prospective study. A primary open approach was chosen in 74 patients (6.8%), whereas a laparoscopic approach was the first option in 1,015 patients (93.2%). Independent predictive factors for a primary open approach were previous history of upper abdominal surgery [odds ratio (OR) 4.13, p < 0.001], patient age greater than 70 years (OR 2.41, p < 0.05), surgeon with more than 10 years' experience (OR 2.08, p = 0.005), and gangrenous cholecystitis (OR 1.71, p < 0.05). In the laparoscopy group, 116 patients (11.4%) required conversion to laparotomy. Overall, 38 patients (3.5%) presented biliary complications and 49 had other local complications (4.5%). Incidence of bile duct injury was 1.2% in the whole series, 2.7% in the open group, and 1.1% in the laparoscopy group. Sixty patients had general complications (5.5%). The overall mortality rate was 0.8%. All patients who died were in poor general condition [American Society of Anesthesiologists (ASA) III or IV]. Although laparoscopic cholecystectomy is currently considered as the standard treatment for acute cholecystitis, an open approach is still a valid option in more advanced disease. However, overall mortality and incidence of bile duct injury remain high.

Does increased experience with laparoscopic cholecystectomy yield more complex bile duct injuries?

BackgroundTwo decades since the advent of laparoscopic cholecystectomy, the rate of bile duct injuries still remains higher than in the open cholecystectomy era. MethodsThe rate and complexity of bile duct injuries was evaluated in 83,449 patients who underwent laparoscopic cholecystectomy between 1995 and 2008 in the Kaiser Permanente Northern California system. Fifty-six surgeons who performed a laparoscopic cholecystectomy in the past were surveyed to determine factors that predispose to bile duct injuries. ResultsThe overall incidence of bile duct injuries was .10%; 59.5% of the 84 injuries were cystic duct leaks. Incidence varied slightly from .10% (1995–1998) to .08% (1999–2003) and .12% (2004–2008). There was a trend toward more proximal injuries (injury <2 cm from the bifurcation: 14.3% to 44.4% to 50.0% of major injuries). The misinterpretation of anatomy was cited by 92.9% of surgeons as the primary cause of bile duct injuries; 70.9% cited a lack of experience as a contributing factor. ConclusionsLaparoscopic cholecystectomy has an overall low risk of bile duct injuries; the rate remains constant, but injury complexity may have increased over time.