Incidence Of Common Bile Duct Injury Research Articles

System Approach to Prevent Common Bile Duct Injury and Enhance Performance of Laparoscopic Cholecystectomy

Experience collected from 5200 cases of laparoscopic cholecystectomy (LC) and 29 patients (6 ours, 23 referred) with major common bile duct (CBD) injury during LC in our institute between December 1990 and July 2004 was reported to demonstrate that the system approach we applied in performing LC prevents CBD injury and enhances surgical performance. Each case of CBD injury was meticulously analyzed to identify causative factors. We developed preventive strategies focusing on 4 dimensions: patient, environment, procedure, and operator. Surgical performance was then evaluated to demonstrate improvements. Incidence of CBD injury was calculated for early and latter halves of the series to compare 5 parameters of surgical performance: patient selection, operation time, indwelling drainage tube, surgeon, and conversion rate. Results of accident analysis demonstrated that CBD injury followed definite mechanisms; several warning signs appearing before and during injury were identified and classified. According to these results, we designed strategies to prevent injury, including: setting up patient-selection program, controlling surgical environment, developing error-proof procedures, and constructing training programs. Incidence of CBD injury in the whole series was 0.12% (6/5200), 0.27% in early half (6/2224), and zero (0/2967) in latter half. Attending doctors had significantly shorter operation times in latter period for both elective and emergent LC. Rate of using drainage tubes for elective surgery by attending doctors was significantly decreased in latter period. Operation time for elective surgery by residents was similar in both early and latter periods. However, residents in latter period had longer operation times (around 23 min long, P<0.001) for emergent LC. Steps of our system approach include: (1) detailed accident analysis focusing on patient, environment, procedure, and surgeon; (2) developing 4 strategies directly responding to accident analysis results, including proper patient selection, control of environment, error-proof procedures, and a well-designed training program; and (3) demonstrating improved patient safety and surgical performance. Consistent use of systems approach promises continuing quality improvement. We believe our working model will help perform safer LC and also benefit other medical disciplines.

Routine vs Selective Intraoperative Cholangiography During Cholecystectomy

THE ISSUE OF ROUTINE VS SELECTIVE INTRAOPERATIVE cholangiography (IOC) during cholecystectomy has been controversial for decades. During the era of open cholecystectomy, a policy of performing selective IOC during cholecystectomy had largely become accepted based on criteria regarding preoperative and operative clinical findings. The advent of safe and effective endoscopic-retrograde cholangiopancreatography and its ability to help the surgeon detect and treat common bile duct (CBD) stones was beginning to change the practice of IOC when laparoscopic cholecystectomy transformed the field of biliary tract surgery. Prior to the advent of laparoscopic cholecystectomy, some surgeons recommended routine use of IOC, but the common practice among surgeons was selective use of IOC. When laparoscopic cholecystectomy emerged, this debate was re-energized. In this issue of the JOURNAL, Flum and colleagues provide an important study on the relationship among cholecystectomy, IOC, and rate of CBD injury. Based on their analysis of more than 1.5 million patients with Medicare who underwent cholecystectomy between 1992 and 1999, including 7911 with CBD injury, the authors conclude that routine use of IOC may reduce the incidence of CBD injury. If this conclusion is true, it will radically alter the current practice of cholecystectomy, since the standard practice for surgeons is to not routinely perform an IOC during laparoscopic cholecystectomy. In the analysis by Flum et al, IOC was performed in 39% of cholecystectomies. The routine use of IOC has substantial ramifications from both a cost perspective and legal standpoint. During the early part of the experience of laparoscopic cholecystectomy, the number of CBD injury lawsuits against surgeons surged. Surgeons who espoused the necessity of performing routine IOC claimed that such a policy could reduce CBD injury. Therefore, if a patient sustained a CBD injury and the surgeon had not performed a routine IOC this could be used as possible evidence of malpractice. Thus, the findings of Flum et al could potentially have implications beyond the medical issues. Surgeons who advocate routine use of IOC as a means of reducing CBD injury claim that this method clearly delineates biliary tract anatomy prior to actually dividing any structure. Surgeons who do not believe that routine use of IOC is a means of avoiding CBD injury make the point that if a surgeon encircles a structure believed to be the cystic duct, clips it on one end, and incises it to perform an IOC, and if, in fact, that structure turns out to be the CBD, an injury would have occurred through the act of attempting the IOC. The advocates of routine use of IOC reply by stating that when a CBD injury occurs, it is less severe than what would have occurred through misidentification of the CBD. Thus, the argument rages back and forth, with experienced surgeons from many institutions taking positions on both sides of the argument. One small randomized trial comparing routine IOC to selective IOC use during laparoscopic cholecystectomy was undertaken in Germany but did not provide sufficient data to make a specific conclusion regarding CBD injury. However, the authors did conclude that preoperative use of endoscopic-retrograde cholangiopancreatography was superior to routine use of IOC during laparoscopic cholecystectomy for the purpose of clearing CBD stones. A number of issues need to be considered in the analysis by Flum et al. The first is the possibility of coding error, which is inherent in the analysis of administrative Medicare data. Second is a concern regarding patients who underwent reconstruction of the CBD at the time of cholecystectomy if an injury was recognized immediately. It seems possible that immediate reconstruction of the CBD injury might have been more likely among surgeons who performed routine IOC, that is, the more experienced surgeons who had performed a higher number of cholecystectomies. The analysis did not recognize these CBD injuries, since the outcome sought was reoperative repair of the CBD injury. Since the number of CBD repair is small (albeit significant), a few of these CBD injuries that underwent immediate reconstruction could invalidate the conclusion by Flum et al. Third, the study included only Medicare patients, and the findings may not be generalizable to the total population of patients undergoing CBD repair. Fourth, only 76% of cholecystectomies were reported as laparoscopic procedures, which seems low even if procedures converted to open cholecystectomies are included. Finally, the relationship among a surgeon’s experience (number of cholecystectomies performed), frequency of IOC use, and incidence of CBD injury is not clear. For instance, the situation most likely to create a CBD injury is when the surgeon who routinely performs IOC ( 75% cholecystectomies) does not perform an IOC (1.50% rate of CBD injury). The surgeon who does not

Imaging of cholelithiasis: what does the surgeon need?

Laparoscopic cholecystectomy (LC) has become the standard approach for cholecystectomy despite relatively scant evidence that it is superior to open cholecystectomy (OC) in several prospective randomized studies [1‐ 4]. The overwhelmingly fast spread of the laparoscopic technology and the purported lower invasiveness and quicker recovery after LC as opposed to OC have led to important modifications in the management of biliary disease and especially in the attitude of many surgeons toward common bile duct (CBD) stones. Despite consensus that only symptomatic gallbladder stones require surgery [5], the general enthusiasm for laparoscopic surgery has lowered the threshold for LC. In most developed countries, the total number of cholecystectomies performed has increased by 14 ‐24% during 1991‐1993 [6, 7]. Data from Scandinavia suggest that the number of procedures has remained stable [6]. When cholecystectomy was performed for symptomatic cholelithiasis, the prevalence of CBD stones was 8 ‐15% in patients younger than 60 years and 15‐ 60% in patients older than 60 [5]. Performing LC in an increasing number of patients with little or only short-lasting symptoms has decreased the prevalence of CBD stones in the surgical population. Because the predictive values of any diagnostic test are directly related to the prevalence of the disease in the population tested, it is more than likely that the currently available preoperative diagnostic tools have lower positive predictive values than in populations with truly symptomatic cholelithiasis. Although LC is relatively safe (mortality rate ,0.1%), it is associated with a 0.36 ‐ 0.7% incidence of CBD injuries, which is almost twice the incidence for OC [6 ‐ 8]. Obviously, the increasing absolute number of cholecystectomies has increased the overall number of operative CBD injuries. The increasing number of cholecystectomies has also been responsible for the rising number of preoperative biologic and radiologic tests currently performed for the detection of CBD stones. A large variety of morphologic diagnostic investigations are available to the present-day clinician: conventional or endoscopic ultrasound, intravenous cholangiography, spiral computed tomographic (CT) cholangiography, magnetic resonance (MR) cholangiography, endoscopic retrograde cholangiography (ERC), and laparoscopic ultrasound. In addition to their variable efficiency for the detection of CBD stones, these techniques differ in terms of invasiveness, cost, and availability. Standardized and cost-efficient diagnostic strategies for CBD stones are required more than ever to limit the performance of diagnostic tests that may not only be noncontributive for most patients referred for cholecystectomy but also potentially harmful.

Cholecystectomy without operative cholangiography. Implications for common bile duct injury and retained common bile duct stones.

This study evaluated the selective use of endoscopic retrograde cholangiopancreatography (ERCP) in the context of laparoscopic cholecystectomy (LC) while minimizing the use of operative cholangiography. There has been a long-standing debate between routine and selective operative cholangiography that has resurfaced with LC. Prospective data were collected on the first 1300 patients undergoing LC at McGill University. Preoperative indications for ERCP were recorded, radiologic findings were standardized, and technical points for a safe LC were emphasized. A total of 106 patients underwent 127 preoperative ERCPs. Fifty patients were found to have choledocholithiasis (3.8%), and clearance of the common bile duct (CBD) with endoscopic sphincterotomy was achieved in 45 patients. The other five patients underwent open cholecystectomy with common duct exploration. Intraoperative cholangiography (IOC) was attempted in only 54 patients (4.2%), 6 of whom demonstrated choledocholithiasis. Forty-nine postoperative ERCPs were performed in 33 patients and stones were detected in 17 (1.3%), with a median follow-up time of 22 months. Endoscopic duct clearance was successful in all of these. The incidence of CBD injury was 0.38%, and a policy of routine operative cholangiography might only have led to earlier recognition of duct injury in one case. The rate of complication for all ERCPs was 9% and the associated median duration of the hospital stay was 4 days. The median duration of the hospital stay after open CBD exploration was 13 days. LC can be performed safely without routine IOC. The selective use of preoperative and postoperative ERCP will clear the CBD of stones in 92.5% of patients.