Rate Of Bile Duct Injury Research Articles

Management of Complicated Gallstone Disease

Nearly 9% of men and 30% of women in the United States experience symptoms or complications of gallstone disease. As such, nearly every general surgeon in the country encounters patients with this pathology numerous times during his or her career. Cholelithiasis can cause complications such as acute cholecystitis, choledocholithiasis, gallstone pancreatitis, and the rare entities of Mirizzi syndrome and gallstone ileus. Patients with gallstones have a 1 to 3% risk per year of a complication, and that risk increases significantly to 30% in those with biliary colic. Surgical management of the complications of gallstones is especially intriguing because the cases are often perceived as low complexity; however, it is an operation that can challenge even the most seasoned attending and result in significant complications. Studies demonstrate complication rates up to 10% following cholecystectomy, with bile duct injury rates hovering at 4 in 1,000. This chapter aims to provide the reader with knowledge of the presentation, imaging, work-up, and framework for the management of complicate gallbladder disease. Furthermore, we hope to provide you with a foundation of how to perform a safe cholecystectomy in a variety of circumstances and impart a few tips and tricks for some challenging intraoperative situations. This review contains 2 figures, and 55 references. Key Words: cholecystitis, choledocholithiasis, cholescintigraphy, common bile duct exploration, critical view of safety, ERCP, gallstone pancreatitis, subtotal cholecystectomy

Addressing the ethical grey zone in surgery: a framework for identification and safe introduction of novel surgical techniques and procedures.

While the introduction of new surgical techniques can radically improve patient care, they may equally expose patients to unforeseen harms associated with untested procedures. The enthusiastic uptake of laparoscopic cholecystectomy in the early 1990s saw a dramatic increase in the rate of common bile duct injuries, and was described by Alfred Cuschieri as 'the biggest unaudited free-for-all in the history of surgery' due to 'a lack of effective centralised control'. Whether a new surgical intervention is considered an acceptable 'minor' variation of an established procedure, or is sufficiently 'novel' to constitute experimentation on human subjects is often unclear. Furthermore, once a new technique is identified as experimental, there is no agreed protocol for safety evaluation in a first-in-human setting. In phase I (first-in-human) pharmacological trials only small, single arm cohorts of highly selected patients are enrolled in order to establish the safety profile of a new drug. This exposes only a small number of patients to the unknown or unforeseen risks that may be associated with a new agent, in a highly regulated and scientifically rigorous manner. There is no equivalent study design for the introduction of new and experimental surgical procedures. This article proposes a practical stepwise approach to the safe introduction of new surgical procedures that surgeons and surgical departments can adopt. It includes criteria for new surgical techniques which require formal prospective ethical evaluation, and a novel study design for conducting a safety evaluation at the 'first in human' stage.

The role of indocyanine green fluoroscopy for intraoperative bile duct visualization during laparoscopic cholecystectomy: an observational cohort study in 70 patients

BackgroundBile duct injury is the most feared complication during laparoscopic cholecystectomy. Real-time intraoperative imaging using indocyanine green (ICG) might reduce the risk of bile duct injury by improving visualization of the biliary tree during laparoscopic cholecystectomy. We compared the outcomes of laparoscopic cholecystectomy in patients with and without real-time ICG.MethodsA retrospective analysis of the data of patients undergoing laparoscopic cholecystectomy with and without ICG in a referral centre for minimally invasive surgery was performed. We hypothesized that laparoscopic cholecystectomy with real-time ICG enables a better identification of the biliary tree and thus increases surgical safety. The outcomes of laparoscopic cholecystectomy with and without ICG were compared using the duration of surgery, the rate of bile duct injury, the rate of conversion, complications and the length of stay.ResultsSeventy patients including 29 with and 41 without ICG underwent laparoscopic cholecystectomy within the period of investigation. The median duration of surgery was 53.0 vs. 54.0 min while the median length of stay was 2.0 d in the group with and without ICG respectively. The rate of conversion was 2.4% in the group without ICG, while no conversion was performed in the group with ICG. NO bile duct injury occurred in both groups. These differences were not statistically significant.ConclusionLaparoscopic cholecystectomy with real-time indocyanine green fluorescence cholangiography enables a better visualization and identification of biliary tree and therefore should be considered as a means of increasing the safety of laparoscopic cholecystectomy.

Bile duct injuries (BDI) in the advanced laparoscopic cholecystectomy era.

Laparoscopic cholecystectomy is the most commonly performed laparoscopic procedure. It is superior in nearly every regard compared to open cholecystectomies. The one significant aspect where the laparoscopic approach is inferior regards the association with bile duct injuries (BDI). The BDI rate with laparoscopic cholecystectomy is approximately 0.5%; nearly triple the rate compared to the open approach. We propose that 0.5% BDI rate with the laparoscopic approach is no longer accurate. The National Surgical Quality Improvement Program (NSQIP) registry was retrospectively reviewed. All laparoscopic cholecystectomies performed between 2012 and 2016 were extracted. A total of 217,774 cases meeting inclusion criteria were analyzed. The primary data points were the overall BDI incidence rate and time of diagnosis. BDI were identified by ICD-9 and ICD-10 codes. Secondary data points were variables associated with BDI. The BDI rate was 0.19%. 77% of cases were diagnosed after the index surgical admission. Intra-operative cholangiography (IOC) use was associated with a higher BDI rate and higher identification rate of a BDI intraoperatively (P value < 0.0001). Resident teaching cases were protective with a RR score of 0.56 (P value < 0.0001). The presence of cholecystitis increased the risk of a BDI with a RR score of 1.20 (P value < 0.0001). There was a low conversion rate of 0.04% however converted cases had a nearly hundredfold increase in BDI at 15% (P value < 0.0001). The performance of laparoscopic cholecystectomies in North America is no longer associated with higher BDI rates compared to open. IOC use still is not protective against BDI, and cholecystitis continues to be a risk factor for BDI. When a cholecystectomy requires conversion from a laparoscopic to an open approach the BDI increases a hundredfold; which may raise the concern if this approach is still a safe bailout method for a difficult laparoscopic dissection.

Inter-surgeon Variability in Cystic Artery Lymph Node Excision during Laparoscopic Cholecystectomy.

IntroductionExpert opinion recommends that surgeons perform a laparoscopic cholecystectomy (LC) in a standardized manner by dissecting the hepatobiliary triangle lateral to the cystic artery lymph node (LN) to minimize the rate of a major bile duct injury.MethodsTo determine whether surgeons performed a laparoscopic cholecystectomy in a standardized manner, the study assessed the variability in the frequency of an LN excision. All LCs that were performed at a single hospital were identified from a prospective dataset. The presence of an LN was retrospectively determined from the histology report.ResultsTwenty-seven surgeons were recorded to have performed 2332 laparoscopic cholecystectomies. Out of the total number of patients, 76.8% were female. The median patient age was 42.4 years. About 60.8% of the LCs were elective, while 39.2% of them were acute. Nineteen pathologists reported that in 99% of the specimens – the LN status of 1831 (78.5%) gallbladders was reported and analyzed. Overall, the LN yield per surgeon varied from 0% to 50% (mean 18.7%).Conclusion The high inter-surgeon variability in the rate of LN excision during laparoscopic cholecystectomy shows that surgeons dissect the hepatobiliary triangle differently. The LN yield may also represent a surrogate marker of surgical technique (which is easy to measure).

Outcome trends and safety measures after 30\xa0years of laparoscopic cholecystectomy: a systematic review and pooled data analysis

BackgroundLaparoscopic cholecystectomy (LC), one of the most commonly performed surgical procedures, remains associated with significant major morbidity including bile leak and bile duct injury (BDI). The effect of changes in practice over time, and of interventions to improve patient safety, on morbidity rates is not well understood. The aim of this review was to describe current incidence rates and trends for BDI and other complications during and after LC, and to identify risk factors and preventative measures associated with morbidity and BDI.MethodsPubMed, MEDLINE, and Web of Science database searches and data extraction were conducted for studies which reported individual complications and complication rates following laparoscopic cholecystectomy in a representative population. Outcomes data were pooled. Meta-regression analysis was performed to assess factors associated with conversion, morbidity, and BDI rates.ResultsOne hundred and fifty-one studies reporting outcomes for 505,292 patients were included in the final quantitative synthesis. Overall morbidity, BDI, and mortality rates were 1.6–5.3%, 0.32–0.52%, and 0.08–0.14%, respectively. Reported BDI rates reduced over time (1994–1999: 0.69(0.52–0.84)% versus 2010–2015 0.22(0.02–0.40)%, p = 0.011). Meta-regression analysis suggested higher conversion rates in developed versus developing countries (4.7 vs. 3.4%), though a greater degree of reporting bias was present in these studies, with no other significant associations identified.ConclusionsOverall, trends suggest a reduction in BDI over time with unchanged morbidity and mortality rates. However, data and reporting are heterogenous. Establishment of international outcomes registries should be considered.

Bile duct injury and morbidity following cholecystectomy: a need for improvement

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. 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 1year 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. 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 365days. 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. 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.

Characterization of common bile duct injury after laparoscopic cholecystectomy in a high-volume hospital system.

Despite the popularity of laparoscopic cholecystectomy, rates of common bile duct injury remain higher than previously observed in open cholecystectomy. This retrospective chart review sought to determine the prevalence of, and risk factors for, biliary injury during laparoscopic cholecystectomy within a high-volume healthcare system. 800 of approximately 3000 cases between 2009 and 2015 were randomly selected and retrospectively reviewed. A single reviewer examined all operative notes, thereby including all cases of BDI regardless of ICD code or need for a second procedure. Biliary injuries were classified per Strasberg et al. (J Am Coll Surg 180:101-125, 1995). Logistic regression models were utilized to identify univariable and multivariable predictors of biliary injuries. 31.0% of charts stated that the Critical View of Safety was obtained, and 12.4% of charts correctly described the critical view in detail. Three patients (0.4%) had a cystic duct leak, and 4 (0.5%) had a common bile duct injury. Of the four CBDI, three patients had a partial transection of the CBD and one had a partial stricture. Patients who suffered BDI were more likely to have had lower hemoglobin, urgent surgery, choledocholithiasis, or acutely inflamed gallbladder. Multivariable analysis of BDI risk factors showed higher preoperative hemoglobin to be independently protective against CBDI. Acutely inflamed gallbladder and choledocholithiasis were independently predictive of CBDI. The rate of CBDI in this study was 0.5%. Acutely inflamed conditions were risk factors for biliary injury. Multivariable analysis suggests a protective effect of higher preoperative hemoglobin. There was no correlation of CVS with prevention of biliary injury, although only 12.4% of charts could be verified as following the technique correctly. Better implementation of CVS, and increased caution in patients with perioperative inflammatory signs, may be important for preventing bile duct injury. Additionally, counseling patients with acute inflammation on increased risk is important.

Is cystic artery lymph node excision during laparoscopic cholecystectomy a marker of technique?

In order to minimize bile duct injury, experts suggest that dissection during laparoscopic cholecystectomy (LC) should be performed lateral to the lymph node (LN). This study aims to determine whether the frequency of excision of the LN is related to patient factors, disease severity or surgical difficulty. All LCs performed or supervised by one surgeon were identified from a prospective database. The presence of LN was retrospectively determined by reviewing the gallbladder histology report. The LN was identified in 10.4% of 1332 cholecystectomies. The American Society of Anesthesiologists class 3 was associated with a lower rate of LN excision compared with class 1 (odds ratio: 0.36; P = 0.049) as was the presence of a senior surgical trainee (odds ratio: 0.18; P < 0.001). Rate of LN excision was independent of patient demographic and clinical characteristics, including indication for cholecystectomy, conversion to open, gallbladder perforation, cholangiography, bile duct exploration and overall surgical difficulty. The frequency with which the LN is excised during LC by the one surgeon is independent of the majority of clinical and surgical factors and may represent a surrogate marker of surgical technique. Whether this is related to the rate of bile duct injury remains to be determined.

Delayed Laparoscopic Cholecystectomy for Acute Calculous Cholecystitis: Is it Time for a Change?

Our aim was to evaluate the advantages and limitations of delayed laparoscopic cholecystectomy (LC) in a tertiary center. A retrospective analysis of all patients admitted to our institution with acute calculous cholecystitis (ACC) between January 2003 and December of 2012 was performed. Data collected included patient demographics and comorbidities, presenting symptoms, laboratory findings, imaging results, length of stay (LOS), time to surgery, and surgical complications. A total of 1078 patients were admitted with ACC. There were 593 females (55%), and the mean age was 57±0.6years. Mean LOS at initial admission, re-admission until surgery, and following surgery was 7.9±0.2, 1.5±0.1, and 3.4±0.2days, respectively. Percutaneous cholecystostomy (PC) tube was inserted in 24% of the patients. Only 640 (59%) patients eventually underwent LC. Mean time to surgery was 97±9.8days, and 16.4% of patients were readmitted in this time period resulting in a mean total LOS of 10.6±0.2days. Conversion rate to open surgery was 5.8% and bile duct injury occurred in 1.1%. Postoperative complications occurred in 9.8% of the patients, and 30-day mortality was 0.6%. Patients with more severe inflammation according to Tokyo Criteria grade were more likely to undergo PC, were more likely to be readmitted while waiting for LC, and also had more postoperative complications. Delayed LC is associated with significant loss of follow-up, long LOS, and higher than expected use of PC. Conversion rates are lower than in the literature while rates of bile duct injury and mortality are comparable. We believe these data as well as the available literature are sufficient to change our hospital policy regarding the surgical treatment of ACC from delayed to early same admission surgery in appropriate cases.

Double Cystic Duct Not Detected by Imaging But Diagnosed on Intraoperative Dissection in Laparoscopic Cholecystectomy: A Case Report, Hatwan Hospital-Sulaimani Province-Kurdistan-Iraq

The incidence rate of bile duct injury during laparoscopic cholecystectomy has not been changed for many years. This may be because of biliary tree abnormalities, as variation in cystic duct anatomy is quite common. One of the extremely rare anomalies is a double cystic duct. An old lady underwent laparoscopic cholecystectomy for symptomatic gallstones. Without any clue for this anomaly in preoperative checkup, we found two cystic ducts during the laparoscopy. Operation completed laparoscopically, with smooth early and later postoperative checkups till now.

New insights on the therapeutic strategies for Mirizzi syndrome in the era of laparoscopy

Mirizzi syndrome (MS) is a complication of chronic cholelithiasis, whose pathological changes are severe and complicated. The preoperative diagnosis rate of MS is rather low, and the intraoperative bile duct injury rate is rather high. In the past, MS was considered as a contraindication for laparoscopy, but in the recent decade, with the increasing understanding on pathological changes of MS, the improvement of laparoscopic technique and the accumulation of experience, laparoscopic therapy has been increasingly used in treating MS. The piling experience and knowledge have been modified and optimized the traditional treatment for MS mainly in the following 3 aspects. First, if the skills and experience permit, exploration and treatment of MS may be completed safely and efficiently in laparoscopic route. Second, biliary-enteric anastomosis should be avoided as much as possible in the treatment strategy of MS Ⅲ. Intraoperatively, the wall of cholecystobiliary fistula and the Hartmann's pouch should be retained as much as possible in order to aid in the closure of the destroyed bile duct. When exploration is not needed, MS Ⅲ can be successfully treated with this technique in most cases. When exploration is needed, bile duct incision both in upper and lower directions from the fistula and T tube placement through the fistula are suggested. Third, for MS Ⅳ, bile duct repair and T-tube drainage can be used as the preferred method, and biliary-enteric anastomosis can only be considered as a remedial measure when the bile duct is completely transected or the continuity is not satisfactory. Key words: Mirizzi syndrome; Gallstones; Chronic cholecystitis; Laparoscopy; Treatment

The Sooner, the Better? The Importance of Optimal Timing of Cholecystectomy in Acute Cholecystitis: Data from the National Swedish Registry for Gallstone Surgery, GallRiks

Up-front cholecystectomy is the recommended therapy for acute cholecystitis (AC). However, the scientific basis for the definition of the optimal timing for surgery is scarce. The aim of this study was to analyze how the timing of surgery, after the admission to hospital for AC, affects the intra- and postoperative outcomes. Within the national Swedish Registry for Gallstone Surgery and Endoscopic Retrograde Cholangiopancreatography (GallRiks), all patients undergoing cholecystectomy for acute cholecystitis between January 2006 and December 2014 were identified. Data regarding patient characteristics, intra- and postoperative adverse events (AEs), bile duct injuries, and 30- and 90-day mortality risk were captured, and the correlation between the surgical timing and these parameters was analyzed. In total, data on 87,108 cholecystectomies were analyzed of which 15,760 (18.1 %) were performed due to AC. Bile duct injury, 30- and 90-day mortality risk, and intra- and postoperative AEs were significantly higher if the time from admission to surgery exceeded 4 days. The time course between surgery and complication risks seemed to be optimal if surgery was done within 2 days after hospital admission. Although AC patients operated on the day of hospital admission had a slightly increased AE rate as well as 30- and 90-day mortality rates than those operated during the interval of 1–2 days after admission, the bile duct injury and conversion rates were, in fact, significantly lower. The optimal timing of cholecystectomy for patients with AC seems to be within 2 days after admission. However, the somewhat higher frequency of AE on admission day may emphasize the importance of optimizing the patient before surgery as well as ensuring that adequate surgical resources are available.

Increasing resident utilization and recognition of the critical view of safety during laparoscopic cholecystectomy: a pilot study from an academic medical center.

Laparoscopic cholecystectomy (LC) is a commonly performed surgical procedure; however, it is associated with an increased rate of bile duct injury (BDI) when compared to the open approach. The critical view of safety (CVS) provides a secure method of ductal identification to help avoid BDI. CVS is not universally utilized by practicing surgeons and/or taught to surgical residents. We aimed to pilot a safe cholecystectomy curriculum to demonstrate that educational interventions could improve resident adherence to and recognition of the CVS during LC. Forty-three general surgery residents at Thomas Jefferson University Hospital were prospectively studied. Fifty-one consecutive LC cases were recorded during the pre-intervention period, while the residents were blinded to the outcome measured (CVS score). As an intervention, a comprehensive lecture on safe cholecystectomy was given to all residents. Fifty consecutive LC cases were recorded post-intervention, while the residents were empowered to "time-out" and document the CVS with a doublet photograph. Two independent surgeons scored the videos and photographs using a 6-point scale. Residents were surveyed pre- and post-intervention to determine objective knowledge and self-reported comfort using a 5-point Likert scale. In the 18-week study period, 101 consecutive LCs were adequately captured and included (51 pre-intervention, 50 post-intervention). Patient demographics and clinical data were similar. The mean CVS score improved from 2.3 to 4.3 (p<0.001). The number of videos with CVS score >4 increased from 15.7 to 52% (p<0.001). There was strong inter-observer agreement between reviewers. The pre- and post-intervention questionnaire response rates were 90.7 and 83.7%, respectively. A greater number of residents correctly identified all criteria of the CVS post-intervention (41-93%, p<0.001) and offered appropriate bailout techniques (77-94%, p<0.001). Residents strongly agreed that the CVS education should be included in general surgery residency curriculum (mean Likert score=4.71, SD=0.54). Residents also agreed that they are more comfortable with their LC skills after the intervention (4.27, σ=0.83). The combination of focused education along with intraoperative time-out significantly improved CVS scores and knowledge during LC in our institution.

Population-Based Studies Should not be Used to Justify a Policy of Routine Cholangiography to Prevent Major Bile Duct Injury During Laparoscopic Cholecystectomy.

Iatrogenic bile duct injury at time of cholecystectomy is a rare but devastating event. A twofold higher frequency of bile duct injury during cholecystectomy without cholangiography is reported in population-based studies. Some interpret this as a cause-and-effect relationship and thus mandate routine cholangiography. A critical appraisal of population studies is required to determine whether these studies are suitable in determining the role of routine cholangiography. The literature search was performed using combinations of the forced search terms "duct injury", "population" and "cholangiography" to identify population-based studies assessing the relationship between cholangiography and iatrogenic bile duct injury. All seven population-based studies reported a numerically higher rate of bile duct injury when an intraoperative cholangiogram was not obtained during cholecystectomy. Five predate the critical view technique. Only one was limited to laparoscopic cholecystectomy. All studies identified cholangiography as a likely marker for disease severity or surgical technique. Six studies did not demonstrate a cause-and-effect relationship by not including effect modifiers. The only study to address confounders reported the same rate of injury irrespective of the use of cholangiography. Critical appraisal of population-based studies does not support their use in justifying a policy of routine cholangiography to prevent major bile duct injury.

Elective laparoscopic cholecystectomy without intraoperative cholangiography: role of preoperative magnetic resonance cholangiopancreatography - a retrospective cohort study.

BackgroundLaparoscopic cholecystectomy (LC) is the standard treatment for gallbladder diseases. Intraoperative cholangiography (IOC) can reduce biliary complications of LC; however, with the emergence of magnetic resonance cholangiopancreatography (MRCP), IOC nowadays is faced with unprecedented challenge. The purpose of this study is to evaluate whether preoperative MRCP can safely replace IOC during elective LC in terms of retained common bile duct (CBD) stones and bile duct injury (BDI).MethodsA retrospective study on candidates for elective LC who underwent IOC or preoperative MRCP between January 2009 and December 2014 was conducted.ResultsIn the IOC group, 1972 patients underwent LC and 213 required IOC. In the MRCP group, 2268 patients underwent LC and 257 required MRCP. In the IOC group, the rate of retained CBD stones was 0.45 % without IOC and 1.41 % with IOC. In five of 157 patients who underwent IOC, endoscopic retrograde cholangiopancreatography or laparoscopic CBD exploration showed no evidence of CBD stones. In the MRCP group, the rate of retained CBD stones was 0.45 % without MRCP. No patients with normal MRCP findings returned with symptomatic CBD stones during 1-year follow-up. The rate of BDIs was 0.20 % in the IOC group and 0.13 % in the MRCP group.ConclusionsSelective use of preoperative MRCP is an effective and safe strategy when conducting elective LC to treat gallstones. LC resorting to preoperative MRCP can be performed safely without IOC, with an acceptable rate of retained CBD stones and BDIs.

414 The Sooner the Better-The Importance of Optimal Timing of Cholecystectomy in Acute Cholecystitis. Data From the National Swedish Registry for Gallstone Surgery, Gallriks (2006 to 2014)

Up-front cholecystectomy is the recommended therapy for acute cholecystitis (AC). However, the scientific basis for the definition of the optimal timing for surgery is scarce. The aim of this study was to analyze how the timing of surgery, after the admission to hospital for AC, affects the intra- and postoperative outcomes. Within the national Swedish Registry for Gallstone Surgery and Endoscopic Retrograde Cholangiopancreatography (GallRiks), all patients undergoing cholecystectomy for acute cholecystitis between January 2006 and December 2014 were identified. Data regarding patient characteristics, intra- and postoperative adverse events (AEs), bile duct injuries, and 30- and 90-day mortality risk were captured, and the correlation between the surgical timing and these parameters was analyzed. In total, data on 87,108 cholecystectomies were analyzed of which 15,760 (18.1 %) were performed due to AC. Bile duct injury, 30- and 90-day mortality risk, and intra- and postoperative AEs were significantly higher if the time from admission to surgery exceeded 4 days. The time course between surgery and complication risks seemed to be optimal if surgery was done within 2 days after hospital admission. Although AC patients operated on the day of hospital admission had a slightly increased AE rate as well as 30- and 90-day mortality rates than those operated during the interval of 1–2 days after admission, the bile duct injury and conversion rates were, in fact, significantly lower. The optimal timing of cholecystectomy for patients with AC seems to be within 2 days after admission. However, the somewhat higher frequency of AE on admission day may emphasize the importance of optimizing the patient before surgery as well as ensuring that adequate surgical resources are available.

Bile duct injury (BDI) and conversion rate (CR) in laparoscopic cholecystectomy (LC) performed by general surgery residents

Introduction: LC is associated with a steep learning curve, with a higher incidence of BDI and conversions to open surgery in the first cases. The impact of simulation and hands on training is usually associated with a decrease in complications. Our aim was to investigate the rate of BDI and CR in LC performed by surgical residents, previously undergoing systematic simulation training, under supervision of faculty staff. Methods: Between june 2010 and june 2015, 1651 elective LC were performed by PGY2, PGY3 and PGY4 surgical residents, with previous and certified training in laparoscopic skills in our Training Center, assisted and supervised by faculty staff with an average experience of 1200 procedures (range 650-1800). Results: Of the total 1651 LC, 1074 (65.1%) were performed by PGY2, 359 (21.7%) by PGY3 and 218 (13.2%) by PGY4. There were a total of 91 (5.5%) conversions, 17 (1%) in LC performed by PGY2; 31 (1.8%), by PGY3 and 43 (2.6%), by PGY4. There were 2 (0.12%) BDI, 1 (0.06%) for a PGY3 and 1 (0.06%) for a PGY4, which corresponded to cases Nº115 and 147, respectively. No other major intraoperative or postoperative complications were attained. Conclusions:a)Simulation and hands on training for laparoscopic skills honing represent a very important aid in surgical education with ethical and medicolegal implications for surgical traineesb)Adequate supervision by expert staff allows surgical residents clinical exposure without an added increase in complications or BDI andc)Surgical patient safety should be a concern in academic teaching institutions.

Cracking the Code: The Unexpected Challenge of Identifying Major Bile Duct Injuries

The reported rate of major bile duct injury (BDI) after cholecystectomy is 0.2 to 0.5 per cent. We evaluated the accuracy of coding major BDIs integrating both Current Procedural Terminology (CPT) and ICD-9 coding. A retrospective review was conducted for more than 3.5 million members of a large managed health-care organization from January 2007 to December 2013. A total of 56,194 cholecystectomies were captured over this 6-year period. Major BDIs were defined as unintended transection of a major bile duct, Bismuth-Strasberg classification E1-E5, and requiring biliary reconstruction within one year of cholecystectomy. Based on two published study methods (CPT 47760, 47765, 47780 and ICD-9 code 998.2), 173 possible BDIs were identified. Only 13 (7.5%) were confirmed to have a major BDI. The remaining 160 cases were minor complications or were unrelated to cholecystectomy. This reflects an overall BDI rate of 0.02 per cent, an order of magnitude less than commonly published rates. There is a lack of consistent methodology to identify major bile duct injuries. This calls into question the accuracy of published rates. We suspect that some major injuries were not captured. We recommend a universal clinical registry and specific ICD codes to accurately identify this serious complication.

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."