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

Abstract

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 national registry of gallstone surgery and endoscopic retrograde cholangiopancreatography, GallRiks. Multivariate analysis done by Cox regression. Population All cholecystectomies recorded in GallRiks between 1 May 2005 and 31 December 2010.Main outcome measures Evidence of bile duct injury, rate of intended use of intraoperative cholangiography, and rate of survival after cholecytectomy.Results During the study, 51 041 cholecystectomies were registered in GallRiks and 747 (1.5%) iatrogenic bile duct injuries identified. Patients with bile duct injuries had an impaired survival compared with those without injury (mortality at one year 3.9% v 1.1%). Kaplan-Meier analysis showed that early detection of a bile duct injury, during the primary operation, improved survival. The intention to use intraoperative cholangiography reduced the risk of death after cholecystectomy by 62% (hazard ratio 0.38 (95% confidence interval 0.31 to 0.46)). ConclusionsThe high incidence of bile duct injury recorded is probably from GallRiks' ability to detect the entire range of injury severities, from minor ductal lesions to complete transections of major ducts. Patients with bile duct injury during cholecystectomy had impaired survival, and early detection of the injury improved survival. The intention to perform an intraoperative cholangiography reduced the risk of death after cholecystectomy. IntroductionBile duct injury during cholecystectomy is a serious surgical complication that can have devastating consequences, including a significant risk of early death.1 2 Bile duct injury also has a major effect on healthcare costs, since injured patients frequently need prolonged and repeated hospital stay, multiple reinterventions, and long sick leave. 3 Many efforts have been made to determine which factors affect the risk of death after bile duct injury. Advanced age and severe comorbidity have been clearly established as causally linked to poor survival. 1 2 4 Indeed, the most intensely debated factor is the use of intraoperative cholangiography; previous studies by our group 2 and other researchers 1 have shown an association between the performance of intraoperative cholangiography and improved survival. However, since all previous results have been based on data for intraoperative cholangiography actually performed, skeptics have validly argued that this association might be due to bias through differential misclassification.In anatomically difficult cholecystectomies, which probably carry a high risk of bile duct injury, it is difficult to perform a successful intraoperative cholangiogram, thus reducing the cholangiography rate in cholecystectomies prone to bile duct injury. In the present study, we have the advantage, compared with previous studies, of using data that are validated, pr...

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

“…Even if QoL data was not reported this demonstrated that all postoperative complications must be promptly and properly managed if one is to avoid negative impact on outcome. 3,22 The reduced QoL reported here by patients being referred to tertiary referral centres is explained only in part by the severity of the injury and that the diagnosis was made postoperatively/late. In the Swedish context an intraoperative cholangiogram is standard which have resulted in an exceptionally high degree of intraoperative bile duct injury diagnosis.…”

“…[1][2][3][4][5][6] The variation in frequency in the literature is mainly due to various ways of defining a BDI, i.e. if leakage from the cystic duct and liver bed is classified as a bile duct injury or not.…”

Bile Duct Injuries Following Laparoscopic Cholecystectomy and their Outcome

“…Retrospective studies might contain selection bias, thereby giving a too low incidence of injuries. In a prospective Swedish registry, the frequency of bile duct injuries was reported to be 1.5% which is much higher than the usually stated frequency of 0.2%-0.9% (16) . In our series, we found a frequency of 0.4% injuries of the main bile duct and 0.9% when cystic duct problems and aberrant ducts are included.…”

Delphi consensus on bile duct injuries during laparoscopic cholecystectomy: an evolutionary cul‐de‐sac or the birth pangs of a new technical framework?

“…Several authors claimed that IOC cannot prevent BDI and its implication has yet to be defined [42, 43]. However, IOC is a definitive procedure to confirm BDI and may preclude further damage to the biliary system and surrounding vital vessels [44]. In the aforementioned SAGES survey, almost 90% of respondents agreed that "Surgeons should be able to perform and interpret IOC" [27].…”