Laparoscopic Cholecystectomy Should Be Routinely Performed With Intraoperative Cholangiography

Hookman, Perry; Unger, Stephen Wise; Barkin, Jamie S.; Johnson, David
November 2000
American Journal of Gastroenterology;Nov2000, Vol. 95 Issue 11, p3299
Academic Journal
The authors noted that with the introduction of laparoscopic cholecystectomy (LC) in Western Australia in 1991, the proportion of all cholecystectomy cases with intraoperative injury increased from 0.67% in 1988-1990 to 1.33% in 1993-1994. This increase was observed in bile duct injuries, major bile leaks, and other injuries to bowel or vascular structures. Therefore, the authors of the Department of Surgery at the University of Western Australia performed this population-based statistical study to determine the exact risk of intraoperative injury involving the bile duct, bowel, and vascular structures of LC compared with those of open cholecystectomy (OC). These authors reviewed all suspected cases of intraoperative injury associated with cholecystectomy in Western Australia from 1988 to 1994. They defined biliary injury as that which occurred as a result of surgery, and they recorded its location and type, method of detection, and its management. Bowel and vascular injuries and hemorrhage were defined as those documented in the operation notes or those requiring reintervention, such as laparotomy. Bile leaks were defined as that which were of sufficient severity to require surgical or endoscopic intervention. Minor biliary leaks such as those associated with drains left in situ after surgery were excluded. All cases were identified from routinely collected hospital surgical records and linked with persons undergoing postoperative endoscopic retrograde cholangiography (ERCP). The nature and site of injury were recorded. Ordinal logistic regression was used to estimate the risk of injury associated with LC compared with OC after adjusting for confounding factors. It is easier to determine the true incidence of bile duct injury in Western Australia because 1) the health department maintains patient statistics that cover all admissions to all Western Australian hospitals. They also maintain all hospital morbidity data since 1971. Its capital city, Perth, is the only Western Australian City large enough to support tertiary referral centers. Additionally, patients with major surgical complications are referred to one of only three teaching hospitals; 2) this population is geographically isolated, with low emigration, and therefore have a low number of patients who are lost to follow-up; and 3) all hospital records include personal identifiers (1) with links to all postoperative admissions so that readmission to any of the other hospitals for complications after surgical procedures can be easily identified. The authors' experience was divided into three periods: a pre-LC period, a period of transition to LC, and period of LC performance. Each time period contained more than 6000 cases, which was used as a reliable denominator for the complication rate. The numerator was the actual number of complications. The authors identified a total of 456 cases with possible intraoperative injury from 19,187 cholecystectomies that were performed. Overall, they found that LC was two and one-half times more likely to result in intraoperative injury than an open cholecystectomy. The authors documented that 1) even after adjusting for all known confounders, LC remained a significant risk factor for bile duct injuries, major bile leaks (odds ratio 2.5; 95% confidence interval 1.53, 4.22), and other injuries; 2) intraoperative cholangiography has a statistically significant protective effect for all injuries and leaks (odds ratio 0.5; 95% confidence interval 0.35, 0.70). They found a significant risk for intraoperative injury or bile leak or both for the following variables: Men were at 2.3 times greater risk than women; performance in a teaching hospital resulted in a 2.6 times greater risk than in a nonteaching hospital; a laparoscopic procedure was 1.52 times riskier than an open procedure; the presence of preoperative pancreatitis or objective jaundice or cholangitis posed a 3.47 times greater risk for injury than if these diseases were not present. In this study, the risk of bile duct injury was less than half when intraoperative cholangiography was performed in both LC and OC. This confirmed that there was a high risk of injury in the absence of intraoperative cholangiography when both disease severity (i.e., increasing inflammation in and around the gall bladder) and operative type were held constant. Indeed, the protective effect of intraoperative cholangiography on bile duct injury was nearly 8-fold in cases with increased severity, i.e., acute cholecystitis, pancreatitis, or cholangitis. If intraoperative cholangiography were performed on all cases, the authors calculated that about one-third of all bile duct injuries during the study period could have been prevented. In summary, after adjustment for age, gender, hospital type, severity of disease, and intraoperative cholangiography, the odds ratio for intraoperative injury in patients undergoing LC compared with OC was 1.79. Operative cholangiography significantly reduced the risk of injury and subsequent complications of cholecystectomy.


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