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Filiberto AC, Nyren MQ, Underwood PW, Balch JA, Abbott KL, Efron PA, Sarosi GA, Bihorac A, Upchurch GR, Loftus TJ. Resource use for cholecystectomy with versus without cholangiography: A multicenter, propensity-matched analysis. Surgery 2023; 174:152-158. [PMID: 37188579 DOI: 10.1016/j.surg.2023.04.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 02/23/2023] [Accepted: 04/09/2023] [Indexed: 05/17/2023]
Abstract
BACKGROUND Intraoperative cholangiography may allow for earlier identification of common bile duct injury and choledocholithiasis. The role of intraoperative cholangiography in decreasing resource use related to biliary pathology remains unclear. This study tests the null hypothesis that there is no difference in resource use for patients undergoing laparoscopic cholecystectomy with versus without intraoperative cholangiography. METHODS This retrospective, longitudinal cohort study included 3,151 patients who underwent laparoscopic cholecystectomy at 3 university hospitals. To minimize differences in baseline characteristics while maintaining adequate statistical power, propensity scores were used to match 830 patients who underwent intraoperative cholangiography at surgeon discretion and 795 patients who underwent cholecystectomy without intraoperative cholangiography. Primary outcomes were the incidence of postoperative endoscopic retrograde cholangiography, the interval between surgery and endoscopic retrograde cholangiography, and total direct costs. RESULTS In the propensity-matched analysis, the intraoperative cholangiography and no intraoperative cholangiography cohorts had similar age, comorbidities, American Society of Anesthesiologists Sequential Organ Failure Assessment scores, and total/direct bilirubin ratios. The intraoperative cholangiography cohort had a lower postoperative endoscopic retrograde cholangiography (2.4% vs 4.3%; P = .04), a shorter interval between cholecystectomy and endoscopic retrograde cholangiography (2.5 [1.0-17.8] vs 4.5 [2.0-9.5] days; P = .04), and shorter length of stay (0.3 [0.2-1.5] vs 1.4 [0.3-3.2] days; P < .001). Patients undergoing intraoperative cholangiography had lower total direct costs ($4.0K [3.6K-5.4K] vs $8.1K [4.9K-13.0K]; P < .001). There were no differences in 30-day or 1-year mortality among the cohorts. CONCLUSION Compared with laparoscopic cholecystectomy without intraoperative cholangiography, cholecystectomy with intraoperative cholangiography was associated with decreased resource use, which was primarily attributable to decreased incidence and the earlier timing of postoperative endoscopic retrograde cholangiography.
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Affiliation(s)
| | - Molly Q Nyren
- College of Medicine, University of Florida Health, Gainesville, FL. https://twitter.com/Molly_Nyren
| | - Patrick W Underwood
- Department of Surgery, University of Florida Health, Gainesville, FL. https://twitter.com/P_Underwood21
| | - Jeremy A Balch
- Department of Surgery, University of Florida Health, Gainesville, FL. https://twitter.com/balchja
| | - Kenneth L Abbott
- Department of Surgery, University of Florida Health, Gainesville, FL
| | - Philip A Efron
- Department of Surgery, University of Florida Health, Gainesville, FL
| | - George A Sarosi
- Department of Surgery, University of Florida Health, Gainesville, FL
| | - Azra Bihorac
- Department of Medicine, University of Florida Health, Gainesville, FL. https://twitter.com/AzraBihorac
| | - Gilbert R Upchurch
- Department of Surgery, University of Florida Health, Gainesville, FL. https://twitter.com/gru6n
| | - Tyler J Loftus
- Department of Surgery, University of Florida Health, Gainesville, FL.
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Kovács N, Németh D, Földi M, Nagy B, Bunduc S, Hegyi P, Bajor J, Müller KE, Vincze Á, Erőss B, Ábrahám S. Selective intraoperative cholangiography should be considered over routine intraoperative cholangiography during cholecystectomy: a systematic review and meta-analysis. Surg Endosc 2022; 36:7126-7139. [PMID: 35794500 PMCID: PMC9485186 DOI: 10.1007/s00464-022-09267-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 04/09/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Decades of debate surround the use of intraoperative cholangiography (IOC) during cholecystectomy. To the present day, the role of IOC is controversial as regards decreasing the rate of bile duct injury (BDI). We aimed to review and analyse the available literature on the benefits of IOC during cholecystectomy. METHODS A systematic literature search was performed until 19 October 2020 in five databases using the following search keys: cholangiogra* and cholecystectomy. The primary outcomes were BDI and retained stone rate. To investigate the differences between the groups (routine IOC vs selective IOC and IOC vs no IOC), we calculated weighted mean differences (WMD) for continuous outcomes and relative risks (RR) for dichotomous outcomes, with 95% confidence intervals (CI). RESULTS Of the 19,863 articles, 38 were selected and 32 were included in the quantitative synthesis. Routine IOC showed no superiority compared to selective IOC in decreasing BDI (RR = 0.91, 95% CI 0.66; 1.24). Comparing IOC and no IOC, no statistically significant differences were found in the case of BDI, retained stone rate, readmission rate, and length of hospital stay. We found an increased risk of conversion rate to open surgery in the no IOC group (RR = 0.64, CI 0.51; 0.78). The operation time was significantly longer in the IOC group compared to the no IOC group (WMD = 11.25 min, 95% CI 6.57; 15.93). CONCLUSION Our findings suggest that IOC may not be indicated in every case, however, the evidence is very uncertain. Further good quality research is required to address this question.
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Affiliation(s)
- Norbert Kovács
- Doctoral School of Clinical Medicine, University of Szeged, Szeged, Hungary
- Institute for Translational Medicine, University of Pécs Medical School, Pécs, Hungary
| | - Dávid Németh
- Institute for Translational Medicine, University of Pécs Medical School, Pécs, Hungary
- Institute of Bioanalysis, University of Pécs Medical School, Pécs, Hungary
| | - Mária Földi
- Doctoral School of Clinical Medicine, University of Szeged, Szeged, Hungary
- Institute for Translational Medicine, University of Pécs Medical School, Pécs, Hungary
| | - Bernadette Nagy
- Institute for Translational Medicine, University of Pécs Medical School, Pécs, Hungary
| | - Stefania Bunduc
- Institute for Translational Medicine, University of Pécs Medical School, Pécs, Hungary
- Gastroenterology, Hepatology and Liver Transplant Department, Fundeni Clinical Institute, Bucharest, Romania
- Doctoral School, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Péter Hegyi
- Institute for Translational Medicine, Szentágothai Research Centre, University of Pécs Medical School, Pécs, Hungary
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
- Division of Pancreatic Diseases, Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Judit Bajor
- Division of Gastroenterology, First Department of Medicine, University of Pécs Medical School, Pécs, Hungary
| | - Katalin Eszter Müller
- Institute for Translational Medicine, University of Pécs Medical School, Pécs, Hungary
- Heim Pál National Institute of Pediatrics, Budapest, Hungary
| | - Áron Vincze
- Division of Gastroenterology, First Department of Medicine, University of Pécs Medical School, Pécs, Hungary
| | - Bálint Erőss
- Institute for Translational Medicine, University of Pécs Medical School, Pécs, Hungary
- Institute for Translational Medicine, Szentágothai Research Centre, University of Pécs Medical School, Pécs, Hungary
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
| | - Szabolcs Ábrahám
- Department of Surgery, Szent-Györgyi Albert Medical and Pharmaceutical Centre, University of Szeged, Semmelweis u. 8, 6720, Szeged, Hungary.
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Chikamori F, Ueta K, Iwabu J, Sharma N. Modified and dynamic intraoperativecholangiography during laparoscopic cholecystectomy in two patients with aberrant right posterior hepatic duct. Radiol Case Rep 2022; 17:1843-1847. [PMID: 35401891 PMCID: PMC8990060 DOI: 10.1016/j.radcr.2022.03.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 03/04/2022] [Accepted: 03/09/2022] [Indexed: 11/29/2022] Open
Abstract
Aberrant right posterior hepatic duct (ARPHD) is one of the anatomical anomalies of the bile duct. It is a risk factor for bile duct injury during laparoscopic cholecystectomy (LC). ARPHD can be diagnosed before surgery by magnetic resonance cholangiopancreatography or drip infusion cholangiographic-computed tomography. However, it is not easy to identify ARPHD during LC. Classic intraoperative cholangiography (IOC) procedure that does not lead to bile duct injury avoidance needs to be modified. In modified IOC, cannulation is performed from the infundibulum or neck of the gallbladder. We reported a modified and dynamic IOC procedure that can identify ARPHD safely and precisely during LC. The modified IOC provided direct evidence of no injury to ARPHD in 2 cases.
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Affiliation(s)
- Fumio Chikamori
- Department of Surgery, Japanese Red Cross Kochi Hospital, 1-4-63-11 Hadaminamimachi, Kochi, 780-8562, Japan
- Corresponding author.
| | - Koji Ueta
- Department of Surgery, Japanese Red Cross Kochi Hospital, 1-4-63-11 Hadaminamimachi, Kochi, 780-8562, Japan
| | - Jun Iwabu
- Department of Surgery, Japanese Red Cross Kochi Hospital, 1-4-63-11 Hadaminamimachi, Kochi, 780-8562, Japan
| | - Niranjan Sharma
- Adv Train Gastroint & Organ Transp Surgery, Dunedin, New Zealand
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Georgiou K, Sandblom G, Alexakis N, Enochsson L. Intraoperative cholangiography 2020: Quo vadis? A systematic review of the literature. Hepatobiliary Pancreat Dis Int 2022; 21:145-153. [PMID: 35031229 DOI: 10.1016/j.hbpd.2022.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 01/03/2022] [Indexed: 02/05/2023]
Abstract
BACKGROUND There are few randomized controlled trials with sufficient statistical power to assess the effectiveness of intraoperative cholangiography (IOC) in the detection and treatment of common bile duct injury (BDI) or retained stones during cholecystectomy. The best evidence so far regarding IOC and reduced morbidity related to BDI and retained common bile duct stones was derived from large population-based cohort studies. Population-based studies also have the advantage of reflecting the outcome of the procedure as it is practiced in the community at large. However, the outcomes of these population-based studies are conflicting. DATA SOURCES A systematic literature search was conducted in 2020 to search for articles that contained the terms "bile duct injury", "critical view of safety", "bile duct imaging" or "retained stones" in combination with IOC. All identified references were screened to select population-based studies and observational studies from large centers where socioeconomic or geographical selections were assumed not to cause selection bias. RESULTS The search revealed 273 references. A total of 30 articles fulfilled the criteria for a large observational study with minimal risk for selection bias. The majority suggested that IOC reduces morbidity associated with BDI and retained common bile duct stones. In the short term, IOC increases the cost of surgery. However, this is offset by reduced costs in the long run since BDI or retained stones detected during surgery are managed immediately. CONCLUSIONS IOC reduces morbidity associated with BDI and retained common bile duct stones. The reports reviewed are derived from large, unselected populations, thereby providing a high external validity. However, more studies on routine and selective IOC with well-defined outcome measures and sufficient statistical power are needed.
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Affiliation(s)
- Konstantinos Georgiou
- First Department of Propaedeutic Surgery, Hippokration General Hospital of Athens, Athens Medical School, National and Kapodistrian University of Athens, Athens 10679, Greece
| | - Gabriel Sandblom
- Department of Clinical Science and Education, Department of Surgery, Karolinska Institutet, Södersjukhuset, Stockholm 17177, SE, Sweden
| | - Nicholas Alexakis
- First Department of Propaedeutic Surgery, Hippokration General Hospital of Athens, Athens Medical School, National and Kapodistrian University of Athens, Athens 10679, Greece
| | - Lars Enochsson
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå 90187, SE, Sweden.
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5
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Donnellan E, Coulter J, Mathew C, Choynowski M, Flanagan L, Bucholc M, Johnston A, Sugrue M. A meta-analysis of the use of intraoperative cholangiography; time to revisit our approach to cholecystectomy? Surg Open Sci 2021; 3:8-15. [PMID: 33937738 PMCID: PMC8076912 DOI: 10.1016/j.sopen.2020.07.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 07/16/2020] [Accepted: 07/27/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Despite some evidence of improved survival with intraoperative cholangiography during cholecystectomy, debate has raged about its benefit, in part because of its questionable benefit, time, and resources required to complete. METHODS An International Prospective Register of Systematic Reviews-registered (ID CRD42018102154) meta-analysis following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines using PubMed, Scopus, Web of Science, and Cochrane library from 2003 to 2018 was undertaken including search strategy "intraoperative AND cholangiogra* AND cholecystectomy." Articles scoring ≥ 16 for comparative and ≥ 10 for noncomparative using the Methodological Index for Non-Randomized Studies criteria were included. A dichotomous random effects meta-analysis using the Mantel-Haenszel method performed on Review Manager Version 5.3 was carried out. RESULTS Of 2,059 articles reviewed, 62 met criteria for final analysis. The mean rate of intraoperative cholangiography was 38.8% (range 1.6%-96.4%).There was greater detection of bile duct stones during cholecystectomy with routine intraoperative cholangiography compared with selective intraoperative cholangiography (odds ratio = 3.28, confidence interval = 2.80-3.86, P value < .001). While bile duct injury during cholecystectomy was less with intraoperative cholangiography (0.39%) than without intraoperative cholangiography (0.43%), it was not statistically significant (odds ratio = 0.88, confidence interval = 0.65-1.19, P value = .41). Readmission following cholecystectomy with intraoperative cholangiography was 3.0% compared to 3.5% without intraoperative cholangiography (odds ratio = 0.91, confidence interval = 0.78-1.06, P value = .23). CONCLUSION The use of intraoperative cholangiography still has its place in cholecystectomy based on the detection of choledocholithiasis and the potential reduction of unfavorable outcomes associated with common bile duct stones. This meta-analysis, the first to review intraoperative cholangiography use, identified a marked variation in cholangiography use. Retrospective studies limit the ability to critically define association between intraoperative cholangiography use and bile duct injury.
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Affiliation(s)
- Eoin Donnellan
- Department of Surgery, Letterkenny University Hospital and Donegal Clinical Research Academy, Letterkenny, County Donegal, Ireland
- School of Medicine, National University of Ireland, Galway, Ireland
| | - Jonathan Coulter
- Department of Surgery, Letterkenny University Hospital and Donegal Clinical Research Academy, Letterkenny, County Donegal, Ireland
- EU INTERREG Emergency Surgery Outcome Advancement Project, Centre for Personalised Medicine, Letterkenny, Ireland
| | - Cherian Mathew
- Department of Surgery, Letterkenny University Hospital and Donegal Clinical Research Academy, Letterkenny, County Donegal, Ireland
- School of Medicine, National University of Ireland, Galway, Ireland
| | - Michelle Choynowski
- Department of Surgery, Letterkenny University Hospital and Donegal Clinical Research Academy, Letterkenny, County Donegal, Ireland
| | - Louise Flanagan
- EU INTERREG Emergency Surgery Outcome Advancement Project, Centre for Personalised Medicine, Letterkenny, Ireland
| | - Magda Bucholc
- Intelligent Systems Research Centre, School of Computing, Engineering and Intelligent Systems, Ulster University, Londonderry, Northern Ireland
| | - Alison Johnston
- Department of Surgery, Letterkenny University Hospital and Donegal Clinical Research Academy, Letterkenny, County Donegal, Ireland
| | - Michael Sugrue
- Department of Surgery, Letterkenny University Hospital and Donegal Clinical Research Academy, Letterkenny, County Donegal, Ireland
- EU INTERREG Emergency Surgery Outcome Advancement Project, Centre for Personalised Medicine, Letterkenny, Ireland
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6
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Quiroz HJ, Valencia SF, Willobee BA, Ferrantella AR, Ryon EL, Thorson CM, Sola JE, Perez EA. Utility of routine intraoperative cholangiogram during cholecystectomy in children: A nationwide analysis of outcomes and readmissions. J Pediatr Surg 2021; 56:61-65. [PMID: 33158507 DOI: 10.1016/j.jpedsurg.2020.09.047] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Accepted: 09/22/2020] [Indexed: 01/12/2023]
Abstract
PURPOSE This study aims to determine postoperative outcomes and readmissions in pediatric cholecystectomy with routine intraoperative cholangiogram (IOC) utilization. METHODS The Nationwide Readmissions Database 2010-2014 was queried for all pediatric cholecystectomies. A propensity score-matched analysis (PSMA) with over 30 covariates was performed between cholecystectomy alone (CCY) versus those with routine IOC (CCY + IOC, no biliary obstruction, dilatation, or pancreatitis). χ2 analysis or Mann-Whitney U were used for statistical analysis with p < 0.05 set as significant. RESULTS 34,390 cholecystectomies were performed: 92% were laparoscopic, most were teenage females (75%, 15 years [13-17]) and did not undergo IOC (75%). Postoperative mortality rate was 0.1%. The PSMA cohort comprised of 1412 CCY and 1453 CCY + IOC. Patients with CCY alone had higher rates of 30-day (7% vs 5%), 1-year readmissions (13% vs 11%) and had higher rates of overall complications (22% vs 12%) compared with CCY + IOC, all p < 0.05. Although uncommon, bile duct injuries were more prevalent in CCY (2% vs 0%, p < 0.001), while there was no difference in readmissions for retained stones. Resource utilization was increased in CCY patients, likely due to increased complication rates. CONCLUSION This nationwide PSMA suggests pediatric CCY with routine IOC is associated with decreased readmissions, overall resource utilization, complications, and bile duct injuries. TYPE OF STUDY Retrospective Comparative Study. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Hallie J Quiroz
- Dewitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, FL
| | | | - Brent A Willobee
- Dewitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, FL
| | - Anthony R Ferrantella
- Dewitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, FL
| | - Emily L Ryon
- Dewitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, FL
| | - Chad M Thorson
- Division of Pediatric Surgery, Dewitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Juan E Sola
- Division of Pediatric Surgery, Dewitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Eduardo A Perez
- Division of Pediatric Surgery, Dewitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida.
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Beck AC, Goffredo P, Gao X, McGonagill PW, Weigel RJ, Hassan I. Unanticipated Admission Following Outpatient Laparoscopic Cholecystectomy: Identifying Opportunities for Improvement. Am Surg 2020; 87:1080-1086. [PMID: 33316162 DOI: 10.1177/0003134820956347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Unanticipated admissions are a burden to the health care system. Over 400 000 outpatient laparoscopic cholecystectomies (LCs) are performed annually in the United States. The aim of this study is to identify causes of unanticipated admissions and modifiable risk factors. METHODS Patients undergoing elective outpatient LCs were identified from the 2013-2015 American College of Surgeons National Surgical Quality Improvement Program database. RESULTS A total of 69 376 patients underwent outpatient LC or LC+ intraoperative cholangiogram (IOC); 2027 (2.9%) were admitted after a median of 5 days (interquartile range 3-8). Admission rates varied by preoperative indications: pancreatitis (4.9%), gallstones with obstruction (3.9%), cholecystitis (3.0%), and gallstones without obstruction (2.6%) (P = .003). The most frequent causes were infection, retained stones, and other GI complications. Patients admitted for infection or cardiopulmonary complications were older with higher American Society of Anesthesiologists (ASA) (P < .01), while patients with pain and retained stones were younger with lower ASA (P < .01). Patients who underwent LC+IOC had a lower admission rate due to retained stones (.17% vs. .31% LC, P = .006). CONCLUSIONS Unanticipated admissions following outpatient LC occur infrequently for diverse reasons usually within the first week after surgery. Associated factors are patient and disease related and not at all modifiable. In selected patients, increased IOC use may decrease admissions from retained stones.
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Affiliation(s)
- Anna C Beck
- Department of Surgery, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Paolo Goffredo
- Department of Surgery, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Xiang Gao
- Department of Surgery, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Patrick W McGonagill
- Department of Surgery, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Ronald J Weigel
- Department of Surgery, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Imran Hassan
- Department of Surgery, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
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Mattila A, Larjava H, Helminen O, Kairaluoma M. INTRAOPERATIVE CHOLANGIOGRAPHY DURING CHOLECYSTECTOMY RESULTS IN LOW EXPOSURE TO RADIATION: A RETROSPECTIVE COHORT STUDY. RADIATION PROTECTION DOSIMETRY 2020; 188:73-78. [PMID: 31730694 DOI: 10.1093/rpd/ncz262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Revised: 08/08/2019] [Accepted: 10/01/2019] [Indexed: 06/10/2023]
Abstract
This study aimed to determine the exposure to radiation delivered to the patient during routine intraoperative cholangiography (IOC) in cholecystectomy and examine the factors affecting radiation dose and fluoroscopy time (FT). From January 2016 to December 2017, 598 IOC examinations were performed. This study included 324 intraoperative cholangiographies performed with c-arm equipment not exceeding 10 years of age. When residents performed the procedures, the mean kerma area product (KAP) was 0.36 (standard deviation [SD] 0.70) Gycm 2 and in specialist surgeons group 0.36 (SD 0.47) Gycm2, P = 0.47. In residents group, the mean FT was 11.4 (SD 10.1) seconds and in specialist surgeons group, 9.2 (SD 11.9) seconds, P < 0.01. Linear regression analysis showed association between increased KAP-values and the presence of common bile duct (CBD) stones and body mass index (BMI). Age, BMI, laparoscopic surgery, acute cholecystitis, presence of CBD stones, resident surgeon performing IOC and ASA III-IV were associated with higher FT. National diagnostic reference level for IOC has not been introduced in Finland so far. Our mean KAP values (0.36 Gycm2) were 3-4 times lower and FT (10.1 seconds) were 3-5 times lower than the few reported in the literature. Routine use of IOC during cholecystectomy results in relatively low-radiation dose performed either by residents or specialist surgeons, irrespective of whether CBD stones were visualized or not.
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Affiliation(s)
- Anne Mattila
- Department of Surgery, Central Finland Central Hospital, Keskussairaalantie 19, Jyväskylä 40620, Finland
| | - Heli Larjava
- Department of Surgery, Central Finland Central Hospital, Keskussairaalantie 19, Jyväskylä 40620, Finland
- Department of Medical Imaging, Central Finland Central Hospital, Keskussairaalantie 19, Jyväskylä 40620, Finland
| | - Olli Helminen
- Department of Surgery, Central Finland Central Hospital, Keskussairaalantie 19, Jyväskylä 40620, Finland
| | - Matti Kairaluoma
- Department of Surgery, Central Finland Central Hospital, Keskussairaalantie 19, Jyväskylä 40620, Finland
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10
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Mehaffey JH, Hawkins RB, Charles EJ, Turrentine FE, Kaplan B, Fogel S, Harris C, Reines D, Posadas J, Ailawadi G, Hanks JB, Hallowell PT, Jones RS. Community level socioeconomic status association with surgical outcomes and resource utilisation in a regional cohort: a prospective registry analysis. BMJ Qual Saf 2019; 29:232-237. [PMID: 31540969 DOI: 10.1136/bmjqs-2019-009800] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Revised: 09/12/2019] [Accepted: 09/15/2019] [Indexed: 12/27/2022]
Abstract
BACKGROUND Socioeconomic status affects surgical outcomes, however these factors are not included in clinical quality improvement data and risk models. We performed a prospective registry analysis to determine if the Distressed Communities Index (DCI), a composite socioeconomic ranking by zip code, could predict risk-adjusted surgical outcomes and resource utilisation. METHODS All patients undergoing surgery (n=44,451) in a regional quality improvement database (American College of Surgeons-National Surgical Quality Improvement Program ACS-NSQIP) were paired with DCI, ranging from 0-100 (low to high distress) and accounting for unemployment, education level, poverty rate, median income, business growth and housing vacancies. The top quartile of distress was compared to the remainder of the cohort and a mixed effects modeling evaluated ACS-NSQIP risk-adjusted association between DCI and the primary outcomes of surgical complications and resource utilisation. RESULTS A total of 9369 (21.1%) patients came from severely distressed communities (DCI >75), who had higher rates of most medical comorbidities as well as transfer status (8.4% vs 4.8%, p<0.0001) resulting in higher ACS-NSQIP predicted risk of any complication (8.0% vs 7.1%, p<0.0001). Patients from severely distressed communities had increased 30-day mortality (1.8% vs 1.4%, p=0.01), postoperative complications (9.8% vs 8.5%, p<0.0001), hospital readmission (7.7 vs 6.8, p<0.0001) and resource utilisation. DCI was independently associated with postoperative complications (OR 1.07, 95% CI 1.04 to 1.10, p<0.0001) as well as resource utilisation after adjusting for ACS-NSQIP predicted risk CONCLUSION: Increasing Distressed Communities Index is associated with increased postoperative complications and resource utilisation even after ACS-NSQIP risk adjustment. These findings demonstrate a disparity in surgical outcomes based on community level socioeconomic factors, highlighting the continued need for public health innovation and policy initiatives.
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Affiliation(s)
| | | | - Eric J Charles
- Surgery, University of Virginia, Charlottesville, Virginia, USA
| | | | - Brian Kaplan
- Department of Surgery, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Sandy Fogel
- Department of Surgery, Carilion Clinic, Roanoke, Virginia, USA
| | - Charles Harris
- Department of Surgery, Carilion Clinic, Roanoke, Virginia, USA
| | - David Reines
- Department of Surgery, Inova Mount Vernon Hospital, Alexandria, Virginia, USA
| | - Jorge Posadas
- Department of Surgery, Winchester Medical Center, Winchester, Virginia, USA
| | - Gorav Ailawadi
- Surgery, University of Virginia, Charlottesville, Virginia, USA
| | - John B Hanks
- Surgery, University of Virginia, Charlottesville, Virginia, USA
| | | | - R Scott Jones
- Surgery, University of Virginia, Charlottesville, Virginia, USA
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11
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Cohen JT, Charpentier KP, Beard RE. An Update on Iatrogenic Biliary Injuries: Identification, Classification, and Management. Surg Clin North Am 2019; 99:283-299. [PMID: 30846035 DOI: 10.1016/j.suc.2018.11.006] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Common bile duct injury is a feared complication of cholecystectomy, with an incidence of 0.1% to 0.6%. A majority of injuries go unnoticed at index operation, and postoperative diagnosis can be difficult. Patient presentation can vary from vague abdominal pain to uncontrolled sepsis and peritonitis. Diagnostic evaluation typically begins with ultrasound or CT scan in the acute setting, and source control is paramount at time of presentation. In a stable patient, hepatobiliary iminodiacetic acid scan can be useful in identifying an ongoing bile leak, which requires intervention. A variety of diagnostic techniques define biliary anatomy. Treatment often requires a multidisciplinary approach.
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Affiliation(s)
- Joshua T Cohen
- Department of Surgery, Rhode Island Hospital, 2 Dudley Street, Suite 370, Providence, RI 02905, USA
| | - Kevin P Charpentier
- Department of Surgery, Rhode Island Hospital, 2 Dudley Street, Suite 370, Providence, RI 02905, USA
| | - Rachel E Beard
- Department of Surgery, Rhode Island Hospital, 2 Dudley Street, Suite 370, Providence, RI 02905, USA.
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12
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Iranmanesh P, Tobler O, De Sousa S, Andres A, Frossard JL, Morel P, Toso C. Feasibility, benefit and risk of systematic intraoperative cholangiogram in patients undergoing emergency cholecystectomy. PLoS One 2018; 13:e0199147. [PMID: 29953458 PMCID: PMC6023227 DOI: 10.1371/journal.pone.0199147] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Accepted: 06/01/2018] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND The role of intraoperative cholangiogram (IOC) during cholecystectomy is debated. The aim of the present study was to evaluate the feasibility, benefit and risk of performing systematic IOC in patients undergoing cholecystectomy for acute gallstone-related disease. METHODS Between July 2013 and January 2015, all patients admitted for an acute gallstone-related condition and undergoing same-hospital-stay cholecystectomy were prospectively followed. IOC was systematically attempted and predictors of IOC failure were analyzed. RESULTS Among the 581 enrolled patients, IOC was deliberately not performed in 3 cases. IOC was successful in 509/578 patients (88.1%). The main predictors of IOC failure were age, body mass index, male gender and associated acute cholecystitis. Thirty-two patients with suspected common bile duct stone on IOC underwent 38 unnecessary negative postoperative common bile duct investigations (32/509, 6.3%). There was one IOC-related adverse outcome (mild pancreatitis, 1/578, 0.2%). CONCLUSIONS IOC can be successfully and safely performed in the majority of patients undergoing cholecystectomy for acute gallstone-related disease. Although its positive predictive value is suboptimal and results in a number of unnecessary postoperative common bile duct investigations, IOC accurately rules out common bile duct stones in patients with acute gallstone-related conditions.
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Affiliation(s)
- Pouya Iranmanesh
- Department of Digestive and Transplant Surgery, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
- * E-mail:
| | - Olivier Tobler
- Department of Digestive and Transplant Surgery, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Sandra De Sousa
- Department of Digestive and Transplant Surgery, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Axel Andres
- Department of Digestive and Transplant Surgery, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
- Hepato-Pancreato-Biliary Centre, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Jean-Louis Frossard
- Hepato-Pancreato-Biliary Centre, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
- Department of Gastroenterology, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Philippe Morel
- Department of Digestive and Transplant Surgery, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
- Hepato-Pancreato-Biliary Centre, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Christian Toso
- Department of Digestive and Transplant Surgery, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
- Hepato-Pancreato-Biliary Centre, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
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13
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van Manen L, Handgraaf HJM, Diana M, Dijkstra J, Ishizawa T, Vahrmeijer AL, Mieog JSD. A practical guide for the use of indocyanine green and methylene blue in fluorescence-guided abdominal surgery. J Surg Oncol 2018; 118:283-300. [PMID: 29938401 PMCID: PMC6175214 DOI: 10.1002/jso.25105] [Citation(s) in RCA: 186] [Impact Index Per Article: 31.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Accepted: 04/21/2018] [Indexed: 12/14/2022]
Abstract
Near-infrared (NIR) fluorescence imaging is gaining clinical acceptance over the last years and has been used for detection of lymph nodes, several tumor types, vital structures and tissue perfusion. This review focuses on NIR fluorescence imaging with indocyanine green and methylene blue for different clinical applications in abdominal surgery with an emphasis on oncology, based on a systematic literature search. Furthermore, practical information on doses, injection times, and intraoperative use are provided.
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Affiliation(s)
- Labrinus van Manen
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Michele Diana
- IHU-Strasbourg, Institute of Image-Guided Surgery, Strasbourg, France.,IRCAD, Research Institute against Cancer of the Digestive System, Strasbourg, France.,Department of General, Digestive and Endocrine Surgery, University Hospital of Strasbourg, Strasbourg, France
| | - Jouke Dijkstra
- Division of Image Processing, Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Takeaki Ishizawa
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | | | - Jan Sven David Mieog
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
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14
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Conrad C, Wakabayashi G, Asbun HJ, Dallemagne B, Demartines N, Diana M, Fuks D, Giménez ME, Goumard C, Kaneko H, Memeo R, Resende A, Scatton O, Schneck AS, Soubrane O, Tanabe M, van den Bos J, Weiss H, Yamamoto M, Marescaux J, Pessaux P. IRCAD recommendation on safe laparoscopic cholecystectomy. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2017; 24:603-615. [PMID: 29076265 DOI: 10.1002/jhbp.491] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
An expert recommendation conference was conducted to identify factors associated with adverse events during laparoscopic cholecystectomy (LC) with the goal of deriving expert recommendations for the reduction of biliary and vascular injury. Nineteen hepato-pancreato-biliary (HPB) surgeons from high-volume surgery centers in six countries comprised the Research Institute Against Cancer of the Digestive System (IRCAD) Recommendations Group. Systematic search of PubMed, Cochrane, and Embase was conducted. Using nominal group technique, structured group meetings were held to identify key items for safer LC. Consensus was achieved when 80% of respondents ranked an item as 1 or 2 (Likert scale 1-4). Seventy-one IRCAD HPB course participants assessed the expert recommendations which were compared to responses of 37 general surgery course participants. The IRCAD recommendations were structured in seven statements. The key topics included exposure of the operative field, appropriate use of energy device and establishment of the critical view of safety (CVS), systematic preoperative imaging, cholangiogram and alternative techniques, role of partial and dome-down (fundus-first) cholecystectomy. Highest consensus was achieved on the importance of the CVS as well as dome-down technique and partial cholecystectomy as alternative techniques. The put forward IRCAD recommendations may help to promote safe surgical practice of LC and initiate specific training to avoid adverse events.
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15
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Rosero EB, Joshi GP. Hospital readmission after ambulatory laparoscopic cholecystectomy: incidence and predictors. J Surg Res 2017; 219:108-115. [PMID: 29078868 DOI: 10.1016/j.jss.2017.05.071] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Revised: 04/22/2017] [Accepted: 05/19/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND The aim of the study was to assess the rate of 30-d hospital readmissions after ambulatory laparoscopic cholecystectomy. MATERIALS AND METHODS The 2009 to 2011 State Ambulatory Surgery and Services and State Inpatient Databases from California, Florida, and New York were analyzed to evaluate the incidence of 30-d readmissions after laparoscopic cholecystectomy performed in outpatient settings. Hospital transfers and the principal diagnoses of hospital readmission were analyzed as secondary outcomes. Multilevel generalized mixed linear regression analyses with fixed and random effects were used to evaluate variables associated with increased likelihood of readmissions. RESULTS A total of 230,745 encounters for ambulatory laparoscopic cholecystectomies performed in 890 ambulatory facilities between 2009 and 2011 in the three states were analyzed. The rate of 30-d readmission was 20.2 per 1000 discharges. The rate of direct transfers from the ambulatory surgery center to an acute care hospital was 0.6 per 1000 discharges. The most common diagnoses of readmission were surgical complications, postoperative pain, infection, and nausea or vomiting. After adjusting for comorbidities, increasing age, male sex, non-Hispanic white race/ethnicity, any nonprivate insurance type, diagnosis of acute cholecystitis, use of intraoperative cholangiography, and having the procedure performed on a weekend were significantly associated with increased odds of 30-d readmissions. CONCLUSIONS This large-state data analysis reveals that the unplanned admission and readmission rates after laparoscopic cholecystectomy are very low. Some causes of readmission (e.g., pain, nausea, and vomiting) are modifiable by the intervention of surgeons and anesthesia providers.
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Affiliation(s)
- Eric B Rosero
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas.
| | - Girish P Joshi
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas
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16
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Ishii H, Noguchi A, Fukami T, Sugimoto R, Tada H, Takeshita H, Umehara S, Izumi H, Tani N, Yamaguchi M, Yamane T. Preoperative evaluation of accessory hepatic ducts by drip infusion cholangiography with CT. BMC Surg 2017; 17:52. [PMID: 28482819 PMCID: PMC5422935 DOI: 10.1186/s12893-017-0251-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Accepted: 04/19/2017] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND This retrospective study aimed to investigate the incidence of each type of accessory hepatic duct by drip infusion cholangiography with CT (DIC-CT). METHODS Five hundred sixty nine patients who underwent preoperative DIC-CT and laparoscopic cholecystectomy were reviewed. Accessory hepatic ducts were classified as follows: type I (accessory hepatic ducts that merged with the common hepatic duct between the confluence of the right and left hepatic ducts and the cystic duct confluence), type II (those that merged with the common hepatic duct at the same site as the cystic duct), type III (those that merged with the common bile duct distal to the cystic duct confluence), type IV (the cystic duct merged with the accessory hepatic duct), and type V (accessory hepatic ducts that merged with the common hepatic or bile duct on the left side). RESULTS Accessory hepatic ducts were observed in 50 patients. Type I, II, III, IV, and V accessory hepatic ducts were detected in 32, 3, 1, 11, and 3 patients, respectively. Based on their drainage areas, the accessory hepatic ducts were also classified as follows: a posterior branch in 22 patients, an anterior branch in 9 patients, a combination of posterior and anterior branches in 16 patients, a left-sided branch in 2 patients, and a caudate branch in 1 patient. None of the patients with accessory hepatic ducts suffered bile duct injuries. CONCLUSION There are a number of variants of the accessory hepatic duct. DIC-CT is useful to detect the accessory hepatic duct.
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Affiliation(s)
- Hiromichi Ishii
- Department of Surgery, Matsushita Memorial Hospital, 5-55 Sotojima-cho, Moriguchi city, Osaka, 570-8540, Japan.
| | - Akinori Noguchi
- Department of Surgery, Matsushita Memorial Hospital, 5-55 Sotojima-cho, Moriguchi city, Osaka, 570-8540, Japan
| | - Tomoyuki Fukami
- Department of Surgery, Matsushita Memorial Hospital, 5-55 Sotojima-cho, Moriguchi city, Osaka, 570-8540, Japan
| | - Riho Sugimoto
- Department of Surgery, Matsushita Memorial Hospital, 5-55 Sotojima-cho, Moriguchi city, Osaka, 570-8540, Japan
| | - Hiroyuki Tada
- Department of Surgery, Matsushita Memorial Hospital, 5-55 Sotojima-cho, Moriguchi city, Osaka, 570-8540, Japan
| | - Hiroki Takeshita
- Department of Surgery, Matsushita Memorial Hospital, 5-55 Sotojima-cho, Moriguchi city, Osaka, 570-8540, Japan
| | - Seiji Umehara
- Department of Surgery, Matsushita Memorial Hospital, 5-55 Sotojima-cho, Moriguchi city, Osaka, 570-8540, Japan
| | - Hiroyuki Izumi
- Department of Surgery, Matsushita Memorial Hospital, 5-55 Sotojima-cho, Moriguchi city, Osaka, 570-8540, Japan
| | - Naoki Tani
- Department of Surgery, Matsushita Memorial Hospital, 5-55 Sotojima-cho, Moriguchi city, Osaka, 570-8540, Japan
| | - Masahide Yamaguchi
- Department of Surgery, Matsushita Memorial Hospital, 5-55 Sotojima-cho, Moriguchi city, Osaka, 570-8540, Japan
| | - Tetsuro Yamane
- Department of Surgery, Matsushita Memorial Hospital, 5-55 Sotojima-cho, Moriguchi city, Osaka, 570-8540, Japan
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Halawani HM, Tamim H, Khalifeh F, Mailhac A, Taher A, Hoballah J, Jamali FR. Outcomes of Laparoscopic vs Open Common Bile Duct Exploration: Analysis of the NSQIP Database. J Am Coll Surg 2017; 224:833-840.e2. [DOI: 10.1016/j.jamcollsurg.2017.01.062] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2016] [Revised: 01/18/2017] [Accepted: 01/23/2017] [Indexed: 01/16/2023]
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18
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Boogerd LSF, Handgraaf HJM, Huurman VAL, Lam HD, Mieog JSD, van der Made WJ, van de Velde CJH, Vahrmeijer AL. The Best Approach for Laparoscopic Fluorescence Cholangiography: Overview of the Literature and Optimization of Dose and Dosing Time. Surg Innov 2017; 24:386-396. [PMID: 28457194 PMCID: PMC5505227 DOI: 10.1177/1553350617702311] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Fluorescence cholangiography using indocyanine green (ICG) can enhance orientation of bile duct anatomy during laparoscopic cholecystectomy. To ensure clear discrimination between bile ducts and liver, the fluorescence ratio between both should be sufficient. This ratio is influenced by the ICG dose and timing of fluorescence imaging. We first systematically identified all strategies for fluorescence cholangiography. Second, we aimed to optimize the dose of ICG and dosing time in a prospective clinical trial. METHODS PubMed was searched for clinical trials studying fluorescence cholangiography. Furthermore, 28 patients planned to undergo laparoscopic cholecystectomy were divided into 7 groups, receiving different intravenous doses (5 or 10 mg ICG) at different time points (0.5, 2, 4, 6, or 24 hours prior to surgery). RESULTS The systematic review revealed 27 trials including 1057 patients. The majority of studies used 2.5 mg administered within 1 hour before imaging. Imaging 3 to 24 hours after ICG administration was never studied. The clinical trial demonstrated that the highest bile duct-to-liver ratio was achieved 3 to 7 hours after administration of 5 mg and 5 to 25 hours after administration of 10 mg ICG. Up to 3 hours after administration of 5 mg and up to 5 hours after administration of 10 mg ICG, the liver was equally or more fluorescent than the cystic duct, resulting in a ratio ≤1.0. CONCLUSION This study shows for the first time that the interval between ICG administration and intraoperative fluorescence cholangiography should be extended. Administering 5 mg ICG at least 3 hours before imaging is easy to implement in everyday clinical practice and results in bile duct-to-liver ratios >1.0.
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Affiliation(s)
| | | | | | - Hwai-Ding Lam
- 1 Leiden University Medical Center, Leiden, Netherlands
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19
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Manuel-Vázquez A, Latorre-Fragua R, Ramiro-Pérez C, López-Marcano A, Al-Shwely F, De la Plaza-Llamas R, Ramia JM. Ninety-day readmissions after inpatient cholecystectomy: A 5-year analysis. World J Gastroenterol 2017; 23:2972-2977. [PMID: 28522915 PMCID: PMC5413792 DOI: 10.3748/wjg.v23.i16.2972] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Revised: 02/24/2017] [Accepted: 03/31/2017] [Indexed: 02/07/2023] Open
Abstract
AIM To determine the incidence of readmission after cholecystectomy using 90 d as a time limit.
METHODS We retrospectively reviewed all patients undergoing cholecystectomy at the General Surgery and Digestive System Service of the University Hospital of Guadalajara, Spain. We included all patients undergoing cholecystectomy for biliary pathology who were readmitted to hospital within 90 d. We considered readmission to any hospital service as cholecystectomy-related complications. We excluded ambulatory cholecystectomy, cholecystectomy combined with other procedures, oncologic disease active at the time of cholecystectomy, finding of malignancy in the resection specimen, and scheduled re-admissions for other unrelated pathologies.
RESULTS We analyzed 1423 patients. There were 71 readmissions in the 90 d after discharge, with a readmission rate of 4.99%. Sixty-four point seven nine percent occurred after elective surgery (cholelithiasis or vesicular polyps) and 35.21% after emergency surgery (acute cholecystitis or acute pancreatitis). Surgical non-biliary causes were the most frequent reasons for readmission, representing 46.48%; among them, intra-abdominal abscesses were the most common. In second place were non-surgical reasons, at 29.58%, and finally, surgical biliary reasons, at 23.94%. Regarding time for readmission, almost 50% of patients were readmitted in the first week and most second readmissions occurred during the second month. Redefining the readmissions rate to 90 d resulted in an increase in re-hospitalization, from 3.51% at 30 d to 4.99% at 90 d.
CONCLUSION The use of 30-d cutoff point may underestimate the incidence of complications. The current tendency is to use 90 d as a limit to measure complications associated with any surgical procedure.
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Hori T, Oike F, Furuyama H, Machimoto T, Kadokawa Y, Hata T, Kato S, Yasukawa D, Aisu Y, Sasaki M, Kimura Y, Takamatsu Y, Naito M, Nakauchi M, Tanaka T, Gunji D, Nakamura K, Sato K, Mizuno M, Iida T, Yagi S, Uemoto S, Yoshimura T. Protocol for laparoscopic cholecystectomy: Is it rocket science? World J Gastroenterol 2016; 22:10287-10303. [PMID: 28058010 PMCID: PMC5175242 DOI: 10.3748/wjg.v22.i47.10287] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2016] [Revised: 10/16/2016] [Accepted: 11/28/2016] [Indexed: 02/06/2023] Open
Abstract
Laparoscopic cholecystectomy (LC) does not require advanced techniques, and its performance has therefore rapidly spread worldwide. However, the rate of biliary injuries has not decreased. The concept of the critical view of safety (CVS) was first documented two decades ago. Unexpected injuries are principally due to misidentification of human factors. The surgeon’s assumption is a major cause of misidentification, and a high level of experience alone is not sufficient for successful LC. We herein describe tips and pitfalls of LC in detail and discuss various technical considerations. Finally, based on a review of important papers and our own experience, we summarize the following mandatory protocol for safe LC: (1) consideration that a high level of experience alone is not enough; (2) recognition of the plateau involving the common hepatic duct and hepatic hilum; (3) blunt dissection until CVS exposure; (4) Calot’s triangle clearance in the overhead view; (5) Calot’s triangle clearance in the view from underneath; (6) dissection of the posterior right side of Calot’s triangle; (7) removal of the gallbladder body; and (8) positive CVS exposure. We believe that adherence to this protocol will ensure successful and beneficial LC worldwide, even in patients with inflammatory changes and rare anatomies.
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