Characterization of common bile duct injury after laparoscopic cholecystectomy in a high-volume hospital system. Surg Endosc. 2018;32:1184-1191. [PMID: 28840410 DOI: 10.1007/s00464-017-5790-8]

Preoperative difficulty assessment of interval laparoscopic cholecystectomy for gallstones

BACKGROUND

Laparoscopic cholecystectomy is the gold standard treatment for benign gallbladder disease. However, few studies have reported the difficulty of interval cholecystectomy after cholecystitis because early cholecystectomy is recommended for acute cholecystitis. In this study, we evaluated the difficulties associated with interval cholecystectomy for cholecystitis with gallstones.

METHODS

We retrospectively analyzed patients with gallstones who underwent interval laparoscopic cholecystectomy for cholecystitis at our institution between January 2012 and December 2021. Patients were classified into laparoscopic total cholecystectomy and bailout procedure groups depending on whether they were converted to a bailout procedure, and their characteristics and outcomes were subsequently compared. Additionally, a logistic regression analysis of the preoperative factors contributing to bailout procedure conversion was performed.

RESULTS

Of the 269 participants, 39 converted to bailout procedure, and bile duct injury occurred in one case (0.4%). In patient characteristics comparison, patients in the bailout procedure group were significantly older, had more impacted stones, had higher post-treatment choledocholithiasis, had severe cholecystitis, and had a higher rate of percutaneous transhepatic gallbladder drainage. There were no differences in the bile duct injury or perioperative complications between the two groups. In logistic regression multivariate analysis of the factors contributing to the bailout procedure, post-treatment of choledocholithiasis (P < .001), impacted stone (P = .002), and age ≥71 (P = .007) were independent risk factors.

CONCLUSION

Impacted stones and choledocholithiasis are risk factors for conversion to bailout procedure and high difficulty in interval cholecystectomy. For such patients, interval cholecystectomy should be performed cautiously.

Advancing laparoscopy in resource-limited settings

BACKGROUND

Although laparoscopic surgery has made remarkable progress and become the standard approach for various surgical procedures worldwide over the past 30 years, its establishment in low-resource settings, particularly in public hospitals, has been challenging. The lack of equipment and trained expertise has hindered its widespread adoption in these settings. Cholecystectomy is one of the most commonly performed procedures using laparoscopy world wide AIM: The aim of the study is to determine whether laparoscopic cholecystectomy is feasible in a resource challenged setting METHODS: The research focused on individuals who underwent laparoscopic or open cholecystectomies at Yekatit 12 Hospital in Addis Ababa, Ethiopia, over a one-year period. Comprehensive data collection was conducted prospectively, encompassing both intraoperative and postoperative parameters. Follow-up was carried out via phone calls. The surgical procedures employed innovative techniques, including the reuse of sterilized single-use equipment and the utilization of local resources. The evaluation involved a comparison of demographic information, intraoperative details (such as critical view determination and operative duration), and postoperative complications, including assessments of pain and wound infections RESULTS: From August 2021 to September 2022, 119 patients were assessed. Among these patients, 65 (54.6%) underwent open cholecystectomies, while the remaining 54 (45.4%) underwent laparoscopic cholecystectomies. The average duration of the laparoscopic cholecystectomies was 90.7 min, which is 17.7 min behind the open. Patients in the laparoscopy group had significantly shorter hospital stays than the open group, and 94% were discharged by post operative day 2. The conversion rate from laparoscopic to open surgery was determined to be 3.3% CONCLUSION: To sum up, the safe execution of laparoscopic cholecystectomies is feasible in public hospitals and settings with limited resources, given adequate training and resource distribution. The study findings showcased superior outcomes, including reduced hospitalization duration and fewer complications, while maintaining comparable levels of operative duration and patient satisfaction in both groups.

Indocyanine green fluorescent cholangiography: The new standard practice to perform laparoscopic cholecystectomy in pediatric patients. A comparative study with conventional laparoscopic technique

BACKGROUND

This study aimed to compare outcomes of standard laparoscopic cholecystectomy and indocyanine green fluorescent cholangiography laparoscopic cholecystectomy over a 10-year period.

METHODS

From 2013 to 2023, 173 laparoscopic cholecystectomies were performed in 2 pediatric surgery units: 83 using standard technique (G1) and 90 using indocyanine green fluorescent cholangiography (G2). Patients included 96 girls and 77 boys, with a median age of 12.3 years (range 4-17) and a median weight of 51 kg (range 19-114). The 2 groups were compared regarding the following: (1) perioperative complications rate; (2) overall length of surgery (T1); (3) length of cystic duct isolation, clipping, and sectioning (T2); (4) time of gallbladder removal (T3); (5) degree of visualization of biliary tree; (6) safety and feasibility of indocyanine green fluorescent cholangiography; (7) incidence of anatomical anomalies detected intraoperatively.

RESULTS

All laparoscopic cholecystectomies were accomplished without conversion to open. The perioperative complications rate was significantly higher in G1 compared with G2 (12% vs 0%; P = .0007). Median T1, T2, and T3 were significantly longer in G1 (90, 37, 35 minutes) compared with G2 (55, 17, 19 minutes) (P = .0001), respectively. The visualization rate of the complete biliary tree was significantly higher in G2 (98.8%) than in G1 (80.7%) (P = .0001). No adverse reactions to indocyanine green were recorded. The incidence of biliary anomalies detected intraoperatively was significantly higher in G2 (7.8%) than in G1 (1.2%) (P = .03).

CONCLUSION

Indocyanine green fluorescent cholangiography can be considered the new standard practice to perform laparoscopic cholecystectomy in pediatrics. Indocyanine green fluorescence provided superior visualization of biliary anatomy, increased detection of anatomic variants, faster procedure, and fewer complications compared with conventional technique. Indocyanine green fluorescent cholangiography was safe, feasible, simple, inexpensive, and a timesaving tool.

Achieving Critical View of Safety via a New Technique: The Triple One (111) Technique

BACKGROUND

Misidentification of anatomical structures is one of the most common causes of bile duct injury following laparoscopic cholecystectomy. Achieving Critical View of Safety (CVS) is a standard step in conducting safe cholecystectomy all over the world. In our institute, we achieve CVS via a unique technique called Triple One or 111 and find it very helpful and easy to achieve CVS. Moreover, the rate of conversion has also decreased while achieving CVS via this technique. The unique aspect of the Triple One technique is that by following this method, even new laparoscopic surgeons can achieve CVS very easily in difficult cases and, hence, it decreases the chances of vasculobiliary injury (VBI).

OBJECTIVE

This study aimed to determine how effective the Triple One technique is in achieving CVS as well as in lessening the chances of VBI.

MATERIAL AND METHODS

A total of 545 patients were admitted through the outpatient department, ranging in age from 30 to 70 years, with a mean of 50 years. The study comprised patients with American Society of Anaesthesiologists (ASA) I & II, acute and chronic cholecystitis, and symptomatic cholelithiasis. The study excluded patients with co-morbidities, prior abdominal procedures, and suspected complications. On the second postoperative day, all patients received their discharge papers and on the seventh postoperative day, follow-up was completed.

RESULTS

Successful gallbladder extraction using the Triple One technique was achieved in 540 (99%) cases. The other five (1%) cases converted to open cholecystectomy because of the difficult gallbladder anatomy and extensive scarring. No VBI or bile duct injury was noted. No mortality was recorded during the study period.

CONCLUSION

By incorporating CVS using the Triple One technique into our policies and curriculum, we may encourage safe cholecystectomy practices and prevent bile duct injuries.

Determinants, Costs, and Consequences of Common Bile Duct Injury Requiring Operative Repair Among Privately Insured Individuals in the United States, 2003-2020

Objective

Characterize the determinants, all-cause mortality risk, and healthcare costs associated with common bile duct injury (CBDI) following cholecystectomy in a contemporary patient population.

Background

Retrospective cohort study using nationwide patient-level commercial and Medicare Advantage claims data, 2003-2019. Beneficiaries ≥18 years who underwent cholecystectomy were identified using Current Procedure Terminology (CPT) codes. CBDI was defined by a second surgical procedure for repair within one year of cholecystectomy.

Methods

We estimated the association of common surgical indications and comorbidities with risk of CBDI using logistic regression; the association between CBDI and all-cause mortality using Cox proportional hazards regression; and calculated average healthcare costs associated with CBDI repair.

Results

Among 769,782 individuals with cholecystectomy, we identified 894 with CBDI (0.1%). CBDI was inversely associated with biliary colic (odds ratio [OR] = 0.82; 95% confidence interval [CI]: 0.71-0.94) and obesity (OR = 0.70, 95% CI: 0.59-0.84), but positively associated with pancreas disease (OR = 2.16, 95% CI: 1.92-2.43) and chronic liver disease (OR = 1.25, 95% CI: 1.05-1.49). In fully adjusted Cox models, CBDI was associated with increased all-cause mortality risk (hazard ratio = 1.57, 95% CI: 1.38-1.79). The same-day CBDI repair was associated with the lowest mean overall costs, with the highest mean overall costs for repair within 1 to 3 months.

Conclusions

In this retrospective cohort study, calculated rates of CBDI are substantially lower than in prior large studies, perhaps reflecting quality-improvement initiatives over the past two decades. Yet, CBDI remains associated with increased all-cause mortality risks and significant healthcare costs. Patient-level characteristics may be important determinants of CBDI and warrant ongoing examination in future research.

Use of Critical View of Safety and Proctored Preceptorship in Preventing Bile Duct Injury During Laparoscopic Cholecystectomy-Experience of 3726 Cases From a Tertiary Care Teaching Institute

INTRODUCTION

Bile duct injury (BDI) continues to occur despite technological advances and improvements in surgical training over the past 2 decades. This study was conducted to audit our data on laparoscopic cholecystectomies performed over the past 2 decades to determine the role of Critical View of Safety (CVS) and proctored preceptorship in preventing BDI and postoperative complications.

MATERIALS AND METHODS

All patients undergoing elective laparoscopic cholecystectomy were analyzed retrospectively. The data were obtained from a prospectively maintained database from January 2004 to December 2019. Proctored preceptorship was used in all cases. Intraoperative details included the number of patients where CVS was defined, number of BDI and conversions. Postoperative outcomes, including hospital stay, morbidity, and bile duct stricture, were noted.

RESULTS

Three thousand seven hundred twenty-six patients were included in the final analysis. Trainee surgeons performed 31.6% of surgeries and 9.5% of these surgeries were taken over by the senior surgeon. A CVS could be delineated in 96.6% of patients. The major BDI rate was only 0.05%.

CONCLUSION

This study reiterates the fact that following the basic tenets of safe laparoscopic cholecystectomy, defining and confirming CVS, and following proctored preceptorship are critical in preventing major BDI.

National clinical practice guidelines for the treatment of symptomatic gallstone disease: 2021 recommendations from the Danish Surgical Society

BACKGROUND AND OBJECTIVE

Gallstones are highly prevalent, and more than 9000 cholecystectomies are performed annually in Denmark. The aim of this guideline was to improve the clinical course of patients with gallstone disease including a subgroup of high-risk patients. Outcomes included reduction of complications, readmissions, and need for additional interventions in patients with uncomplicated gallstone disease, acute cholecystitis, and common bile duct stones (CBDS).

METHODS

An interdisciplinary group of clinicians developed the guideline according to the GRADE methodology. Randomized controlled trials (RCTs) were primarily included. Non-RCTs were included if RCTs could not answer the clinical questions. Recommendations were strong or weak depending on effect estimates, quality of evidence, and patient preferences.

RESULTS

For patients with acute cholecystitis, acute laparoscopic cholecystectomy is recommended (16 RCTs, strong recommendation). Gallbladder drainage may be used as an interval procedure before a delayed laparoscopic cholecystectomy in patients with temporary contraindications to surgery and severe acute cholecystitis (1 RCT and 1 non-RCT, weak recommendation). High-risk patients are suggested to undergo acute laparoscopic cholecystectomy instead of drainage (1 RCT and 1 non-RCT, weak recommendation). For patients with CBDS, a one-step procedure with simultaneous laparoscopic cholecystectomy and CBDS removal by laparoscopy or endoscopy is recommended (22 RCTs, strong recommendation). In high-risk patients with CBDS, laparoscopic cholecystectomy is suggested to be included in the treatment (6 RCTs, weak recommendation). For diagnosis of CBDS, the use of magnetic resonance imaging or endoscopic ultrasound prior to surgical treatment is recommended (8 RCTs, strong recommendation). For patients with uncomplicated symptomatic gallstone disease, observation is suggested as an alternative to laparoscopic cholecystectomy (2 RCTs, weak recommendation).

CONCLUSIONS

Seven recommendations, four weak and three strong, for treating patients with symptomatic gallstone disease were developed. Studies for treatment of high-risk patients are few and more are needed.

ENDORSEMENT

The Danish Surgical Society.

Early versus delayed reconstruction for bile duct injury a multicenter retrospective analysis of a hepatopancreaticobiliary group

Common bile duct injury is a severe complication. It is related to increased rates of morbidity and mortality. Early recognition and on-time diagnosis plus multidisciplinary management of this disease led by a hepatobiliary surgeon show fewer complications rate and best postoperative outcomes. However, no guidelines exist about the proper time of reconstruction. This study aims to describe the experience of a specialized Hepato-Pancreatic-Biliary (HPB) group and to analyze the outcomes regarding the time of bile duct injury (BDI) repair. A multicenter retrospective review of a prospective database was conducted. All the patients older than 18 years old that underwent common bile duct reconstruction between January 2014 and December 2021 were included. Analysis and description of preoperative characteristics and postoperative outcomes were performed. A reconstruction time-based group differentiation was made and analyzed. 44 patients underwent common bile duct reconstruction between January 2014 and December 2021. 56.82% of the patients were female. The mean age was 53.27 years ± 20.7 years. The most common injury was type E2 (29.55%). Hepaticojejunostomy was performed in 81.81% (of the patients. Delayed reconstruction (> 72 h) was performed in the majority of the cases (75.00%) due to delays in the referral centers or poor condition. No statistically significant difference regarding complications in early or delayed BDI reconstruction. The mortality rate was 2.7% (n = 1). 2-year follow-up bilioenteric stenosis was observed in 7 patients. Biloma showed a statistical relationship with complex bile duct injuries (p = 0.02). Bile duct injury is a severe and complex postoperative complication that increases morbidity and mortality rates in the short and long term in patients undergoing cholecystectomy. In our study, there were no statistical differences between the timing of bile duct reconstruction and the postoperative outcomes; we identified the presence of biloma as a statistically related factor associated with complex bile duct injury; however, further prospective or studies with an increased sample size are required to prove our results.

Machine Learning-Based Analysis in the Management of Iatrogenic Bile Duct Injury During Cholecystectomy: a Nationwide Multicenter Study

BACKGROUND

Iatrogenic bile duct injury (IBDI) is a challenging surgical complication. IBDI management can be guided by artificial intelligence models. Our study identified the factors associated with successful initial repair of IBDI and predicted the success of definitive repair based on patient risk levels.

METHODS

This is a retrospective multi-institution cohort of patients with IBDI after cholecystectomy conducted between 1990 and 2020. We implemented a decision tree analysis to determine the factors that contribute to successful initial repair and developed a risk-scoring model based on the Comprehensive Complication Index.

RESULTS

We analyzed 748 patients across 22 hospitals. Our decision tree model was 82.8% accurate in predicting the success of the initial repair. Non-type E (p < 0.01), treatment in specialized centers (p < 0.01), and surgical repair (p < 0.001) were associated with better prognosis. The risk-scoring model was 82.3% (79.0-85.3%, 95% confidence interval [CI]) and 71.7% (63.8-78.7%, 95% CI) accurate in predicting success in the development and validation cohorts, respectively. Surgical repair, successful initial repair, and repair between 2 and 6 weeks were associated with better outcomes.

DISCUSSION

Machine learning algorithms for IBDI are a novel tool may help to improve the decision-making process and guide management of these patients.

Efficacy of indocyanine green (ICG) fluorescent cholangiography to improve intra-operative visualization during laparoscopic cholecystectomy in pediatric patients: a comparative study between ICG-guided fluorescence and standard technique

BACKGROUND

In the last few years, indocyanine green (ICG) fluorescent cholangiography (FC) has been adopted to perform intra-operative biliary mapping during laparoscopic cholecystectomy (LC). This study aimed to compare the results of LC with and without use of ICG-FC.

METHODS

All LC operated from June 2017 to June 2021 in our unit were retrospectively reviewed. Pre-operative workup included ultrasonography to assess dilation of main biliary tree. The ICG dosage was 0.35 mg/kg and the median timing of administration was 15.5 h pre-operatively. We evaluated, analyzing videorecorded procedures, 3 parameters in both groups: the total operative time (T1), the time of cystic duct isolation, clipping and sectioning (T2), and the time of gallbladder removal from hepatic fossa (T3).

RESULTS

Forty-three LC were operated in the study period: 22 using standard technique (G1) and 21 using ICG-FC (G2). There were 27 girls and 16 boys, with median age at surgery of 11.5 years (range 7-17) and median weight of 47 kg (range 31-110). No conversions were reported in our series. In all ICG cases (except one patient under therapy with phenobarbital) the biliary tree was perfectly visualized during dissection. Intra-operative complications occurred in 3 G1 patients (13.6%): 2 bleedings from the Calot's triangle and 1 bleeding from the liver bed during the gallbladder removal. LC was significantly faster in G2 than in G1 (p = 0.001). In fact, the parameters analyzed (T1, T2, T3) were all significantly greater in G1 than in G2 (p = 0.001).

CONCLUSIONS

Based upon our experience, we strongly recommend the use of ICG-FC in all pediatric patients undergoing LC. ICG-guided fluorescence provided an excellent real-time visualization of the extrahepatic biliary tree and allowed faster and safer dissection, minimizing the risk of bile duct injuries. Furthermore, ICG use was clinically safe, with no adverse reactions to the product.

Indocyanine green (ICG) fluorescent cholangiography during laparoscopic cholecystectomy using RUBINA™ technology: preliminary experience in two pediatric surgery centers

Background

Recently, we reported the feasibility of indocyanine green (ICG) near-infrared fluorescence (NIRF) imaging to identify extrahepatic biliary anatomy during laparoscopic cholecystectomy (LC) in pediatric patients. This paper aimed to describe the use of a new technology, RUBINA™, to perform intra-operative ICG fluorescent cholangiography (FC) in pediatric LC.

Methods

During the last year, ICG-FC was performed during LC using the new technology RUBINA™ in two pediatric surgery units. The ICG dosage was 0.35 mg/Kg and the median timing of administration was 15.6 h prior to surgery. Patient baseline, intra-operative details, rate of biliary anatomy identification, utilization ease, and surgical outcomes were assessed.

Results

Thirteen patients (11 girls), with median age at surgery of 12.9 years, underwent LC using the new RUBINA™ technology. Six patients (46.1%) had associated comorbidities and five (38.5%) were practicing drug therapy. Pre-operative workup included ultrasound (n = 13) and cholangio-MRI (n = 5), excluding biliary and/or vascular anatomical anomalies. One patient needed conversion to open surgery and was excluded from the study. The median operative time was 96.9 min (range 55–180). Technical failure of intra-operative ICG-NIRF visualization occurred in 2/12 patients (16.7%). In the other cases, ICG-NIRF allowed to identify biliary/vascular anatomic anomalies in 4/12 (33.3%), including Moynihan's hump of the right hepatic artery (n = 1), supravescicular bile duct (n = 1), and short cystic duct (n = 2). No allergic or adverse reactions to ICG, post-operative complications, or reoperations were reported.

Conclusion

Our preliminary experience suggested that the new RUBINA™ technology was very effective to perform ICG-FC during LC in pediatric patients. The advantages of this technology include the possibility to overlay the ICG-NIRF data onto the standard white light image and provide surgeons a constant fluorescence imaging of the target anatomy to assess position of critical biliary structures or presence of anatomical anomalies and safely perform the operation.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00464-021-08596-7.

MRI evaluation of bile duct injuries and other post-cholecystectomy complications

Laparoscopic cholecystectomy is one of the most common procedures performed each year and can be associated with various post-operative complications. Imaging is integral to diagnosis and management of patients with suspected cholecystectomy complications, and a thorough understanding of normal and abnormal biliary anatomy, risk factors for biliary injury, and the spectrum of adverse events is crucial for interpretation of imaging studies. Magnetic resonance cholangiography (MRC) enhanced with hepatobiliary contrast agent is useful in delineating biliary anatomy and pathology following cholecystectomy. In this article, we provide a protocol for contrast-enhanced MR imaging of the biliary tree. We also review the classification and imaging manifestations of post-cholecystectomy bile duct injuries in addition to other complications such as bilomas, retained/dropped gallstones, and vascular injuries.

2020 WSES guidelines for the detection and management of bile duct injury during cholecystectomy

Bile duct injury (BDI) is a dangerous complication of cholecystectomy, with significant postoperative sequelae for the patient in terms of morbidity, mortality, and long-term quality of life. BDIs have an estimated incidence of 0.4-1.5%, but considering the number of cholecystectomies performed worldwide, mostly by laparoscopy, surgeons must be prepared to manage this surgical challenge. Most BDIs are recognized either during the procedure or in the immediate postoperative period. However, some BDIs may be discovered later during the postoperative period, and this may translate to delayed or inappropriate treatments. Providing a specific diagnosis and a precise description of the BDI will expedite the decision-making process and increase the chance of treatment success. Subsequently, the choice and timing of the appropriate reconstructive strategy have a critical role in long-term prognosis. Currently, a wide spectrum of multidisciplinary interventions with different degrees of invasiveness is indicated for BDI management. These World Society of Emergency Surgery (WSES) guidelines have been produced following an exhaustive review of the current literature and an international expert panel discussion with the aim of providing evidence-based recommendations to facilitate and standardize the detection and management of BDIs during cholecystectomy. In particular, the 2020 WSES guidelines cover the following key aspects: (1) strategies to minimize the risk of BDI during cholecystectomy; (2) BDI rates in general surgery units and review of surgical practice; (3) how to classify, stage, and report BDI once detected; (4) how to manage an intraoperatively detected BDI; (5) indications for antibiotic treatment; (6) indications for clinical, biochemical, and imaging investigations for suspected BDI; and (7) how to manage a postoperatively detected BDI.

Impacto de la participación del residente y su rol en desenlaces clínicos de los pacientes llevados a colecistectomía en un hospital universitario

Introducción. La colecistectomía es uno de los procedimientos quirúrgicos más realizados a nivel mundial, por lo que su aprendizaje es cada vez más necesario para los médicos residentes en entrenamiento, pero sin comprometer la seguridad de los pacientes. El objetivo de este estudio fue determinar el impacto de la participación de los médicos residentes en los principales desenlaces clínicos de la colecistectomía. Métodos. Se realizó un estudio prospectivo de cohortes, donde se incluyeron los pacientes llevados a colecistectomía laparoscópica, desde junio de 2019 hasta julio de 2020. Se llevó a cabo el análisis estadístico para describir medidas de frecuencia, tendencia central, dispersión y análisis bivariados para los desenlaces de interés. Resultados. Se incluyeron 482 pacientes a quienes se les practicó colecistectomía, 475 de ellas por vía laparoscópica. El 62,5 % fueron mujeres y el 76,2 % se realizaron de carácter urgente. En el 96 % de los procedimientos se contó con la participación de un residente. En el análisis bivariado no se encontró una diferencia estadísticamente significativa entre la participación del residente y un impacto negativo en los desenlaces clínicos de las variables relevantes. Discusión. No hay evidencia de que la participación de médicos residentes en la colecistectomía laparoscópica se asocie con desenlaces adversos en los pacientes, lo que sugiere estar en relación con una introducción temprana y responsable a este procedimiento por parte de los docentes, permitiendo que la colecistectomía sea un procedimiento seguro.

Achieving the critical view of safety in the difficult laparoscopic cholecystectomy: a prospective study of predictors of failure

BACKGROUND

Bile duct injury rates for laparoscopic cholecystectomy (LC) remain higher than during open cholecystectomy. The "culture of safety" concept is based on demonstrating the critical view of safety (CVS) and/or correctly interpreting intraoperative cholangiography (IOC). However, the CVS may not always be achievable due to difficult anatomy or pathology. Safety may be enhanced if surgeons assess difficulties objectively, recognise instances where a CVS is unachievable and be familiar with recovery strategies.

AIMS AND METHODS

A prospective study was conducted to evaluate the achievability of the CVS during all consecutive LC performed over four years. The primary aim was to study the association between the inability to obtain the CVS and an objective measure of operative difficulty. The secondary aim was to identify preoperative and operative predictors indicating the use of alternate strategies to complete the operation safely.

RESULTS

The study included 1060 consecutive LC. The median age was 53 years, male to female ratio was 1:2.1 and 54.9% were emergency admissions. CVS was obtained in 84.2%, the majority being difficulty grade I or II (70.7%). Displaying the CVS failed in 167 LC (15.8%): including 55.6% of all difficulty grade IV LC and 92.3% of difficulty grade V. There were no biliary injuries or conversions.

CONCLUSION

All three components of the critical view of safety could not be demonstrated in one out of 6 consecutive laparoscopic cholecystectomies. Preoperative factors and operative difficulty grading can predict cases where the CVS may not be achievable. Adapting instrument selection and alternate dissection strategies would then need to be considered.

Fluorescent cholangiography significantly improves patient outcomes for laparoscopic cholecystectomy

BACKGROUND

Laparoscopic cholecystectomy (LC) is the most common elective abdominal surgery in the USA, with over 750,000 performed annually. Fluorescent cholangiography (FC) using indocyanine green dye (ICG) permits identification of extrahepatic biliary structures to facilitate dissection without requiring cystic duct cannulation. Achieving the "critical view of safety" with assistance of ICG cholangiogram may support identification of anatomy, safely reduce conversion to open procedures, and decrease operative time. We assess the utility of FC with respect to anatomic visualization during LC and its effects on patient outcomes.

METHODS

A retrospective review of a prospectively maintained database identified patients undergoing laparoscopic cholecystectomy at a single academic center from 2013 to 2019. Exclusion criteria were primary open and single incision cholecystectomy. Patient factors included age, sex, BMI, and Charlson Comorbidity Index. Outcomes included operative time, conversion to open procedure, length of stay (LOS), mortality rate, and 30-day complications. A multivariable logistic regression was performed to determine independent predictors for open conversion.

RESULTS

A total of 1389 patients underwent laparoscopic cholecystectomy. 69.8% were female; mean age 48.6 years (range 15-94), average BMI 29.4 kg/m² (13.3-55.6). 989 patients (71.2%) underwent LC without fluorescence and 400 (28.8%) underwent FC with ICG. 30-day mortality detected 2 cases in the non-ICG group and zero with ICG. ICG reduced operative time by 26.47 min per case (p < 0.0001). For patients with BMI ≥ 30 kg/m², operative duration for ICG vs non-ICG groups was 75.57 vs 104.9 min respectively (p < 0.0001). ICG required conversion to open at a rate of 1.5%, while non-ICG converted at a rate of 8.5% (p < 0.0001). Conversion rate remained significant with multivariable analysis (OR 0.212, p = 0.001). A total of 19 cases were aborted (1.35%), 8 in the ICG group (1.96%) and 11 in the non-ICG group (1.10%), these cases were not included in LC totals. Average LOS was 0.69 vs 1.54 days in the ICG compared to non-ICG LCs (p < 0.0001), respectively. Injuries were more common in the non-ICG group, with 9 patients sustaining Strasberg class A injuries in the non-ICG group and 2 in the ICG group. 1 CBDI occurred in the non-ICG group. There was no significant difference in 30-day complication rates between groups.

CONCLUSION

ICG cholangiography is a non-invasive adjunct to laparoscopic cholecystectomy, leading to improved patient outcomes with respect to operative times, decreased conversion to open procedures, and shorter length of hospitalization. Fluorescence cholangiography improves visualization of biliary anatomy, thereby decreasing rate of CBDI, Strasberg A injuries, and mortality. These findings support ICG as standard of care during laparoscopic cholecystectomy.

Safe Cholecystectomy Multi-society Practice Guideline and State of the Art Consensus Conference on Prevention of Bile Duct Injury During Cholecystectomy

BACKGROUND

BDI is the most common serious complication of laparoscopic cholecystectomy. To address this problem, a multi-society consensus conference was held to develop evidenced-based recommendations for safe cholecystectomy and prevention of BDI.

METHODS

Literature reviews were conducted for 18 key questions across 6 broad topics around cholecystectomy directed by a steering group and subject experts from 5 surgical societies (Society of Gastrointestinal and Endoscopic Surgeons, Americas Hepato-Pancreato-Biliary Association, International Hepato-Pancreato-Biliary Association, Society for Surgery of the Alimentary Tract, and European Association for Endoscopic Surgery). Evidence-based recommendations were formulated using the grading of recommendations assessment, development, and evaluation methodology. When evidence-based recommendations could not be made, expert opinion was documented. A number of recommendations for future research were also documented. Recommendations were presented at a consensus meeting in October 2018 and were voted on by an international panel of 25 experts with greater than 80% agreement considered consensus.

RESULTS

Consensus was reached on 17 of 18 questions by the guideline development group and expert panel with high concordance from audience participation. Most recommendations were conditional due to low certainty of evidence. Strong recommendations were made for (1) use of intraoperative biliary imaging for uncertainty of anatomy or suspicion of biliary injury; and (2) referral of patients with confirmed or suspected BDI to an experienced surgeon/multispecialty hepatobiliary team.

CONCLUSIONS

These consensus recommendations should provide guidance to surgeons, training programs, hospitals, and professional societies for strategies that have the potential to reduce BDIs and positively impact patient outcomes. Development of clinical and educational research initiatives based on these recommendations may drive further improvement in the quality of surgical care for patients undergoing cholecystectomy.

Management of Postcholecystectomy Biliary Complications: A Narrative Review

Every year approximately 750,000 cholecystectomies are performed in the United States, most of those are performed laparoscopically. Postcholecystectomy complications are not uncommon and lead to increased morbidity and financial burden. Some of the most commonly encountered complications with laparoscopic cholecystectomy include biliary injury (0.08%-0.5%), bile leak (0.42%-1.1%), retained common bile duct stones (0.8%-5.7%), postcholecystectomy syndrome (10%-15%), and postcholecystectomy diarrhea (5%-12%). Endoscopy has an important role in the diagnosis and management of biliary complications and in many cases can provide definitive management. There is no consensus on the best therapeutic approach for biliary complications. Therefore, biliary complications should be approached by an experienced multidisciplinary team. It is important for the gastroenterologist to be familiar with the management of such complications (Visual Abstract, Supplemental Digital content 1, http://links.lww.com/AJG/B544).

Safe cholecystectomy multi-society practice guideline and state-of-the-art consensus conference on prevention of bile duct injury during cholecystectomy

BACKGROUND

Bile duct injury (BDI) is the most common serious complication of laparoscopic cholecystectomy. To address this problem, a multi-society consensus conference was held to develop evidenced-based recommendations for safe cholecystectomy and prevention of BDI.

METHODS

Literature reviews were conducted for 18 key questions across six broad topics around cholecystectomy directed by a steering group and subject experts from five surgical societies (SAGES, AHPBA IHPBA, SSAT, and EAES). Evidence-based recommendations were formulated using the GRADE methodology. When evidence-based recommendations could not be made, expert opinion was documented. A number of recommendations for future research were also documented. Recommendations were presented at a consensus meeting in October 2018 and were voted on by an international panel of 25 experts with greater than 80% agreement considered consensus.

RESULTS

Consensus was reached on 17 of 18 questions by the Guideline Development Group (GDG) and expert panel with high concordance from audience participation. Most recommendations were conditional due to low certainty of evidence. Strong recommendations were made for (1) use of intraoperative biliary imaging for uncertainty of anatomy or suspicion of biliary injury; and (2) referral of patients with confirmed or suspected BDI to an experienced surgeon/multispecialty hepatobiliary team.

CONCLUSION

These consensus recommendations should provide guidance to surgeons, training programs, hospitals, and professional societies for strategies that have the potential to reduce BDIs and positively impact patient outcomes. Development of clinical and educational research initiatives based on these recommendations may drive further improvement in the quality of surgical care for patients undergoing cholecystectomy.

Fluorescence cholangiography enhances surgical residents’ biliary delineation skill for laparoscopic cholecystectomies

BACKGROUND

Laparoscopic cholecystectomy (LC) is a minimally invasive procedure, often performed by surgical residents (SRs). Fluorescence cholangiography (FC) enables real-time identification of biliary anatomy.

AIM

To investigate the benefit of FC for enhancing SRs’ identification skills.

METHODS

Prospective data was collected from January 2018 to June 2018 at our hospital. The study cohorts were the SRs (study group, n = 15) and the surgical staff (SS; control group, n = 9). Participants were assigned to watch videos of LCs with FC from five different patients who had gallbladder disease, and identify structures in the video clips (including cystic duct, common bile duct, common hepatic duct, and cystic artery), first without FC, and then with FC.

RESULTS

In the without-FC phase, the overall misidentification rate by SRs (21.7%) was greater than that of the SS (11.8%; P = 0.018), However, in the FC phase, the two groups did not significantly differ in misidentification rates (23.3% vs 23.3%, P = 0.99). Paired-structure analysis of the without-FC and with-FC phases for the SR group found a significantly higher misidentification rate in the without-FC phase than the with-FC phase (21.9% vs 10.9%; P < 0.01). However, misidentification rates in the with-FC phase did not significantly differ between SRs and SS.

CONCLUSION

FC enhanced identification skills of inexperienced surgeons during LC compared with conventional training. Combined with simulation-based video training, FC is a promising tool for enhancing technical and decision skills of trainees and inexperienced surgeons.

[Intraoperative fluorescence angiography and cholangiography with indocyanine green in hepatobiliary surgery]

Intraoperative fluorescence angiography and cholangiography with indocyanine green (ICG) are increasingly used in routine hepatobiliary surgery. Its usage is manifold. It improves and facilitates navigation especially in minimal invasive and robotic surgery and therefore increases the safety of the surgical intervention. In laparoscopic cholecystectomy for example, the bileduct anatomy can be easily visualized, even in complicated cholecystitis or anatomical variants without being too time consuming. ICG fluorescence also enables the visualization of vascular structures and perfusion. Anatomical liver resections, for example in hepatocellular carcinoma (HCC), can be performed easily as liver segments and territories can be identified. Anatomical resection is becoming more important, e.g. in the treatment of HCC. Another useful application is the intraoperative detection of bile leakages after liver resection. In particular, the intraoperative control of a biliodigestive anastomosis is possible with ICG fluorescence cholangiography and therefore reduces morbidity. Even primary and secondary liver tumors can be detected with ICG fluorescence. Whereas well-differentiated HCCs homogeneously take up ICG, poorly differentiated HCCs and metastases do not: however, in these cases the adjacent liver parenchyma stores ICG more intensively than healthy liver tissue, which creates a ring-like fluorescence pattern. To conclude, the use of ICG fluorescence in hepatobiliary surgery is diverse but in Germany it is still at the beginning compared to other countries.

Imaging of Abdominal Postoperative Complications

We present a case-based review of abdominal postoperative complications, organized by organ system affected, including wound/superficial, hepatobiliary, pancreatic, gastrointestinal, genitourinary, and vascular complications. Both general complications and specific considerations for certain types of operations are described, as well as potential pitfalls that can be confused with complications. Representative cases are shown using all relevant imaging modalities, including CT, fluoroscopy, ultrasound, MRI, and nuclear medicine. Management options are also described, highlighting those that require radiologist input or intervention.

Post-cholecystectomy acute injury: What can go wrong?

Backgrounds/Aims

Most of the emphasis of postcholecystectomy injuries is laid on iatrogenic bilary trauma. However, they can involve a wide spectrum of injuries.

Methods

We prospectively evaluated 42 patients with postcholecystectomy injuries referred to us from July 2011 to December 2012. Based on spectrum of injuries, we proposed an algorithm of management.

Results

Injuries occurred following laparoscopy in 20 (2 converted) patients and open in 22 patients. Mean time of detection of injury was 4.32±2.33 days. The nature of drainage was bilious in 36, bile with blood in 2, only blood in 2, and enteric in 2. Nine had organ failure at presentation. Six (14%) needed re-operation. Source of hemorrhage was from right hepatic artery in three and small bowel mesentry in 1. Enteric injuries were one each to duodenum and colon. Six patient (14%) died. Advancing age and organ failure were the predictors of mortality. Persistant biliary fistula was seen in 5 (14%). Ten had lateral leaks that closed at 28.89±2.34 days. Twenty-two formed stricture which was successfully managed with definitive hepaticojejunostomy.

Conclusions

Post cholecystectomy acute injury does not limit itself to bile duct or vascular injury but it can traumatize adjacent hollow viscus or mesentery. It is important to diagnose and intervene enteric injury early. Presentation and management for such injury should be followed as per the proposed algorithm.

Preoperative predictors of choledocholithiasis in patients presenting with acute calculous cholecystitis

BACKGROUND AND AIMS

Markedly increased liver chemistries in patients presenting with acute calculous cholecystitis (AC) often prompt an evaluation for concomitant choledocholithiasis (CDL). However, current guidelines directing the workup for CDL fail to address this unique population. The aims of this study are to define the range of presenting laboratory values and imaging findings in AC, develop a model to predict the presence of concurrent CDL, and develop a management algorithm that can be easily applied on presentation.

METHODS

We conducted a retrospective review of patients presenting with AC to a large tertiary hospital over a 3.5-year period. CDL was defined as common bile duct (CBD) stone(s), sludge, or debris seen on any of the following studies: US, CT, magnetic resonance imaging/MRCP, EUS, ERCP, or intraoperative cholangiogram. A multivariable model to predict CDL was developed on 70% of the patients and validated on the remaining 30%.

RESULTS

A total of 366 patients were identified and 65 (17.8%) had concurrent CDL. Univariable analysis was used to predict CDL and demonstrated statistically significant odds ratios for transaminases >3 times the upper limit of normal, alkaline phosphatase (AlkPhos) above normal, lipase >3 times the upper limit of normal, total bilirubin ≥1.8 mg/dL, and CBD diameter >6 mm. In the validation cohort, an optimal model containing alanine transaminase (ALT) >3 times the upper limit of normal, abnormal AlkPhos, and CBD diameter >6 mm was found to have an area under the receiver operating curve of 0.91. When 0 or 1 risk factors were present, 98.6% of patients did not have CDL. When all 3 risk factors were present, 77.8% were found to have CDL.

CONCLUSIONS

The prevalence of CDL is high among patients with AC. When a validated model is used, application of cutoffs for ALT, AlkPhos, and CBD diameter can effectively triage patients with low and high likelihood for CDL to surgery or ERCP, respectively.

A Memorable Moment During Laparoscopic Cholecystectomy: A Case Report

Common bile duct (CBD) stones are encountered in 14%-15% of patients with symptomatic gall stone disease. Endoscopic retrograde cholangiopancreatography (ERCP) is a primary modality for the management of pancreaticobiliary disorders. We present a case of unintentional stent placement into the gall bladder discovered during surgery.

Evaluation of the usefulness of the SAGES Safe Cholecystectomy Program from the viewpoint of the European surgeon

Introduction

Common bile duct injury (CBDI) is a severe complication of laparoscopic cholecystectomy (LC). To minimize its occurrence, SAGES established the Safe Cholecystectomy Program (SCP) with 6 rules to follow during surgery.

Aim

To assess the knowledge of SCP among European surgeons and their opinion on its usefulness.

Material and methods

Data were gathered using questionnaires during surgical conferences in Poland and Denmark. The questionnaire asked about the surgeon’s experience in cholecystectomy and the number of complications in the form of CBDI. It asked about the surgeon’s opinion on the usefulness of SCP rules on a 10-point scale. A comparison between specialists and residents was performed. The study has been registered in the ClinicalTrials.gov – NCT03155321.

Results

One hundred eighty-four questionnaires were gathered. One hundred fourteen (61.96%) specialists (72.8% male, mean age: 50 years) and 70 (38.04%) residents (56% male, mean age: 34 years) completed the questionnaire. Mean work experience was 22 years among specialists and 4.5 years among residents. A high percentage of specialists have experienced CBDI (46% vs. 17% of residents, p = 0.014). More specialists are familiar with the SCP than residents (49.3% vs. 21.7%, p = 0.021). Significant differences in the mean usefulness score were observed for three rules: rules 2 and 6 were found more useful by residents (mean score: 7.07 vs. 6.01, p = 0.025 and 8.70 vs. 8.27, p < 0.001), and rule 3 was found more useful by specialists (mean: 8.73 vs. 8.36, p < 0.001).

Conclusions

The awareness of the SCP in Europe is low. Participants consider the rules of the SCP to be useful during surgery, although there are differences in the usefulness scores between the groups. An educational program to promote and further implement the SCP should be established.

An Update on Iatrogenic Biliary Injuries: Identification, Classification, and Management

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.

Magnetic resonance imaging-guided three-dimensional real-time bile duct reconstruction and end-to-end anastomosis under laparoscopy: A case report

In laparoscopic cholecystectomy (LC), the anatomical variation of gallbladder canal should be noted. Bile duct injury is one of the most serious complications of LC, which might lead to serious complications. This case because of an intraoperative accidental cut to right anterior inferior lobe bile duct which joins to the cystic duct, after confirming by intraoperative magnetic resonance imaging-guided real-time three-dimensional bile duct reconstruction and performing end-to-end anastomosis of the right anterior inferior lobe bile duct and the gallbladder tube under laparoscopy, the patient was discharged 5 days after surgery, was followed up for 4 months and was disease-free.

[Influence of biliary decompression technique on the outcomes of reconstructive surgery]

AIM

To evaluate bile ducts injuries and effect of biliary decompression technique on the outcomes of reconstructive surgery.

MATERIAL AND METHODS

There were 21 patients with biliary injury during cholecystectomy, 20 patients with cholelithiasis, and 1 patient after surgery for perforated duodenal ulcer. Their age was 22-81 years (mean 54.3 years). Primary surgery through median laparotomy was followed by biliary injury in 12 patients, laparoscopic cholecystectomy - in 6 patients, open laparoscopy - in 3 patients. Patients were divided into 2 groups. In group 1 (n=11) biliary injury was diagnosed intraoperatively, in group 2 (n=10) - in 2-11 days after primary procedure. According to European Association for Endoscopic Surgery (EAES) 2013 classification biliary injury type 1 was found in 5 patients, type 2 - in 9 cases, high damage involving confluence (type 3) - in 1 patient, type 4 - in 1 patient, and type 6 - in 5 patients. Endoscopic retrograde cholangiopancreatography in 3 patients revealed that biliary drainage output after laparoscopic cholecystectomy was caused by cystic duct clipping failure, endoscopic papillosphincterotomy was successfully used for biliary drainage output (type 6). In 3 patients operated through median laparotomy biliary excretion cessation was observed after 2-3 days that indicated damage of aberrant bile ducts.

RESULTS

Bile outflow into gastrointestinal tract was restored in 11 out of 16 patients with iatrogenic biliary injury types 1-4, external biliary drainage was used in 4 patients due to their severe condition and abdominal inflammatory changes. Biliary fistulae occurred in 5 out of 8 patients in both groups after primary reconstructive surgery. Biliary stricture was observed in 3 cases due to external biliary drainage failure followed by peritonitis. 7 patients underwent reconstructive surgery with positive result. Mortality was absent. In 1 patient with biliary fistula outcome is unknown.

CONCLUSION

Transumbilical biliary drainage is optimal during reconstructive surgery.