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Capparelli MA, Cotignola L, Domínguez MV, D'Alessandro PD, Ayarzabal VH, Barrenechea ME. Clinical Utility of Definitive Diagnostic Tests for Choledocholithiasis in Pediatric Patients with Mild Gallstone Pancreatitis. J Pediatr Surg 2023; 58:2352-2355. [PMID: 37460346 DOI: 10.1016/j.jpedsurg.2023.06.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Revised: 06/14/2023] [Accepted: 06/17/2023] [Indexed: 11/08/2023]
Abstract
BACKGROUND Gallstone pancreatitis was historically considered a risk factor for choledocholithiasis (CD). However, recent studies of adult patients evidenced a weak association between gallstone pancreatitis and CD. The aim of this study was to analyze this association in pediatric patients. METHODS We conducted a retrospective study on patients with mild gallstone pancreatitis who underwent any definitive testing for CD (MRCP, ERCP, IOC), managed between March 2010 and September 2022. Patients were classified according to the presence or absence of risk factors for CD (total bilirubin ≥2 mg/dl; common bile duct >6 mm on ultrasound; and/or CD on ultrasound). We evaluated the diagnosis of CD on definitive testing in both groups and analyzed the predictive capacity of the presence of risk factors. RESULTS Eighty-four patients were included in the final analysis. Seventy-nine percent were females. The median age was 13 (4-17) years. Forty-seven (55.9%) patients had one or more risk factors. The definitive testing confirmed 13 (15.5%) cases of CD, 12 (25.5%) in the group of patients with risk factors and 1 (2.7%) in those without risk factors. The sensitivity, specificity, positive predictive value and negative predictive value of the presence of associated risk factors were 92.3, 50.7, 25.5 and 97.3%, respectively. CONCLUSION Pediatric patients with gallstone pancreatitis without associated risk factors have a very low incidence of CD. In these patients we suggest performing a laparoscopic cholecystectomy without intraoperative cholangiography or any other definitive test for CD. LEVEL OF EVIDENCE Level II, retrospective study.
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Affiliation(s)
| | - Luciana Cotignola
- Division of General Surgery, J.P. Garrahan Hospital, Buenos Aires, Argentina
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2
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Osailan S, Esailan M, Alraddadi AM, Almutairi FM, Sayedalamin Z. The Use of Intraoperative Cholangiography During Cholecystectomy: A Systematic Review. Cureus 2023; 15:e47646. [PMID: 37899894 PMCID: PMC10612988 DOI: 10.7759/cureus.47646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/25/2023] [Indexed: 10/31/2023] Open
Abstract
Cholecystectomy is a widespread surgical procedure for gallbladder diseases. Evolving techniques and technologies, such as intraoperative cholangiography (IOC), enhance safety and outcomes by providing real-time biliary system visualization during surgery. This systematic review explored available data on using IOC during cholecystectomy, highlighting its effectiveness, safety, and cost-effectiveness. To perform this systematic review, a thorough literature search was conducted using relevant keywords in electronic databases, such as PubMed, Medical Literature Analysis and Retrieval System Online (MEDLINE), Cochrane Library, Web of Science, and Google Scholar. We included studies published during the last 10 years exploring the use of IOC during cholecystectomy. The findings showed success rates of up to 90% with a median time of 21.9 minutes without complications. Most (90%) patients with acute gallstone pancreatitis underwent cholecystectomy with IOC, with unclear IOC results in 10.7% and failure in 14.7%. IOC failure factors included age, body mass index (BMI), male sex, concurrent acute cholecystitis, common bile duct (CBD) stone evidence on imaging, CBD diameter of >6 mm, total bilirubin of >4 mg/dL, abnormal liver tests, and gallstone pancreatitis. The detection of choledocholithiasis by IOC prompted trans-cystic duct exploration and endoscopic retrograde cholangiopancreatography (ERCP). Biliary abnormalities and stone identification were observed using IOC, and routine use increased bile duct stone detection while decreasing bile duct injury and readmission rates. The sensitivity, specificity, accuracy, positive predictive value, and negative predictive value of IOC for common bile duct stone detection were reported at 77%, 98%, 97.2%, 63%, and 99%, respectively. Routine IOC was projected to provide substantial quality-adjusted life years (QALY) and cost-effectiveness gains compared to selective IOC. Regarding safety, IOC was generally associated with reduced complication and open surgery conversion risks, with similar rates of CBD injury and bile leaks. These findings indicate that IOC enhances cholecystectomy outcomes through precision and decreasing complications.
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Affiliation(s)
- Samah Osailan
- General Surgery, King Abdulaziz University Faculty of Medicine, Jeddah, SAU
| | | | | | | | - Zaid Sayedalamin
- General Surgery, King Abdulaziz University Faculty of Medicine, Jeddah, SAU
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3
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Chung D. Comparison of pre-operative computed tomography cholangiography and intraoperative cholangiography in laparoscopic cholecystectomy: a retrospective analysis. BMC Surg 2023; 23:187. [PMID: 37391720 DOI: 10.1186/s12893-023-02089-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Accepted: 06/22/2023] [Indexed: 07/02/2023] Open
Abstract
BACKGROUND The role of intra-operative cholangiography (IOC) in laparoscopic cholecystectomy (LC) is controversial. CT cholangiography (CTC) provides a reliable assessment of biliary anatomy, potentially reducing operating times, open conversion, and complication rates. This study aims to assess the safety and effectiveness of routine pre-operative CTC. METHODS A single centre retrospective analysis was undertaken of all elective laparoscopic cholecystectomies between 2017 and 2021. Information was obtained from a general surgical database alongside hospital electronic medical records. T-tests and Chi2 tests were used to assess statistical significance. RESULTS Of 1079 patients, 129 (12.0%) underwent routine pre-operative CTC, 786 (72.8%) routine IOC, and 161 patients (14.9%) neither modality. Comparing CTC and IOC, the CTC group had higher rates of open conversion (3.1% vs. 0.6%, p 0.009), subtotal cholecystectomies (3.1% vs. 0.8%, p 0.018), and length of stay (1.47 vs. 1.18 nights, p 0.015). Comparing the prior groups together against those utilising neither modality, the latter had reduced operative time (66.29 vs. 72.47, p 0.011), but increased rate of bile leak (1.9% vs. 0.4%, p 0.037) and bile duct injury (1.2% vs. 0.2%, p 0.049). Co-dependence between operative complications was noted in linear regression. CONCLUSION Biliary imaging with either CTC or IOC is beneficial in reducing bile leak and bile duct injury, and its routine use LC is recommended. However, routine CTC is inferior to routine IOC in preventing conversions to open surgery and subtotal cholecystectomy. Further research may be undertaken to evaluate criteria for a selective CTC protocol.
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Affiliation(s)
- Douglas Chung
- Campbelltown Hospital, Therry Road, Campbelltown, NSW, 2560, Australia.
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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] [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. Supplementary Information The online version contains supplementary material available at 10.1007/s00464-022-09267-x.
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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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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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6
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Turco J, Ballal M, Fletcher D. What is the role of intraoperative cholangiography at cholecystectomy in the modern era? ANZ J Surg 2021; 91:1329-1330. [PMID: 34402168 DOI: 10.1111/ans.17052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 06/21/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Jennifer Turco
- Department of General Surgery, Fiona Stanley Hospital, Murdoch, Western Australia, Australia
| | - Mohammed Ballal
- Department of General Surgery, Fiona Stanley Hospital, Murdoch, Western Australia, Australia.,Division of Surgery, School of Medicine, University of Western, Australia, Australia
| | - David Fletcher
- Department of General Surgery, Fiona Stanley Hospital, Murdoch, Western Australia, Australia.,Division of Surgery, School of Medicine, University of Western, Australia, Australia
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When Should We Perform Intraoperative Cholangiography? A Prospective Assessment of 1000 Consecutive Laparoscopic Cholecystectomies. SURGICAL LAPAROSCOPY, ENDOSCOPY & PERCUTANEOUS TECHNIQUES 2021; 32:3-8. [PMID: 34369481 DOI: 10.1097/sle.0000000000000985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Accepted: 06/18/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Intraoperative cholangiography (IOC) has been historically used to detect common bile duct (CBD) stones, delineate biliary anatomy, and avoid or promptly diagnose bile duct injuries (BDIs) during laparoscopic cholecystectomy (LC). We aimed to determine the usefulness of routine IOC during LC in an urban teaching hospital. METHODS A consecutive series of patients undergoing LC with routine IOC from 2016 to 2018 was prospectively analyzed. Primary outcomes of interest were: CBD stones, BDI, and anatomical variations of the biliary tract. Secondary outcomes of interest were: IOC success rate, IOC time, and readmission for residual lithiasis. A comparative analysis was performed between patients with and without preoperative suspicion of CBD stones. RESULTS A total of 1003 LC were analyzed; IOC was successful in 918 (91.5%) patients. Mean IOC time was 10 (4 to 30) minutes. Mean radiation received by the surgeon per procedure was 0.06 millisieverts (mSv). Normal IOC was found in 856 (93.2%) patients. CBD stones and aberrant biliary anatomy were present in 58 (6.3%) and 4 (0.4%) cases, respectively. Two patients (0.2%) underwent unnecessary CBD exploration because of false-positive IOC. Four patients (0.4%) with normal IOC were readmitted for residual CBD stones. Five (0.5%) minor BDI undetected by the IOC were diagnosed. Patients with preoperative suspicion of CBD stones had significantly higher rates of CBD stones detected on IOC as compared with those without suspicion (23.2% vs. 2.1%, P<0.0001). CONCLUSION Routine use of IOC resulted in low rates of BDI diagnosis, aberrant biliary anatomy identification and/or CBD stones detection. Selection of patients for IOC, rather than routine use of IOC appears a more reasonable approach.
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8
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Ng HJ, Nassar AHM. Reinterventions following laparoscopic cholecystectomy and bile duct exploration. A review of prospective data from 5740 patients. Surg Endosc 2021; 36:2809-2817. [PMID: 34076762 PMCID: PMC9001563 DOI: 10.1007/s00464-021-08568-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 05/18/2021] [Indexed: 01/24/2023]
Abstract
Background Complications following laparoscopic cholecystectomy (LC) and common bile duct exploration (CBDE) for the management of gallstones or choledocholithiasis impact negatively on patients’ quality of life and may lead to reinterventions. This study aims to evaluate the causes and types of reintervention following index admission LC with or without CBDE. Methods A prospectively maintained database of LC and CBDE performed by a single surgeon was analysed. Preoperative factors, difficulty grading and perioperative complications requiring reintervention and readmissions were examined. Results Reinterventions were required in 112 of 5740 patients (2.0%), 89 (1.6%) being subsequent to complications. The reintervention cohort had a median age of 64 years, were more likely to be females (p < 0.0023) and to be emergency admissions (67.9%, p < 0.00001) with obstructive jaundice (35.7%, p < 0.00001). 46.4% of the reintervention cohort had a LC operative difficulty grade IV or V and 65.2% underwent a CBDE. Open conversion was predictive of the potential for reintervention (p < 0.00001). The most common single cause of reintervention was retained stones (0.5%) requiring ERCP followed by bile leakage (0.3%) requiring percutaneous drainage, ERCP and relaparoscopy. Relaparoscopy was necessary in 17 patients and open surgery in 13, 6 of whom not resulting from complications. There were 5 deaths. Conclusion This large series had a low incidence of reinterventions resulting from complications in spite of a high workload of index admission surgery for biliary emergencies and bile duct stones. Surgical or endoscopic reinterventions following LC alone occurred in only 0.8%. The most common form of reintervention was ERCP for retained CBD stones. This important outcome parameter of laparoscopic biliary surgery can be optimised through early diagnosis and timely reintervention for complications.
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Affiliation(s)
- Hwei Jene Ng
- Laparoscopic Biliary Surgery Service, University Hospital Monklands, Airdrie, Scotland, UK
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9
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Mui J, Mayne DJ, Davis KJ, Cuenca J, Craig SJ. Increasing use of intraoperative cholangiogram in Australia: is it evidence-based? ANZ J Surg 2021; 91:1534-1541. [PMID: 33982363 DOI: 10.1111/ans.16912] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 04/21/2021] [Indexed: 01/12/2023]
Abstract
BACKGROUND The role of routine intraoperative cholangiograms (IOCs) for prevention of bile duct injury (BDI) is contentious. There are recent reports of limited utility of IOC in preventing BDI. In Australia, IOCs are used more frequently than internationally. This study aimed to evaluate the rate of IOC use in Australia and explore potential changes in practice in light of evolving evidence for the utility of IOC. METHODS Data were collated using service item numbers in Medicare Benefits Scheme records on the Australian Government Medicare website, for services claimed between 1 January 2001 and 31 December 2019. These data were used to analyse trends in rates of IOC, cholecystectomy and BDI repair. Data were age-standardized to account for changes in the population over time. RESULTS The number of IOCs claimed increased by 31.8% and cholecystectomies by 7.0% over the study period. Age-standardized service rates per 100 000 persons increased by 5.5 and 32.6, respectively. Rates of IOC per 100 000 cholecystectomies steadily increased across the study period, while BDI repair rates remained low and erratic. CONCLUSION Increasing use of IOC over the last 20 years reflects a trend towards routine rather than selective IOC; however, there is little discernible change in the number of BDIs requiring repair procedures. This suggests that routine IOC use to prevent or minimize BDI is unwarranted. Further investigation is required into the selective IOC use in high-risk patients rather than mandatory use in all patients.
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Affiliation(s)
- Jasmine Mui
- Department of Surgery, St George Hospital, Sydney, New South Wales, Australia
| | - Darren J Mayne
- Public Health Unit, Illawarra Shoalhaven Local Health District, Wollongong, New South Wales, Australia.,School of Public Health, The University of Sydney, Sydney, New South Wales, Australia.,School of Medicine, University of Wollongong, Wollongong, New South Wales, Australia.,Illawarra Health and Medical Research Institute, University of Wollongong, Wollongong, New South Wales, Australia
| | - Kimberley J Davis
- School of Medicine, University of Wollongong, Wollongong, New South Wales, Australia.,Research Central, Illawarra Shoalhaven Local Health District, Wollongong, New South Wales, Australia
| | - Jose Cuenca
- Research Central, Illawarra Shoalhaven Local Health District, Wollongong, New South Wales, Australia
| | - Steven J Craig
- Illawarra Health and Medical Research Institute, University of Wollongong, Wollongong, New South Wales, Australia.,Department of Surgery, Shoalhaven District Memorial Hospital, Illawarra Shoalhaven Local Health District, Wollongong, New South Wales, Australia
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Werenski HE, Bosley ME, Powell MS, Meredith JW, Randle RW. Outcomes Following Cholecystectomy on a Service Designed to Maximize Chief Resident Entrustment. J Surg Res 2021; 264:474-480. [PMID: 33857791 DOI: 10.1016/j.jss.2021.02.042] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 02/10/2021] [Accepted: 02/27/2021] [Indexed: 12/30/2022]
Abstract
BACKGROUND The chief resident service provides surgical trainees in their final year of training the opportunity to maximize responsibility, continuity, and decision-making. Although supervised, chief residents operate according to personal preferences instead of adapting to their attendings' preferences. We hypothesized that outcomes following cholecystectomy are equivalent between the chief resident service and standard academic services. METHODS We matched adults undergoing cholecystectomy from 07/2016-06/2019 on the chief resident service to two standard academic service patients based on operative indication and age. We compared demographics, operative details, and 30-d complications. RESULTS This study included 186 patients undergoing cholecystectomy. Body mass index (32.4 versus 32.0, P = 0.49) and Charlson comorbidity index (0.9 versus 1.4, P = 0.16) were similar between chief resident and standard academic services, respectively. Operative approach was similar (95.2% laparoscopic on chief resident service versus 94.4% on standard service), but residents on the chief resident service performed cholangiograms more often (48.4% versus 22.6%, P < 0.01) and averaged longer operative times during laparoscopic cholecystectomy with cholangiogram (146±28 versus 85±22 min, P < 0.01) and without (94±31 versus 76±35 min, P < 0.01) compared with standard academic services, respectively. 30-d complication rates were similar (5.2% chief resident versus 5.0% standard, P = 0.95). No patients suffered bile leak, bile duct injury, or reoperation. Emergency Department visits were similar (12.1% chief resident versus 7.4% standard, P = 0.32); readmissions were less frequent on the chief resident service (0.0% versus 5.0% standard, P = 0.03). CONCLUSIONS With appropriate supervision, chief residents provide safe care for patients undergoing cholecystectomy while directing medical decisions and practicing according to their preferences.
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Affiliation(s)
- Hope E Werenski
- Department of Surgery, Wake Forest Baptist Health, Wake Forest University School of Medicine, Winston-Salem, NC
| | - Maggie E Bosley
- Department of Surgery, Wake Forest Baptist Health, Wake Forest University School of Medicine, Winston-Salem, NC
| | - Myron S Powell
- Department of Surgery, Wake Forest Baptist Health, Wake Forest University School of Medicine, Winston-Salem, NC
| | - J Wayne Meredith
- Department of Surgery, Wake Forest Baptist Health, Wake Forest University School of Medicine, Winston-Salem, NC
| | - Reese W Randle
- Department of Surgery, Wake Forest Baptist Health, Wake Forest University School of Medicine, Winston-Salem, NC.
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11
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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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Rystedt JML, Wiss J, Adolfsson J, Enochsson L, Hallerbäck B, Johansson P, Jönsson C, Leander P, Österberg J, Montgomery A. Routine versus selective intraoperative cholangiography during cholecystectomy: systematic review, meta-analysis and health economic model analysis of iatrogenic bile duct injury. BJS Open 2020; 5:6056685. [PMID: 33688957 PMCID: PMC7944855 DOI: 10.1093/bjsopen/zraa032] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 09/26/2020] [Accepted: 09/28/2020] [Indexed: 01/07/2023] Open
Abstract
Background Bile duct injury (BDI) is a severe complication following cholecystectomy. Early recognition and treatment of BDI has been shown to reduce costs and improve patients’ quality of life. The aim of this study was to assess the effect and cost-effectiveness of routine versus selective intraoperative cholangiography (IOC) in cholecystectomy. Methods A systematic review and meta-analysis, combined with a health economic model analysis in the Swedish setting, was performed. Costs per quality-adjusted life-year (QALY) for routine versus selective IOC during cholecystectomy for different scenarios were calculated. Results In this meta-analysis, eight studies with more than 2 million patients subjected to cholecystectomy and 9000 BDIs were included. The rate of BDI was estimated to 0.36 per cent when IOC was performed routinely, compared with to 0.53 per cent when used selectively, indicating an increased risk for BDI of 43 per cent when IOC was used selectively (odds ratio 1.43, 95 per cent c.i. 1.22 to 1.67). The model analysis estimated that seven injuries were avoided annually by routine IOC in Sweden, a population of 10 million. Over a 10-year period, 33 QALYs would be gained at an approximate net cost of €808 000 , at a cost per QALY of about €24 900. Conclusion Routine IOC during cholecystectomy reduces the risk of BDI compared with the selective strategy and is a potentially cost-effective intervention.
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Affiliation(s)
- J M L Rystedt
- Department of Surgery, Skane University Hospital, Clinical Sciences, Lund University, Sweden
| | - J Wiss
- Swedish Agency for Health Technology Assessment and Assessment of Social Services (SBU), Stockholm, Sweden
| | - J Adolfsson
- Swedish Agency for Health Technology Assessment and Assessment of Social Services (SBU), Stockholm, Sweden
| | - L Enochsson
- Department of Clinical Sciences, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden.,Department of Surgical and Perioperative Sciences, Umeå University, Umeå, Sweden
| | - B Hallerbäck
- Department of Surgery, Northern Alvsborg Hospital, Trollhattan, Sweden
| | - P Johansson
- PublicHealth&Economics, Stockholm, Sweden.,Research Centre for Health and Welfare, Halmstad University, Halmstad, Sweden
| | - C Jönsson
- Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - P Leander
- Department of Radiology, Skane University Hospital, Malmö, Sweden
| | - J Österberg
- Department of Surgery, Mora Hospital, Mora, Sweden
| | - A Montgomery
- Department of Surgery, Skane University Hospital, Clinical Sciences, Lund University, Sweden
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13
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Biesterveld BE, Alam HB. Evidence-Based Management of Calculous Biliary Disease for the Acute Care Surgeon. Surg Infect (Larchmt) 2020; 22:121-130. [PMID: 32471330 DOI: 10.1089/sur.2020.110] [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: 12/07/2022] Open
Abstract
Background: Gallstones and cholecystitis are common clinical problems. There is a wide spectrum of disease severity, from rare symptoms of biliary colic to severe cholecystitis with marked gallbladder infection and inflammation that can cause life-threatening sepsis. The care of such patients is similarly varied and multi-disciplinary. Despite the prevalence of cholecystitis, there remain questions about how to manage patients appropriately. Methods: A multi-disciplinary team created institutional cholecystitis guidelines, and supporting evidence was compiled for review. Results: Even in "routine" cholecystitis, patient triage and work-up can be variable, resulting in unnecessary tests and delay to cholecystectomy. Beyond this, there are new treatment options available that may serve special populations particularly well, although the appropriate pattern of emerging endoscopic and percutaneous treatment modalities is not well defined. Conclusions: This review outlines evidence-based management of cholecystitis from diagnosis to treatment with a focused discussion of special populations and emerging therapies.
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Affiliation(s)
- Ben E Biesterveld
- Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Hasan B Alam
- Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
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14
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Luo Y, Yang T, Yu Q, Zhang Y. Laparoscopic Ultrasonography Versus Magnetic Resonance Cholangiopancreatography in Laparoscopic Surgery for Symptomatic Cholelithiasis and Suspected Common Bile Duct Stones. J Gastrointest Surg 2019; 23:1143-1147. [PMID: 30187333 DOI: 10.1007/s11605-018-3949-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Accepted: 08/23/2018] [Indexed: 01/31/2023]
Abstract
BACKGROUND There continues to be controversy regarding the optimal screening modality in patients with symptomatic cholelithiasis and suspected common bile duct (CBD) stones. The aim of this study was to assess the diagnostic accuracy of laparoscopic ultrasonography (LUS) compared to magnetic resonance cholangiopancreatography (MRCP). METHODS Both LUS and MRCP were performed to evaluate the CBD stones and biliary anatomy in 200 patients undergoing laparoscopic surgery. Pre-, intra-, and postoperative data were collected prospectively and reviewed retrospectively. RESULTS Coexisting CBD stones were identified in 64 of 200 (32%) patients by surgical exploration or postoperative ERCP. For the detection of CBD stones, LUS yielded a positive predictive value of 100%, a negative predictive value of 99.3%, a sensitivity of 98.4%, and a specificity of 100%. Preoperative MRCP had a positive predictive value of 87.9%, a negative predictive value of 95.5%, a sensitivity of 90.6%, and a specificity of 94.1%. The non-random concordance between MRCP and LUS was considered to be excellent with a kappa coefficient of 0.92 (p < 0.01). CONCLUSIONS LUS can reduce the need for MRCP examination and can become the primary imaging method for the evaluation of CBD stones in laparoscopic surgery.
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Affiliation(s)
- Ying Luo
- Department of Hepatobiliary Surgery, Chinese PLA General Hospital, Beijing, 100853, China.
| | - Tao Yang
- Department of Hepatobiliary Surgery, Chinese PLA General Hospital, Beijing, 100853, China
| | - Qiang Yu
- Department of Hepatobiliary Surgery, Chinese PLA General Hospital, Beijing, 100853, China
| | - Yu Zhang
- Department of Hepatobiliary Surgery, Chinese PLA General Hospital, Beijing, 100853, China
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15
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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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16
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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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17
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Intraoperative cholangiography during cholecystectomy among hospitalized medicare beneficiaries with non-neoplastic biliary disease. Am J Surg 2017; 214:682-686. [PMID: 28669532 DOI: 10.1016/j.amjsurg.2017.06.021] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Accepted: 06/21/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND Prior studies of Medicare beneficiaries with both neoplastic and non-neoplastic indications for cholecystectomy demonstrated a reduced risk of common bile duct (CBD) injury when intraoperative cholangiography (IOC) was used. We sought to determine the association between IOC and CBD injury during inpatient cholecystectomy for non-neoplastic biliary disease and compare survival among those with or without CBD injury. METHODS Retrospective study of patients ≥66 who underwent inpatient cholecystectomy (2005-2010) for gallstones, cholecystitis, cholangitis, or gallbladder obstruction. The association between IOC and CBD injury was analyzed using multivariable logistic regression and survival after cholecystectomy was analyzed using multivariable Cox regression. RESULTS Among 472,367 patients who underwent cholecystectomy, 0.3% had a CBD injury. IOC was associated with increased CBD injury (adjusted OR 1.41[1.27-1.57]). CBD injury was associated with increased hazards of death (adjusted HR 1.37[1.25-1.51]). CONCLUSIONS IOC in patients with non-neoplastic biliary disease was associated with increased odds of CBD injury. This likely reflects its selective use in patients at higher risk of CBD injury or as a confirmatory test when an injury is suspected.
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18
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Gahagan JV, Maximus S, Whealon MD, Phelan MJ, Demirjian A, Joe VC. Analysis of Endoscopic Retrograde Cholangiopancreatography after Positive Intraoperative Cholangiogram: Is it Necessary? Am Surg 2016. [DOI: 10.1177/000313481608201028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
The necessity of routine endoscopic retrograde cholangiopancreatography (ERCP) after positive intraoperative cholangiogram (IOC) during laparoscopic cholecystectomy is not well defined. We aimed to examine the incidence of positive IOC among patients who undergo IOC during cholecystectomy and the rate of subsequent ERCP stone extraction. The Nationwide Inpatient Sample database was reviewed for all patients undergoing cholecystectomy with IOC from 2002 to 2012. Patients were then analyzed for ERCP and stone extraction. A total of 73,508 patients who underwent cholecystectomy with IOC for a diagnosis of acute cholecystitis and found to have a bile duct stone were identified. Of these patients, 5915 underwent subsequent ERCP. In the patients that underwent subsequent ERCP, 1478 had a documented stone extraction during ERCP. The rate of stone extraction in the ERCP subset is 25 per cent, which is 2 per cent of all patients who had a positive IOC. The rate of stone extraction after positive IOC is low. Positive IOC may not warrant a routine postoperative ERCP. Our results suggest that clinical monitoring of patients with positive IOC is reasonable, as the majority of patients with a positive IOC ultimately have no stone extraction.
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Affiliation(s)
- John V. Gahagan
- Department of Surgery, University of California Irvine School of Medicine, Irvine, California and the
| | - Steven Maximus
- Department of Surgery, University of California Irvine School of Medicine, Irvine, California and the
| | - Matthew D. Whealon
- Department of Surgery, University of California Irvine School of Medicine, Irvine, California and the
| | - Michael J. Phelan
- Department of Statistics, University of California Irvine, Irvine, California
| | - Aram Demirjian
- Department of Surgery, University of California Irvine School of Medicine, Irvine, California and the
| | - Victor C. Joe
- Department of Surgery, University of California Irvine School of Medicine, Irvine, California and the
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19
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Bill JG, Kushnir VM, Mullady DK, Murad FM, Azar RR, Easler JJ, Early DS, Edmundowicz SA. Evaluation of patients with abnormalities on intraoperative cholangiogram: time to abandon endoscopic retrograde cholangiopancreatography as the initial follow-up study. Frontline Gastroenterol 2016; 7:105-109. [PMID: 28839843 PMCID: PMC5369474 DOI: 10.1136/flgastro-2015-100597] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2015] [Revised: 05/28/2015] [Accepted: 05/30/2015] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Endoscopic retrograde cholangiopancreatography (ERCP) is currently the method of choice for the postoperative evaluation of suspected bile duct stones seen on intraoperative cholangiogram (IOC); however, the sensitivity of IOC for identifying biliary pathology is unclear, with studies reporting false positive rates between 30% and 60%. OBJECTIVE Evaluate the sensitivity of IOC for biliary pathology, using ERCP with sphincterotomy and balloon sweep as gold standard. DESIGN Retrospective cohort study. SETTING Tertiary medical centre. PATIENTS 130 consecutive patients (age 51.3±1.7 years, 69.2% women) who underwent ERCP for the evaluation of abnormalities identified on IOC between 2005 and 2013. INTERVENTIONS Endoscopic retrograde cholangiopancreatography. MAIN OUTCOME MEASUREMENTS Sensitivity of IOC, identify predictors of positive postoperative ERCP and ERCP-related complications. RESULTS ERCP was successful in all 130 subjects. ERCP-related adverse events occurred in six (4.3%) patients, including self-limited post-sphincterotomy bleeding in three (2.3%) and mild post-ERCP pancreatitis in three (2.3%). Overall, 41 (31.5%) patients had normal cholangiogram at time of ERCP. Finding of a filling defect on IOC was the only predictor for the presence of common bile duct stones on postoperative ERCP (OR 3.3, 95% CI 1.0 to 10.8, p=0.05). LIMITATIONS Retrospective study design. CONCLUSIONS Nearly one-third of patients with abnormal IOC had a normal postoperative ERCP. Significant pathology could have been missed in 1/130 patients. Based on these findings, we believe the use of less-invasive diagnostic modalities may be used in place of ERCP in patients with suspected choledocholithiasis on IOC.
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Affiliation(s)
- Jason G Bill
- Division of Gastroenterology, Washington University School of Medicine, St Louis, Missouri, USA
| | - Vladimir M Kushnir
- Division of Gastroenterology, Washington University School of Medicine, St Louis, Missouri, USA
| | - Daniel K Mullady
- Division of Gastroenterology, Washington University School of Medicine, St Louis, Missouri, USA
| | - Faris M Murad
- Division of Gastroenterology, Washington University School of Medicine, St Louis, Missouri, USA
| | - Riad R Azar
- Division of Gastroenterology, Washington University School of Medicine, St Louis, Missouri, USA
| | - Jeffery J Easler
- Division of Gastroenterology, Washington University School of Medicine, St Louis, Missouri, USA
| | - Dayna S Early
- Division of Gastroenterology, Washington University School of Medicine, St Louis, Missouri, USA
| | - Steven A Edmundowicz
- Division of Gastroenterology, Washington University School of Medicine, St Louis, Missouri, USA
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20
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da Costa DW, Schepers NJ, Römkens TEH, Boerma D, Bruno MJ, Bakker OJ. Endoscopic sphincterotomy and cholecystectomy in acute biliary pancreatitis. Surgeon 2015; 14:99-108. [PMID: 26542765 DOI: 10.1016/j.surge.2015.10.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2015] [Revised: 10/05/2015] [Accepted: 10/06/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND This review discusses current insights with regard to biliary tract management during and after acute biliary pancreatitis. METHODS A MEDLINE and EMBASE search was done and studies were selected based on methodological quality and publication date. The recommendations of recent guidelines are incorporated in this review. In absence of consensus in the literature, expert opinion is expressed. RESULTS There is no role for early endoscopic retrograde cholangiopancreatography (ERCP) in patients with (predicted) mild biliary pancreatitis to improve outcome. In case of persisting choledocholithiasis, ERCP with stone extraction is scheduled electively when the acute event has subsided. Whether early ERCP with sphincterotomy is beneficial in patients with predicted severe pancreatitis remains subject to debate. Regardless of disease severity, in case of concomitant cholangitis urgent endoscopic sphincterotomy (ES) is recommended. As a definitive treatment to reduce the risk of recurrent biliary events in the long term, ES is inferior to cholecystectomy and should be reserved for patients considered unfit for surgery. After severe biliary pancreatitis, cholecystectomy should be postponed until all signs of inflammation have subsided. In patients with mild pancreatitis, cholecystectomy during the primary admission reduces the risk of recurrent biliary complications. CONCLUSION Recent research has provided valuable data to guide biliary tract management in the setting of acute biliary pancreatitis with great value and benefit for patients and clinicians. Some important clinical dilemmas remain, but it is anticipated that on-going clinical trials will deliver some important insights and additional guidance soon.
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Affiliation(s)
- D W da Costa
- Department of Surgery, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - N J Schepers
- Department of Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam, The Netherlands; Department of Gastroenterology and Hepatology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - T E H Römkens
- Department of Gastroenterology and Hepatology, Jeroen Bosch Hospital, 's-Hertogenbosch, The Netherlands
| | - D Boerma
- Department of Surgery, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - M J Bruno
- Department of Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - O J Bakker
- Department of Surgery, University Medical Center, Utrecht, The Netherlands.
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Eskander MF, Bliss LA, Yousafzai OK, de Geus SWL, Ng SC, Callery MP, Kent TS, Moser AJ, Khwaja K, Tseng JF. A nationwide assessment of outcomes after bile duct reconstruction. HPB (Oxford) 2015; 17:753-62. [PMID: 26096061 PMCID: PMC4557648 DOI: 10.1111/hpb.12436] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2015] [Accepted: 05/01/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND Bile duct reconstruction (BDR) is used to manage benign and malignant neoplasms, congenital anomalies, bile duct injuries and other non-malignant diseases. BDR outcomes overall, by year, and by indication were compared. METHODS Retrospective analysis of Nationwide Inpatient Sample discharges (2004-2011) including ICD-9 codes for BDR. All statistical testing was performed using survey weighting. Univariate analysis of admission characteristics by chi square testing. Multivariate modelling for inpatient complications and inpatient death by logistic regression. RESULTS Identified 67 160 weighted patient admissions: 2.5% congenital anomaly, 37.4% malignant neoplasm, 2.3% benign neoplasm, 9.9% biliary injury, 47.9% other non-malignant disease. Most BDRs were performed in teaching hospitals (69.6%) but only 25% at centres with a BDR volume more than 35/year. 32.3% involved ≥ 1 complication, and 84.7% were discharges home. There was a 4.2% inpatient death rate. The complication rate increased but the inpatient death rate decreased over time. The rates of acute renal failure increased. Significant multivariate predictors of inpatient death include indication of biliary injury or malignancy, and predictors of any complication include public insurance and non-elective admission. CONCLUSION This is the first national description of BDRs using a large database. In this diverse sampling, both procedure indication and patient characteristics influence morbidity and mortality.
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Affiliation(s)
- Mariam F Eskander
- Surgical Outcomes Analysis & Research, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Lindsay A Bliss
- Surgical Outcomes Analysis & Research, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Osman K Yousafzai
- Surgical Outcomes Analysis & Research, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Susanna W L de Geus
- Surgical Outcomes Analysis & Research, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Sing Chau Ng
- Surgical Outcomes Analysis & Research, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Mark P Callery
- Surgical Outcomes Analysis & Research, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Tara S Kent
- Surgical Outcomes Analysis & Research, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - A James Moser
- Surgical Outcomes Analysis & Research, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Khalid Khwaja
- Surgical Outcomes Analysis & Research, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Jennifer F Tseng
- Surgical Outcomes Analysis & Research, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
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Agresta F, Campanile FC, Vettoretto N, Silecchia G, Bergamini C, Maida P, Lombari P, Narilli P, Marchi D, Carrara A, Esposito MG, Fiume S, Miranda G, Barlera S, Davoli M. Laparoscopic cholecystectomy: consensus conference-based guidelines. Langenbecks Arch Surg 2015; 400:429-53. [PMID: 25850631 DOI: 10.1007/s00423-015-1300-4] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2015] [Accepted: 03/24/2015] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Laparoscopic cholecystectomy (LC) is the gold standard technique for gallbladder diseases in both acute and elective surgery. Nevertheless, reports from national surveys still seem to represent some doubts regarding its diffusion. There is neither a wide consensus on its indications nor on its possible related morbidity. On the other hand, more than 25 years have passed since the introduction of LC, and we have all witnessed the exponential growth of knowledge, skill and technology that has followed it. In 1995, the EAES published its consensus statement on laparoscopic cholecystectomy in which seven main questions were answered, according to the available evidence. During the following 20 years, there have been several additional guidelines on LC, mainly focused on some particular aspect, such as emergency or concomitant biliary tract surgery. METHODS In 2012, several Italian surgical societies decided to revisit the clinical recommendations for the role of laparoscopy in the treatment of gallbladder diseases in adults, to update and supplement the existing guidelines with recommendations that reflect what is known and what constitutes good practice concerning LC.
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Affiliation(s)
- Ferdinando Agresta
- Department of Surgery, Presidio Ospedaliero di Adria (RO), Adria, RO, Italy,
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Costi R, Gnocchi A, Di Mario F, Sarli L. Diagnosis and management of choledocholithiasis in the golden age of imaging, endoscopy and laparoscopy. World J Gastroenterol 2014; 20:13382-13401. [PMID: 25309071 PMCID: PMC4188892 DOI: 10.3748/wjg.v20.i37.13382] [Citation(s) in RCA: 83] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2014] [Revised: 03/23/2014] [Accepted: 05/29/2014] [Indexed: 02/06/2023] Open
Abstract
Biliary lithiasis is an endemic condition in both Western and Eastern countries, in some studies affecting 20% of the general population. In up to 20% of cases, gallbladder stones are associated with common bile duct stones (CBDS), which are asymptomatic in up to one half of cases. Despite the wide variety of examinations and techniques available nowadays, two main open issues remain without a clear answer: how to cost-effectively diagnose CBDS and, when they are finally found, how to deal with them. CBDS diagnosis and management has radically changed over the last 30 years, following the dramatic diffusion of imaging, including endoscopic ultrasound (EUS) and magnetic resonance cholangiography (MRC), endoscopy and laparoscopy. Since accuracy, invasiveness, potential therapeutic use and cost-effectiveness of imaging techniques used to identify CBDS increase together in a parallel way, the concept of “risk of carrying CBDS” has become pivotal to identifying the most appropriate management of a specific patient in order to avoid the risk of “under-studying” by poor diagnostic work up or “over-studying” by excessively invasive examinations. The risk of carrying CBDS is deduced by symptoms, liver/pancreas serology and ultrasound. “Low risk” patients do not require further examination before laparoscopic cholecystectomy. Two main “philosophical approaches” face each other for patients with an “intermediate to high risk” of carrying CBDS: on one hand, the “laparoscopy-first” approach, which mainly relies on intraoperative cholangiography for diagnosis and laparoscopic common bile duct exploration for treatment, and, on the other hand, the “endoscopy-first” attitude, variously referring to MRC, EUS and/or endoscopic retrograde cholangiography for diagnosis and endoscopic sphincterotomy for management. Concerning CBDS diagnosis, intraoperative cholangiography, EUS and MRC are reported to have similar results. Regarding management, the recent literature seems to show better short and long term outcome of surgery in terms of retained stones and need for further procedures. Nevertheless, open surgery is invasive, whereas the laparoscopic common bile duct clearance is time consuming, technically demanding and involves dedicated instruments. Thus, although no consensus has been achieved and CBDS management seems more conditioned by the availability of instrumentation, personnel and skills than cost-effectiveness, endoscopic treatment is largely preferred worldwide.
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Osayi SN, Wendling MR, Drosdeck JM, Chaudhry UI, Perry KA, Noria SF, Mikami DJ, Needleman BJ, Muscarella P, Abdel-Rasoul M, Renton DB, Melvin WS, Hazey JW, Narula VK. Near-infrared fluorescent cholangiography facilitates identification of biliary anatomy during laparoscopic cholecystectomy. Surg Endosc 2014; 29:368-75. [PMID: 24986018 DOI: 10.1007/s00464-014-3677-5] [Citation(s) in RCA: 101] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2014] [Accepted: 06/09/2014] [Indexed: 12/17/2022]
Abstract
BACKGROUND Intraoperative cholangiography (IOC) is the current gold standard for biliary imaging during laparoscopic cholecystectomy (LC). However, utilization of IOC remains low. Near-infrared fluorescence cholangiography (NIRF-C) is a novel, noninvasive method for real-time, intraoperative biliary mapping. Our aims were to assess the safety and efficacy of NIRF-C for identification of biliary anatomy during LC. METHODS Patients were administered indocyanine green (ICG) prior to surgery. NIRF-C was used to identify extrahepatic biliary structures before and after partial and complete dissection of Calot's triangle. Routine IOC was performed in each case. Identification of biliary structures using NIRF-C and IOC, and time required to complete each procedure were collected. RESULTS Eighty-two patients underwent elective LC with NIRF-C and IOC. Mean age and body mass index (BMI) were 42.6 ± 13.7 years and 31.5 ± 8.2 kg/m(2), respectively. ICG was administered 73.8 ± 26.4 min prior to incision. NIRF-C was significantly faster than IOC (1.9 ± 1.7 vs. 11.8 ± 5.3 min, p < 0.001). IOC was unobtainable in 20 (24.4 %) patients while NIRF-C did not visualize biliary structures in 4 (4.9 %) patients. After complete dissection, the rates of visualization of the cystic duct, common bile duct, and common hepatic duct using NIRF-C were 95.1, 76.8, and 69.5 %, respectively, compared to 72.0, 75.6, and 74.3 % for IOC. In 20 patients where IOC could not be obtained, NIRF-C successfully identified biliary structures in 80 % of the cases. Higher BMI was not a deterrent to visualization of anatomy with NIRF-C. No adverse events were observed with NIRF-C. CONCLUSIONS NIRF-C is a safe and effective alternative to IOC for imaging extrahepatic biliary structures during LC. This technique should be evaluated further under a variety of acute and chronic gallbladder inflammatory conditions to determine its usefulness in biliary ductal identification.
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Affiliation(s)
- Sylvester N Osayi
- Division of General and Gastrointestinal Surgery, Center for Minimally Invasive Surgery, The Ohio State University Wexner Medical Center, 558 Doan Hall, 410 West 10th Avenue, Columbus, OH, 43210, USA
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Cost analysis and effectiveness comparing the routine use of intraoperative fluorescent cholangiography with fluoroscopic cholangiogram in patients undergoing laparoscopic cholecystectomy. Surg Endosc 2014; 28:1838-43. [PMID: 24414461 DOI: 10.1007/s00464-013-3394-5] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2013] [Accepted: 12/13/2013] [Indexed: 12/19/2022]
Abstract
BACKGROUND Despite the standardization of laparoscopic cholecystectomy (LC), the rate of bile duct injury (BDI) has risen from 0.2 to 0.5%. Routine use of intraoperative cholangiography (IOC) has not been widely accepted because of its cost and a lack of evidence concerning its use in preventing BDI. Fluorescent cholangiography (FC), which has recently been advocated as an alternative to IOC, is a novel intraoperative procedure involving infrared visualization of the biliary structures. This study evaluated costs and effectiveness of routinely implemented FC and IOC during LC. MATERIALS AND METHODS Between February and June 2013, the authors prospectively collected the data of all patients undergoing laparoscopic cholecystectomy. We retrospectively reviewed and compared the use of FC and IOC. Procedure time, procedure cost, and effectiveness of the two methods were analyzed and compared. The surgeons involved in the cases completed a survey on the usefulness of each method. RESULTS A total of 43 patients (21 males and 22 females) were analyzed during the study period. Mean age was 49.53 ± 14.35 years and mean body mass index was 28.35 ± 8 kg/m(2). Overall mean operative time was 64.95 ± 17.43 min. FC was faster than IOC (0.71 ± 0.26 vs. 7.15 ± 3.76 min; p < 0.0001). FC was successfully performed in 43 of 43 cases (100%) and IOC in 40 of 43 cases (93.02%). FC was less expensive than IOC (US$14.10 ± 4.31 vs. US$778.43 ± 0.40; p < 0.0001). According to the survey, all surgeons found routine use of FC useful. CONCLUSION In this study, FC was effective in delineating important anatomic structures. It required less time and expense than IOC, and was perceived by the surgeons to be easier to perform, and at least as useful as IOC. Further prospective studies are warranted to evaluate the effectiveness of FC in decreasing BDI.
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