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Omar MA, Kamal A, Redwan AA, Alansary MN, Ahmed EA. Post-cholecystectomy major bile duct injury: ideal time to repair based on a multicentre randomized controlled trial with promising results. Int J Surg 2023; 109:1208-1221. [PMID: 37072143 PMCID: PMC10389623 DOI: 10.1097/js9.0000000000000403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Accepted: 04/06/2023] [Indexed: 04/20/2023]
Abstract
BACKGROUND Bile duct injury (BDI) is one of the serious complications of cholecystectomy procedures, which has a disastrous impact on long-term survival, health-related quality of life (QoL), healthcare costs as well as high rates of litigation. The standard treatment of major BDI is hepaticojejunostomy (HJ). Surgical outcomes depend on many factors, including the severity of the injury, the surgeons' experiences, the patient's condition, and the reconstruction time. The authors aimed to assess the impact of reconstruction time and abdominal sepsis control on the reconstruction success rate. METHODS This is a multicenter, multi-arm, parallel-group, randomized trial that included all consecutive patients treated with HJ for major post-cholecystectomy BDI from February 2014 to January 2022. Patients were randomized according to the time of reconstruction by HJ and abdominal sepsis control into group A (early reconstruction without sepsis control), group B (early reconstruction with sepsis control), and group C (delayed reconstruction). The primary outcome was successful reconstruction rate, while blood loss, HJ diameter, operative time, drainage amount, drain and stent duration, postoperative liver function tests, morbidity and mortality, number of admissions and interventions, hospital stay, total cost, and patient QoL were considered secondary outcomes. RESULTS Three hundred twenty one patients from three centres were randomized into three groups. Forty-four patients were excluded from the analysis, leaving 277 patients for intention to treat analysis. With univariate analysis, older age, male gender, laparoscopic cholecystectomy, conversion to open cholecystectomy, failure of intraoperative BDI recognition, Strasberg E4 classification, uncontrolled abdominal sepsis, secondary repair, end-to-side anastomosis, diameter of HJ (< 8 mm), non-stented anastomosis, and major complications were risk factors for successful reconstruction. With multivariate analysis, conversion to open cholecystectomy, uncontrolled sepsis, secondary repair, the small diameter of HJ, and non-stented anastomosis were the independent risk factors for the successful reconstruction. Also, group B patients showed decreased admission and intervention rates, decreased hospital stay, decreased total cost, and early improved patient QoL. CONCLUSION Early reconstruction after abdominal sepsis control can be done safely at any time with comparable results for delayed reconstruction in addition to decreased total cost and improved patient QoL.
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Affiliation(s)
| | - Ayman Kamal
- Anesthesia and Intensive Care, South Valley University, Qena
| | - Alaa A. Redwan
- Department of General Surgery, Helwan University, Helwan
| | | | - Emad Ali Ahmed
- Department of General Surgery, Helwan University, Helwan
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Halle-Smith JM, Hodson J, Stevens LG, Dasari B, Marudanayagam R, Perera T, Sutcliffe RP, Muiesan P, Isaac J, Mirza DF, Roberts KJ. A comprehensive evaluation of the long-term clinical and economic impact of minor bile duct injury. Surgery 2020; 167:942-949. [PMID: 32183995 DOI: 10.1016/j.surg.2020.01.022] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Revised: 01/24/2020] [Accepted: 01/31/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND Outcomes after Strasberg grade E bile duct injury have been widely reported. However, there are comparatively few reports of outcomes after Strasberg A to D bile duct injury. Therefore, the aim of this study was to comprehensively evaluate the long-term clinical and economic impact of Strasberg A to D bile duct injury. METHODS Patients with Strasberg A to D bile duct injury were identified from a prospectively collected and maintained database. Long-term biliary complication rates, as well as treatment costs were then estimated, and compared across Strasberg injury grades. RESULTS A total of N = 120 patients were identified, of whom N = 49, 13, 20, and 38 had Strasberg grade A, B, C, and D bile duct injury, respectively. Surgical repair was most commonly performed in Strasberg grade D injuries (74% vs 8%-20% in lower grades, P < .001). By 5 years post bile duct injury, the estimated long-term biliary complication rate was 40% in Strasberg grade D injuries, compared with 15% in Strasberg grade A (P = .022). A significant difference in total treatment and follow-up costs was also detected (P < .001), being highest in Strasberg grade D injuries (mean £11,048/US$14,252 per patient) followed by the Strasberg grade B group (mean £10,612/US$13,689 per patient). DISCUSSION Strasberg grade A to D injuries lead to considerable long-term morbidity and cost. Strasberg grade D injuries are typically managed surgically and result in the highest complication rate and treatment costs. Strasberg grade B injuries lead to a similar complication rate and treatment cost but are often managed without surgery.
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Affiliation(s)
- James M Halle-Smith
- Hepatobiliary and Pancreatic Surgery Unit, University Hospitals Birmingham, Birmingham, United Kingdom
| | - James Hodson
- Institute of Translational Medicine, University Hospitals Birmingham, Birmingham, United Kingdom
| | - Lewis G Stevens
- Hepatobiliary and Pancreatic Surgery Unit, University Hospitals Birmingham, Birmingham, United Kingdom
| | - Bobby Dasari
- Hepatobiliary and Pancreatic Surgery Unit, University Hospitals Birmingham, Birmingham, United Kingdom
| | - Ravi Marudanayagam
- Hepatobiliary and Pancreatic Surgery Unit, University Hospitals Birmingham, Birmingham, United Kingdom
| | - Thamara Perera
- Hepatobiliary and Pancreatic Surgery Unit, University Hospitals Birmingham, Birmingham, United Kingdom
| | - Robert P Sutcliffe
- Hepatobiliary and Pancreatic Surgery Unit, University Hospitals Birmingham, Birmingham, United Kingdom
| | - Paolo Muiesan
- Hepatobiliary and Pancreatic Surgery Unit, University Hospitals Birmingham, Birmingham, United Kingdom
| | - John Isaac
- Hepatobiliary and Pancreatic Surgery Unit, University Hospitals Birmingham, Birmingham, United Kingdom
| | - Darius F Mirza
- Hepatobiliary and Pancreatic Surgery Unit, University Hospitals Birmingham, Birmingham, United Kingdom
| | - Keith J Roberts
- Hepatobiliary and Pancreatic Surgery Unit, University Hospitals Birmingham, Birmingham, United Kingdom.
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Halle-Smith JM, Hodson J, Stevens LG, Dasari B, Marudanayagam R, Perera T, Sutcliffe RP, Muiesan P, Isaac J, Mirza DF, Roberts KJ. A comprehensive evaluation of the long-term economic impact of major bile duct injury. HPB (Oxford) 2019; 21:1312-1321. [PMID: 30862441 DOI: 10.1016/j.hpb.2019.01.018] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Revised: 01/17/2019] [Accepted: 01/31/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Complications and litigation after bile duct injury (BDI) result in clinical and economic burden. The aim of this study was to comprehensively evaluate the long-term clinical and economic impact of major BDI. METHOD Patients with long-term follow-up after Strasberg E BDI were identified. Costs of treatment and litigation were the primary outcome. Relationships between these outcomes and repair factors, like timing of repair and surgeon expertise, were secondary outcomes. RESULTS Among 139 patients with a median follow up of 10.7 years, 40% of patients developed biliary complications. Repairs by non-specialist surgeons had significantly higher follow up and treatment costs than those by specialists (£25,814 vs. £14,269, p < 0.001). Estimated litigation costs were higher in delayed than immediate repairs (£23,295 vs. £12,864). As such, the lowest average costs per BDI are after immediate specialist repair and the highest after delayed non-specialist repair (£27,133 vs. £49,109, ×1.81 more costly, p < 0.001). Repair by a non-specialist surgeon (HR: 4.00, p < 0.001) and vascular injury (HR: 2.35, p = 0.013) were significant independent predictors of increased complication rates. CONCLUSION Costs of major BDI are considerable. They can be reduced by immediate on-table repair by specialist surgeons. This must therefore be considered the standard of care wherever possible.
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Affiliation(s)
- James M Halle-Smith
- Hepatobiliary and Pancreatic Surgery Unit, University Hospitals Birmingham, Birmingham, United Kingdom
| | - James Hodson
- Medical Statistics, University Hospitals Birmingham, Birmingham, United Kingdom
| | - Lewis G Stevens
- Hepatobiliary and Pancreatic Surgery Unit, University Hospitals Birmingham, Birmingham, United Kingdom
| | - Bobby Dasari
- Hepatobiliary and Pancreatic Surgery Unit, University Hospitals Birmingham, Birmingham, United Kingdom
| | - Ravi Marudanayagam
- Hepatobiliary and Pancreatic Surgery Unit, University Hospitals Birmingham, Birmingham, United Kingdom
| | - Thamara Perera
- Hepatobiliary and Pancreatic Surgery Unit, University Hospitals Birmingham, Birmingham, United Kingdom
| | - Robert P Sutcliffe
- Hepatobiliary and Pancreatic Surgery Unit, University Hospitals Birmingham, Birmingham, United Kingdom
| | - Paolo Muiesan
- Hepatobiliary and Pancreatic Surgery Unit, University Hospitals Birmingham, Birmingham, United Kingdom
| | - John Isaac
- Hepatobiliary and Pancreatic Surgery Unit, University Hospitals Birmingham, Birmingham, United Kingdom
| | - Darius F Mirza
- Hepatobiliary and Pancreatic Surgery Unit, University Hospitals Birmingham, Birmingham, United Kingdom
| | - Keith J Roberts
- Hepatobiliary and Pancreatic Surgery Unit, University Hospitals Birmingham, Birmingham, United Kingdom.
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Khadra H, Johnson H, Crowther J, McClaren P, Darden M, Parker G, Buell JF. Bile duct injury repairs: Progressive outcomes in a tertiary referral center. Surgery 2019; 166:698-702. [PMID: 31439402 DOI: 10.1016/j.surg.2019.06.032] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Revised: 05/26/2019] [Accepted: 06/22/2019] [Indexed: 12/27/2022]
Abstract
BACKGROUND Bile duct injury during laparoscopic cholecystectomy persists as a significant problem in general surgery, resulting in complex injuries, arterial damage, and post repair strictures. METHODS We performed a retrospective analysis between 2 eras of bile duct injury repairs: 1987 to 2001 (n = 58) and 2002 to 2016 (n = 52) using logistic regression analyses to assess presentation, repair complexity, and outcomes. RESULTS No differences in demographics, incidence of cholecystitis, conversion, time to presentation, level of injury, or arterial injury were identified. The second era had an increase in patient age, transhepatic catheter use, prior repair, and utilization of complex repairs. This approach resulted in equivalent complications and mortality rates with increased resource utilization but a lesser incidence of post-repair strictures (P = .004). Regression modeling correlated strictures to prior operative repairs (OR 4.25; P = .016) and a protective effect of repairs performed in the second era (OR 0.23; P = .045). CONCLUSION The second era identified a decreasing trend of attempted repairs by referring surgeons but an increase in transhepatic catheters and complex repairs resulting in lesser rates of post-repair stricture. Final regression modeling confirmed increased operative experience decreased post-repair stricture reaffirming the benefits of early identification and referral of bile duct injuries to an experienced hepatobiliary surgeon at a specialty center.
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Affiliation(s)
- Helmi Khadra
- Department of Surgery, Tulane University, New Orleans, LA
| | | | - Jason Crowther
- Department of Surgery, Tulane University, New Orleans, LA
| | - Patrick McClaren
- Department of Surgery, Louisiana State University, New Orleans, LA
| | - Michael Darden
- Carey Business School, Johns Hopkins University, Baltimore, MD
| | - Geoffrey Parker
- Thayer School of Engineering, Dartmouth College, Hanover, NH
| | - Joseph F Buell
- Department of Surgery, Tulane University, New Orleans, LA.
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Surgical management of laparoscopic cholecystectomy (LC) related major bile duct injuries; predictors of short-and long-term outcomes in a tertiary Egyptian center- a retrospective cohort study. ANNALS OF MEDICINE AND SURGERY (2012) 2018. [PMID: 30505442 DOI: 10.1016/j.amsu.2018.11.006.] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Objectives Laparoscopic cholecystectomy - associated bile duct injury is a clinical problem with bad outcome. The study aimed to analyze the outcome of surgical management of these injuries. Patients and methods We retrospectively analyzed 69 patients underwent surgical management of laparoscopic cholecystectomy related major bile duct injuries in the period from the beginning of 2013 to the beginning of 2018. Results Regarding injury type; the Leaking, Obstructing, leaking + obstructing, leaking + vascular, and obstructing + vascular injuries were 43.5%, 27.5%, 18.8%, 2.9%, and 7.2% respectively. However, the Strasberg classification of injury was as follow E1 = 25, E2 = 32, E3 = 8, and E4 = 4. The definitive procedures were as follow: end to end biliary anastomosis with stenting, hepaticojejunostomy (HJ) with or without stenting, and RT hepatectomy plus biliary reconstruction with stenting in 4.3%, 87%, and 8.7% of patients respectively. According to the time of definitive procedure from injury; the immediate (before 72 h), intermediate (between 72 h and 1.5months), and late (after1.5 months) management were 13%, 14.5%, and 72.5% respectively. The hospital and/or 1month (early) morbidity after definitive treatment was 21.7%, while, the late biliary morbidity was 17.4% and the overall mortality was 2.9%, on the other hand, the late biliary morbidity-free survival was 79.7%. On univariate analysis, the following factors were significant predictors of early morbidity; Sepsis at referral, higher Strasberg grade, associated vascular injury, right hepatectomy with biliary reconstruction as a definitive procedure, intra-operative bleeding with blood transfusion, liver cirrhosis, and longer operative times and hospital stays. However, the following factors were significantly associated with late biliary morbidity: Sepsis at referral, end to end anastomosis with stenting, reconstruction without stenting, liver cirrhosis, operative bleeding, and early morbidity. Conclusion Sepsis at referral, liver cirrhosis, and operative bleeding were significantly associated with both early and late morbidities after definitive management of laparoscopic cholecystectomy related major bile duct injuries, so it is crucial to avoid these catastrophes when doing those major procedures.
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Gad EH, Ayoup E, Kamel Y, Zakareya T, Abbasy M, Nada A, Housseni M, Abd-Elsamee MAS. Surgical management of laparoscopic cholecystectomy (LC) related major bile duct injuries; predictors of short-and long-term outcomes in a tertiary Egyptian center- a retrospective cohort study. Ann Med Surg (Lond) 2018; 36:219-230. [PMID: 30505442 PMCID: PMC6251332 DOI: 10.1016/j.amsu.2018.11.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2018] [Revised: 10/30/2018] [Accepted: 11/06/2018] [Indexed: 02/08/2023] Open
Abstract
Objectives Laparoscopic cholecystectomy - associated bile duct injury is a clinical problem with bad outcome. The study aimed to analyze the outcome of surgical management of these injuries. Patients and methods We retrospectively analyzed 69 patients underwent surgical management of laparoscopic cholecystectomy related major bile duct injuries in the period from the beginning of 2013 to the beginning of 2018. Results Regarding injury type; the Leaking, Obstructing, leaking + obstructing, leaking + vascular, and obstructing + vascular injuries were 43.5%, 27.5%, 18.8%, 2.9%, and 7.2% respectively. However, the Strasberg classification of injury was as follow E1 = 25, E2 = 32, E3 = 8, and E4 = 4. The definitive procedures were as follow: end to end biliary anastomosis with stenting, hepaticojejunostomy (HJ) with or without stenting, and RT hepatectomy plus biliary reconstruction with stenting in 4.3%, 87%, and 8.7% of patients respectively. According to the time of definitive procedure from injury; the immediate (before 72 h), intermediate (between 72 h and 1.5months), and late (after1.5 months) management were 13%, 14.5%, and 72.5% respectively. The hospital and/or 1month (early) morbidity after definitive treatment was 21.7%, while, the late biliary morbidity was 17.4% and the overall mortality was 2.9%, on the other hand, the late biliary morbidity-free survival was 79.7%. On univariate analysis, the following factors were significant predictors of early morbidity; Sepsis at referral, higher Strasberg grade, associated vascular injury, right hepatectomy with biliary reconstruction as a definitive procedure, intra-operative bleeding with blood transfusion, liver cirrhosis, and longer operative times and hospital stays. However, the following factors were significantly associated with late biliary morbidity: Sepsis at referral, end to end anastomosis with stenting, reconstruction without stenting, liver cirrhosis, operative bleeding, and early morbidity. Conclusion Sepsis at referral, liver cirrhosis, and operative bleeding were significantly associated with both early and late morbidities after definitive management of laparoscopic cholecystectomy related major bile duct injuries, so it is crucial to avoid these catastrophes when doing those major procedures. Sepsis at referral was associated with poor outcome after management of LC related MBDIs. Liver cirrhosis and operative bleeding were associated with poor outcome after management of these injuries. It is crucial to avoid these catastrophes when doing those major procedures.
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Affiliation(s)
- Emad Hamdy Gad
- Hepatobiliary Surgery, National Liver Institute, Menoufia University, Shebein Elkoum, Egypt
| | - Eslam Ayoup
- Hepatobiliary Surgery, National Liver Institute, Menoufia University, Shebein Elkoum, Egypt
| | - Yasmin Kamel
- Anaesthesia, National Liver Institute, Menoufia University, Shebein Elkoum, Egypt
| | - Talat Zakareya
- Hepatology and Endoscopy, National Liver Institute, Menoufia University, Shebein Elkoum, Egypt
| | - Mohamed Abbasy
- Hepatology and Endoscopy, National Liver Institute, Menoufia University, Shebein Elkoum, Egypt
| | - Ali Nada
- Hepatology and Endoscopy, National Liver Institute, Menoufia University, Shebein Elkoum, Egypt
| | - Mohamed Housseni
- Radioligy, National Liver Institute, Menoufia University, Shebein Elkoum, Egypt
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Is your graduating general surgery resident qualified to take trauma call? A 15-year appraisal of the changes in general surgery education for trauma. J Trauma Acute Care Surg 2017; 82:470-480. [PMID: 28045741 DOI: 10.1097/ta.0000000000001351] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Trauma training in general surgery residency is undergoing an evolution. Hour restrictions, the growth of subspecialty care, and the trend toward nonoperative management have altered resident exposure to operative trauma. We sought to identify trends in resident trauma training since the inception of the 80-hour workweek. METHODS The Accreditation Council for General Medical Education Case Log Statistical Reports for Surgery was abstracted for general surgery resident trauma operative volume for the years 1999-2014. Resident trauma experience (operative caseload [OC]) was compared before inception of the 80-hour workweek (1999-2002) to after the 80-hour workweek began (2003 to current). RESULTS A trend toward decreased operative trauma for general surgery residents was observed (mean OC [before 80-hour workweek vs. 80-hour workweek], 39,252 ± 1,065.2 cases vs. 36,065 ± 1,291.8; p = 0.06). Trauma laparotomies increased (range, 5,446-9,364 cases) with corresponding decreases in vascular trauma (4,704 to 799 cases), neck explorations (1,876 to 1,370 cases), and thoracotomies (2,507 to 2,284 cases). By comparison, an increase in vascular/integrated cases was noted (mean OC [before 80-hour workweek vs. 80-hour workweek], 845 ± 44.2 vs. 1,465 ± 88.4 cases; p < 0.01). Resident deficiencies analyzed by time period (before 80-hour workweek vs. 80-hour workweek) demonstrated deficiencies in thoracic, abdominal, solid organ, and extremity-vascular trauma domains (p < 0.01 for each). Nontrauma cases were also on the decline, specifically in open thoracic, vascular, and solid organ surgery (p < 0.05 for each). Both 1- and 2-year fellowships offset deficiencies in trauma education. CONCLUSIONS Based on the data, an alarming number of graduates complete training with substantially less experience in defined trauma categories. Because of a decline in operative trauma volume, advanced fellowship training should be encouraged specifically for those interested in a career in trauma and acute care surgery.
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