Insufficient safety measures reported in operation notes of complicated laparoscopic cholecystectomies

CRITICAL VIEW OF SAFETY: A PROSPECTIVE SURGICAL AND PHOTOGRAPHIC ANALYSIS IN LAPAROSCOPIC CHOLECYSTECTOMY - DOES IT HELP TO PREVENT IATROGENIC LESIONS?

BACKGROUND

The incidence of biliary duct injuries remains higher in laparoscopic cholecystectomy (LC) in comparison to open surgery. The Critical View of Safety (CVS) was introduced by Strasberg as a strategy for reducing this catastrophic complication. AIM: The aim of this study was to evaluate how often an adequate CVS is achieved during LC, the determining factors for its success, and the associated surgical outcomes.

METHODS

This is a prospective study. CVS photographs of all patients who underwent LC by the same surgeon between 2020 and 2023 were taken. Success in achieving CVS was analyzed by the surgeon herself and posteriorly by hepatobiliary specialists. Patients were classified into two groups: CVS achieved and CVS not achieved. Finally, multivariable logistic regression was used to examine the association between preoperatory factors and surgical complications.

RESULTS

Three hundred and nine consecutive patients were submitted to LC. There were 73.5% elective CL and 26.5% acute cholecystitis. The age ranged from 14 to 87 years, and 76.8% were female. The median body mass index was 26.7. Previous abdominal surgeries were present in 64%, and 26% were obese. The CVS was achieved in 79.9% of the patients, and there were no surgical complications in this group. The factors associated with nonachievement were acute cholecystitis (p=0.007), male sex (p=0.014), and previous surgeries (p=0.021). Three patients needed a subtotal cholecystectomy due to severe inflammation. There was no statistical correlation between the identification of CVS and surgical complications.

CONCLUSIONS

The CVS is achieved in most patients. Acute cholecystitis, male sex, and previous abdominal operations are associated with difficulties in obtaining CVS.

Post-cholecystectomy major bile duct injury: ideal time to repair based on a multicentre randomized controlled trial with promising results

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.

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

INTRODUCTION

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

SAGES safe cholecystectomy modules improve practicing surgeons' judgment: results of a randomized, controlled trial

BACKGROUND

Despite the advantages of laparoscopic cholecystectomy, major bile duct injury (BDI) rates during this operation remain unacceptably high. In October 2018, SAGES released the Safe Cholecystectomy modules, which define specific strategies to minimize the risk of BDI. This study aims to investigate whether this curriculum can change the knowledge and behaviors of surgeons in practice.

METHODS

Practicing surgeons were recruited from the membership of SAGES and the American College of Surgeons Advisory Council for Rural Surgery. All participants completed a baseline assessment (pre-test) that involved interpreting cholangiograms, troubleshooting difficult cases, and managing BDI. Participants' dissection strategies during cholecystectomy were also compared to the strategies of a panel of 15 experts based on accuracy scores using the Think Like a Surgeon validated web-based platform. Participants were then randomized to complete the Safe Cholecystectomy modules (Safe Chole module group) or participate in usually scheduled CME activities (control group). Both groups completed repeat assessments (post-tests) one month after randomization.

RESULTS

Overall, 41 participants were eligible for analysis, including 18 Safe Chole module participants and 23 controls. The two groups had no significant differences in pre-test scores. However, at post-test, Safe Chole module participants made significantly fewer errors managing BDI and interpreting cholangiograms. Safe Chole module participants were less likely to convert to an open operation on the post-test than controls when facing challenging dissections. However, Safe Chole module participants displayed a similar incidence of errors when evaluating adequate critical views of safety.

CONCLUSIONS

In this randomized-controlled trial, the SAGES Safe Cholecystectomy modules improved surgeons' abilities to interpret cholangiograms and safely manage BDI. Additionally, surgeons who studied the modules were less likely to convert to open during difficult dissections. These data show the power of the Safe Cholecystectomy modules to affect practicing surgeons' behaviors in a measurable and meaningful way.

Critical view of safety in laparoscopic cholecystectomy: A prospective investigation from both cognitive and executive aspects

Background

The achievement rate of the critical view of safety during laparoscopic cholecystectomy is much lower than expected. This original study aims to investigate and analyze factors associated with a low critical view of safety achievement.

Materials and Methods

We prospectively collected laparoscopic cholecystectomy videos performed from September 2, 2021, to September 19, 2021, in Sichuan Province, China. The artificial intelligence system, SurgSmart, analyzed videos under the necessary corrections undergone by expert surgeons. Also, we distributed questionnaires to surgeons and analyzed them along with surgical videos simultaneously.

Results

We collected 169 laparoscopic cholecystectomy surgical videos undergone by 124 surgeons, among which 105 participants gave valid answers to the questionnaire. Excluding those who conducted the bail-out process directly, the overall critical view of safety achievement rates for non-inflammatory and inflammatory groups were 18.18% (18/99) and 9.84% (6/61), respectively. Although 80.95% (85/105) of the surgeons understood the basic concept of the critical view of safety, only 4.76% (5/105) of the respondents commanded all three criteria in an error-free way. Multivariate logistic regression results showed that an unconventional surgical workflow (OR:12.372, P &lt; 0.001), a misunderstanding of the 2nd (OR: 8.917, P &lt; 0.05) and 3rd (OR:8.206, P &lt; 0.05) criterion of the critical view of safety, and the don't mistake “fundus-first technique” as one criterion of the critical view of safety (OR:0.123, P &lt; 0.01) were associated with lower and higher achievements of the critical view of safety, respectively.

Conclusions

The execution and cognition of the critical view of safety are deficient, especially the latter one. Thus, increasing the critical view of safety surgical awareness may effectively improve its achievement rate.

It's time for a minimum synoptic operation template in patients undergoing laparoscopic cholecystectomy: a systematic review

BACKGROUND

Despite the call to enhance accuracy and value of operation records few international recommended minimal standards for operative notes documentation have been described. This study undertook a systematic review of existing operative reporting systems for laparoscopic cholecystectomy (LC) to fashion a comprehensive, synoptic operative reporting template for the future.

METHODS

A search for all relevant articles was conducted using PubMed version of Medline, Scopus and Web of Science databases in June 2021, for publications from January 1st 2011 to October 25th 2021, using the keywords: laparoscopic cholecystectomy AND operation notes OR operative notes OR proforma OR documentation OR report OR narrative OR audio-visual OR synoptic OR digital. Two reviewers (NOC, GMC) independently assessed each published study using a MINORS score of ≥ 16 for comparative and ≥ 10 for non-comparative for inclusion. This systematic review followed PRISMA guidelines and was registered with PROSPERO. Synoptic operative templates from published data were assimilated into one "ideal" laparoscopic operative report template following international input from the World Society of Emergency Surgery board.

RESULTS

A total of 3567 articles were reviewed. Following MINORS grading 25 studies were selected spanning 14 countries and 4 continents. Twenty-two studies were prospective. A holistic overview of the operative procedure documentation was reported in 6/25 studies and a further 19 papers dealt with selective surgical aspects of LC. A unique synoptic LC operative reporting template was developed and translated into Chinese/Mandarin, French and Arabic.

CONCLUSION

This systematic review identified a paucity of publications dealing with operative reporting of LC. The proposed new template may be integrated digitally with hospitals' medical systems and include additional narrative text and audio-visual data. The template may help define new OR (operating room) recording standards and impact on care for patients undergoing LC.

The critical view of safety during laparoscopic cholecystectomy: Strasberg Yes or No? An Italian Multicentre study

BACKGROUND

Laparoscopic cholecystectomy is considered the gold standard for the treatment of gallbladder lithiasis; nevertheless, the incidence of bile duct injuries (BDI) is still high (0.3-0.8%) compared to open cholecystectomy (0.2%). In 1995, Strasberg introduced the "Critical View of Safety" (CVS) to reduce the risk of BDI. Despite its widespread use, the scientific evidence supporting this technique to prevent BDI is controversial.

METHODS

Between March 2017 and March 2019, the data of patients submitted to laparoscopic cholecystectomy in 30 Italian surgical departments were collected on a national database. A survey was submitted to all members of Italian Digestive Pathology Society to obtain data on the preoperative workup, the surgical and postoperative management of patients and to judge, at the end of the procedure, if the isolation of the elements was performed according to the CVS. In the case of a declared critical view, iconographic documentation was obtained, finally reviewed by an external auditor.

RESULTS

Data from 604 patients were analysed. The study population was divided into two groups according to the evidence (Group A; n = 11) or absence (Group B; N = 593) of BDI and perioperative bleeding. The non-use of CVS was found in 54.6% of procedures in the Group A, and 25.8% in the Group B, and evaluating the operator-related variables the execution of CVS was associated with a significantly lower incidence of BDI and intraoperative bleeding.

CONCLUSIONS

The CVS confirmed to be the safest technique to recognize the elements of the Calot triangle and, if correctly performed, it significantly impacted on preventing intraoperative complications. Additional educational programs on the correct application of CVS in clinical practice would be desirable to avoid extreme conditions that may require additional procedures.

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

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

Knowledge of the Culture of Safety in Cholecystectomy (COSIC) Among Surgical Residents: Do We Train Them Well For Future Practice?

BACKGROUND

Biliary injury is the most feared complication of laparoscopic cholecystectomy (LC). This study aimed to assess the awareness of culture of safety in cholecystectomy (COSIC) concept among the surgical residents in India.

METHODS

A manual survey was conducted among general surgery residents attending a postgraduate course. Survey consisted of questions pertaining to knowledge of various aspects of COSIC, e.g., the critical view of safety (CVS).

RESULTS

With a response rate of 51%, 259 residents were included in this study. They had more exposure to LC (63.3% assisted / performed > 15 LC) than to open cholecystectomy (60.6% assisted / performed ≤ 10 open cholecystectomy). The majority (80.2%) clearly differentiated Calot triangle from the hepatocystic triangle (HCT). However, 25.8% could not correctly define HCT. The majority (88.5%) had seen the Rouviere's sulcus during LC. While almost all (98.4%) respondents claimed to know about the segment 4, only 41.9% could correctly describe it. Awareness of the correct direction of the gallbladder retraction was lower for the infundibulum (53.5%) than for fundus (89.2%). The majority (88.3%) claimed to know CVS but only 11.5% knew it correctly, and 15.1% described > 3 components. The majority (78.7%) practiced to identify the cystic duct-common bile duct junction. Awareness was low for time-out (28.1%), intraoperative cholangiography (20.6%), bailout techniques (18.9%), and for overall COSIC concept (15.7%).

CONCLUSIONS

Knowledge of COSIC among surgical residents seems to be suboptimal, especially for the CVS, time-out, bailout techniques, and overall concept of COSIC. Strategies to educate them more effectively about COSIC are highly imperative to train them well for future practice.

The “critical view of safety (CVS)” cannot be applied—What to do? Strategies to avoid bile duct injuries

Laparoscopic cholecystectomy has become the standard procedure worldwide since the early 1990s for those patients whose gallbladder has to be removed as part of their underlying disease (NIH Consensus Statement 1992). The most common complication is iatrogenic bile duct injury, which has not improved significantly since the introduction of open laparoscopic cholecystectomy as compared with open cholecystectomy. The intraoperative injuries are mostly the result of a misinterpretation of anatomical structures due to severe inflammation or topographical variations. In order to minimize this risk, a number of improved operative techniques and behavioral measures have been formulated. Here, we present methodological and operative possibilities as well as techniques that in unclear situations can help to minimize the risk of intraoperative injuries of the biliary tract and the accompanying vascular system.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Routine near infra-red indocyanine green fluorescent cholangiography versus intraoperative cholangiography during laparoscopic cholecystectomy: a case-matched comparison

BACKGROUND

The aim is to evaluate safety and efficacy of near infra-red (NIR) indocyanine green (ICG) fluorescence structural imaging during laparoscopic cholecystectomy (LC) (Group A) and to compare perioperative data, including operative time, with a series of patients who underwent LC with routine traditional intraoperative cholangiography (IOC) (Group B).

METHODS

Forty-four patients with acute or chronic cholecystitis underwent NIR-ICG fluorescent cholangiography during LC. ICG was administered intravenously at different time intervals or by direct gallbladder injection during surgery. Fluorescence intensity and anatomy identification were scored according to a visual analogue scale between 1 (least accurate) and 5 (most accurate). Group B patients (n = 44) were chosen from a prospectively maintained database of patients who underwent LC with routine IOC, matched for age, sex, body mass index, and diagnosis with group A patients.

RESULTS

No adverse reactions were recorded. In group A, mean time between intravenous administration of ICG and surgery was 10.7 ± 8.2 (range 2-52) h. Administered doses ranged from 3.5 to 13.5 mg. Fluorescence was present in all cases, scoring ≥ 3 in 41 patients. Mean operative time was 86.9 ± 36.9 (30-180) min in group A and 117.9 ± 43.4 (40-220) min in group B (p = 0.0006). No conversion to open surgery nor bile duct injuries were observed in either group.

CONCLUSIONS

LC with NIR-ICG fluorescent cholangiography is safe and effective for early recognition of anatomical landmarks, reducing operative time as compared to LC with IOC, even when residents were the main operator. NIR-ICG fluorescent cholangiography was effective in patients with acute cholecystitis and in the obese. Data collection into large registries on the results of NIR-ICG fluorescent cholangiography during LC should be encouraged to establish whether this technique might set a new safety standard for LC.

Outcome trends and safety measures after 30 years of laparoscopic cholecystectomy: a systematic review and pooled data analysis

BACKGROUND

Laparoscopic cholecystectomy (LC), one of the most commonly performed surgical procedures, remains associated with significant major morbidity including bile leak and bile duct injury (BDI). The effect of changes in practice over time, and of interventions to improve patient safety, on morbidity rates is not well understood. The aim of this review was to describe current incidence rates and trends for BDI and other complications during and after LC, and to identify risk factors and preventative measures associated with morbidity and BDI.

METHODS

PubMed, MEDLINE, and Web of Science database searches and data extraction were conducted for studies which reported individual complications and complication rates following laparoscopic cholecystectomy in a representative population. Outcomes data were pooled. Meta-regression analysis was performed to assess factors associated with conversion, morbidity, and BDI rates.

RESULTS

One hundred and fifty-one studies reporting outcomes for 505,292 patients were included in the final quantitative synthesis. Overall morbidity, BDI, and mortality rates were 1.6-5.3%, 0.32-0.52%, and 0.08-0.14%, respectively. Reported BDI rates reduced over time (1994-1999: 0.69(0.52-0.84)% versus 2010-2015 0.22(0.02-0.40)%, p = 0.011). Meta-regression analysis suggested higher conversion rates in developed versus developing countries (4.7 vs. 3.4%), though a greater degree of reporting bias was present in these studies, with no other significant associations identified.

CONCLUSIONS

Overall, trends suggest a reduction in BDI over time with unchanged morbidity and mortality rates. However, data and reporting are heterogenous. Establishment of international outcomes registries should be considered.

IRCAD recommendation on safe laparoscopic cholecystectomy

An expert recommendation conference was conducted to identify factors associated with adverse events during laparoscopic cholecystectomy (LC) with the goal of deriving expert recommendations for the reduction of biliary and vascular injury. Nineteen hepato-pancreato-biliary (HPB) surgeons from high-volume surgery centers in six countries comprised the Research Institute Against Cancer of the Digestive System (IRCAD) Recommendations Group. Systematic search of PubMed, Cochrane, and Embase was conducted. Using nominal group technique, structured group meetings were held to identify key items for safer LC. Consensus was achieved when 80% of respondents ranked an item as 1 or 2 (Likert scale 1-4). Seventy-one IRCAD HPB course participants assessed the expert recommendations which were compared to responses of 37 general surgery course participants. The IRCAD recommendations were structured in seven statements. The key topics included exposure of the operative field, appropriate use of energy device and establishment of the critical view of safety (CVS), systematic preoperative imaging, cholangiogram and alternative techniques, role of partial and dome-down (fundus-first) cholecystectomy. Highest consensus was achieved on the importance of the CVS as well as dome-down technique and partial cholecystectomy as alternative techniques. The put forward IRCAD recommendations may help to promote safe surgical practice of LC and initiate specific training to avoid adverse events.

Short- and Long-Term Outcomes after a Reconstituting and Fenestrating Subtotal Cholecystectomy

BACKGROUND

Multiple surgical techniques are recommended to perform cholecystectomy safely in difficult cases, such as conversion to open operation or subtotal cholecystectomy (STC). Reconstituting and fenestrating STC are 2 techniques for STC. The aim of this study was to investigate the short and long-term morbidity and quality of life associated with STC and to compare the outcomes after reconstituting and fenestrating STC.

STUDY DESIGN

Patients who underwent STC were identified. Short-term morbidity assessed included bile leakage, bile duct injury, intra-abdominal infection, reinterventions, and readmittance. Long-term morbidity included bile duct stenosis and recurrent biliary events. Differences in the outcomes of fenestrating and reconstituting STC were assessed. Quality of life was assessed by EuroQol 5 Dimensions, Short-Form 36 Questionnaire, and Gastrointestinal Quality of Life Index questionnaires.

RESULTS

Subtotal cholecystectomy was performed in 191 patients, of which 102 (53%) underwent fenestrating STC and 73 (38%) underwent reconstituting STC. Bile leakage was significantly more common after fenestrating STC (18% vs 7%, respectively; p < 0.022). After a median of 6 years follow-up (interquartile range 5 to 10 years), recurrence rate of biliary events was lower after fenestrating than reconstituting STC (9% vs 18%, respectively; p < 0.022). Overall reintervention rate did not differ between the 2 groups: 32% in the fenestrating STC group and 26% in the reconstituting STC group (p = 0.211). Completion cholecystectomy was performed significantly more in patients after fenestrating STC (9% vs 4%; p < 0.022).

CONCLUSIONS

Subtotal cholecystectomy is a safe and feasible technique for difficult cases for which conversion only will not solve the difficulty of an inflamed hepatocystic triangle. The choice for reconstituting or fenestrating STC depends on intraoperative conditions and both techniques are associated with specific complications.

Timing of Surgical Repair After Bile Duct Injury Impacts Postoperative Complications but Not Anastomotic Patency

OBJECTIVE

Our goal was to determine the optimal timing for repair of bile duct injuries sustained during cholecystectomy.

BACKGROUND

Bile duct injury during cholecystectomy is a serious complication that often requires surgical repair. There is heterogeneity in the literature regarding the optimal timing of surgical repair, and it remains unclear to what extent timing determines postoperative morbidity and long-term anastomotic function.

METHODS

A single institution prospective database was queried for all E1 to E4 injuries from 1989 to 2014 using a standardized tabular reporting format. Timing was stratified into 3 groups [early (<7 days), intermediate (8 days until 6 weeks), and late (>6 weeks) after injury]. Analysis was stratified between those who had a previous bile duct repair or not, including postoperative complications and anastomotic failure as outcome variables in 2 separate multivariate logistic regression models.

RESULTS

There were 614 patients included in the study. The mean age was 41 years (range, 15-85 yrs), and the majority were female (80%). The mean follow-up time was 40.5 months. Side-to-side hepaticojejunostomy was performed in 94% of repairs. Intermediate repair was associated with a higher risk of postoperative complications [odd ratio = 3.7, 95% confidence interval (1.3-10.2), P = 0.01] when compared with early and late in those with a previous repair attempt. Sepsis control and avoidance of biliary stents were protective factors against anastomotic failure.

CONCLUSIONS

Adequate sepsis control and delayed repair of biliary injuries should be considered for patients presenting between 8 days and 6 weeks after injury to prevent complications, if a previous bile duct repair was attempted.

Improving Critical View of Safety in Laparoscopic Cholecystectomy by Teaching Interventions

BACKGROUND

Guidelines recommend obtaining a critical view of safety (CVS) during laparoscopic cholecystectomies to prevent serious bile duct injuries. We sought to evaluate the results of a teaching intervention for surgeons and residents about achieving CVS.

METHODS

The intervention consisted of a lecture followed by a handout on CVS along with a teaching video on how to perform a laparoscopic cholecystectomy and common pitfalls encountered. After 9 months, the whole intervention was repeated. We retrospectively collected demographic data, details about the procedure, and complications for 316 consecutive patients who underwent laparoscopic cholecystectomy and reviewed available videos of laparoscopic cholecystectomy for 229 of these patients. Videos before and after the teaching interventions were reviewed by 2 gastrointestinal surgeons regarding whether CVS was reached, and Kappa statistics were calculated to measure inter-rater agreement.

RESULTS

Most patients (average age 51 years) underwent laparoscopic cholecystectomy for symptomatic cholelithiasis (n = 171, 75%). CVS was reached in 69% of the preteaching intervention patients (n = 54), in 73% after the first teaching intervention (n = 75) and in 82% after the second intervention (n = 100) (not significant, overall p = 0.070). The complication rates were 24% (n = 13) before the intervention, 19% (n = 14) after the first teaching intervention, and 17% (n = 17) after the second intervention (not significant). In these groups, 1, 3, and 5 cases, correspondingly, with biliary injury were identified. All but 1 complication was related to a type A biliary injury.

CONCLUSION

After the teaching interventions, the complication rate and the rate of reaching CVS did not improve significantly. To improve surgeons' success in reaching CVS, more personal interventions may be more effective than the group intervention we used in this study. The next step may be to present surgeons and residents who have a low CVS rate directly with their personal results.

Laparoscopy in cholecysto-choledocholithiasis

Gallstone disease is one of the most common problems in the gastroenterology and is associated with significant morbidity. It may present as stones in the gallbladder (cholecystolithiasis) or in the common bile duct (choledocholithiasis). At the end of the 1980s laparoscopy was introduced and first laparoscopic cholecystectomy was performed in 1985. The laparoscopic technique for removing the gallbladder is the current treatment of choice, although indications for open surgery exist. To perform laparoscopic cholecystectomy as safe as possible multiple safety measures were developed. The gold standard for diagnosing and removing common bile duct stones is Endoscopic Retrograde Cholangiopancreatography (ERCP). The surgical treatment option for choledocholithiasis is laparoscopic cholecystectomy with common bile duct exploration. If experience is not available, than ERCP followed by elective cholecystectomy is by far the best therapeutic modality. The present review will discuss the use, benefits and drawbacks of laparoscopy in patients with cholecystolithiasis and choledocholithiasis.