Nationwide quality improvement of cholecystectomy: results from a national database

Variation in the practice of cholecystectomy for benign biliary disease in Aotearoa New Zealand: a population-based cohort study

INTRODUCTION

Cholecystectomy for benign biliary disease is common and its delivery should be standardised. However, the current practice of cholecystectomy in Aotearoa New Zealand is unknown.

METHODS

A prospective, national cohort study of consecutive patients having cholecystectomy for benign biliary disease was performed between August and October 2021 with 30-day follow-up, through STRATA, a student- and trainee-led collaborative.

RESULTS

Data were collected for 1171 patients from 16 centres. 651 (55.6%) had an acute operation at index admission, 304 (26.0%) had delayed cholecystectomy following a previous admission, and 216 (18.4%) had an elective operation with no preceding acute admissions. The median adjusted rate of index cholecystectomy (as a proportion of index and delayed cholecystectomy) was 71.9% (range 27.2%-87.3%). The median adjusted rate of elective cholecystectomy (as proportion of all cholecystectomies) was 20.8% (range 6.7%-35.4%). Variations across centres were significant (p < 0.001) and inadequately explained by patient, operative, or hospital-factors (index cholecystectomy model R² = 25.8, elective cholecystectomy model R² = 50.6).

CONCLUSIONS

Notable variation in the rates of index and elective cholecystectomy exists in Aotearoa New Zealand not attributable to patient, operative or hospital factors alone. National quality improvement efforts to standardise availability of cholecystectomy are needed.

Evaluation of 30-day morbidity and mortality of laparoscopic cholecystectomy: a multicenter prospective observational Indian Association of Gastrointestinal Endoscopic Surgeons (IAGES) Study

BACKGROUND

Laparoscopic cholecystectomy (LC) is the standard of care for benign gallstone disease. There are no robust Indian data on the 30-day morbidity and mortality of this procedure. A prospective multicentre observational study was conducted by the Indian Association of Gastro-Intestinal Endo Surgeons (IAGES) to assess the 30-day morbidity and mortality of LC in India.

MATERIALS AND METHODS

Participating surgeons were invited to submit data on all consecutive LCs for benign diseases performed between 09/12/2020 and 08/03/2021 in adults. Primary outcome measures were 30-day morbidity and mortality. Univariate and multivariate analyses were performed to identify variables significantly associated with primary outcomes.

RESULTS

A total of 293 surgeons from 125 centres submitted data on 6666 patients. Of these, 71.7% (n = 4780) were elective. A total LC was carried out in 95% (n = 6331). Laparoscopic subtotal cholecystectomy was performed in 1.9% (n = 126) and the procedure were converted to open in 1.4% of patients. Bile duct injury was seen in 0.3% (n = 20). Overall, 30-day morbidity and mortality were 11.1% (n = 743) and 0.2% (n = 14), respectively. Nature of practice, ischemic heart disease, emergency surgery, postoperative intensive care, and postoperative hospital stay were independently associated with 30-day mortality. Age, weight, body mass index, duration of symptoms, nature of the practice, history of Coronavirus Disease-2019, previous major abdominal surgery, acute cholecystitis, use of electrosurgical or ultrasonic or bipolar energy for cystic artery control; use of polymer clips for cystic duct control; conversion to open surgery, subtotal cholecystectomy, simultaneous common bile duct exploration, mucocele, gangrenous gall bladder, dense adhesions, intraoperative cholangiogram, and use of drain were independently associated with 30-day morbidity.

CONCLUSION

LC has 30-day morbidity of 11.1%, 30-day mortality of 0.2%, conversion to open rate of 1.4%, and bile duct injury rate of 0.3% in India.

Laparoscopic subtotal cholecystectomy; change in practice over a 10-year period

BACKGROUND

Laparoscopic subtotal cholecystectomy is a recognised safe, alternative strategy when a critical view of safety cannot be obtained. This study audits the change in practice at a District General Hospital following the adoption of subtotal cholecystectomy in 2013.

METHODS

Retrospective case series included consecutive cholecystectomies over a ten-year period in a single institution. Cases were divided into subgroups based on operation date. Primary outcome was the proportion of patients undergoing laparoscopic total cholecystectomy, laparoscopic subtotal and laparoscopic converted to open cholecystectomy. Secondary outcomes included incidence of bile leak, complication rate, return to theatre, and length of stay.

RESULTS

There were 4217 cases: 1381 in Group A (pre-adoption of subtotal cholecystectomy 2009-2012), and 2836 in Group B (post-adoption of subtotal cholecystectomy 2013-2019). The rate of laparoscopic total cholecystectomy was higher in Group A than Group B (95.4% vs. 92.8%, p < 0.001). In the subtotal group (n = 114, 14 (12.3%) patients had bile leak, 6 (5.3%) underwent re-laparoscopy, and median length of stay was 2 days.

CONCLUSION

Laparoscopic subtotal cholecystectomy appears to be an acceptable alternative technique at this centre, reducing the rate of open conversion and length of stay, with a low reintervention rate for bile leak.

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.

Quality performance indicators for hepato-pancreatico-biliary procedures: a systematic review

BACKGROUND

This systematic review was undertaken to define and summarize existing, proposed quality performance indicators (QPI) for hepato-pancreatico-biliary (HPB) procedures.

METHODS

A systematic literature review identified studies reporting on quality indicators for cholecystectomy, hepatectomy, pancreatectomy and complex biliary surgical procedures. The databases searched were MEDLINE, EMBASE, PubMed, and SCOPUS, with all literature available until the search date of 1 May 2020 included. The reference lists of all included papers, as well as related review articles, were manually searched to identify further relevant studies.

RESULTS

Forty-five publications report quality indicators for pancreatectomy (n = 22), hepatectomy (n = 7), HPB resections in general (n = 12), and cholecystectomy (n = 6). No publications proposed QPI for complex biliary surgery. The 45 papers used national audit (n = 18), consensus methodology (n = 5), state-wide audit (n = 3), unit audit (n = 9), review methodology (n = 9), and survey methodology (n = 1). Sixty-one QPI were reported for pancreatectomy, 22 reported for hepatectomy, and 14 reported for HPB resections in general, in domains of infrastructure, provider, and documentation. Fourteen infrastructure and provider-based QPI were reported for cholecystectomy.

CONCLUSIONS

There are few internationally agreed QPI for HPB procedures that allow global comparison of provider performance and that set aspirational goals for patient care and experience.

Effectiveness of a quality improvement collaborative in reducing time to surgery for patients requiring emergency cholecystectomy

Background

Acute gallstone disease is a high-volume emergency general surgery presentation with wide variations in the quality of care provided across the UK. This controlled cohort evaluation assessed whether participation in a quality improvement collaborative approach reduced time to surgery for patients with acute gallstone disease to fewer than 8 days from presentation, in line with national guidance.

Methods

Patients admitted to hospital with acute biliary conditions in England and Wales between 1 April 2014 and 31 December 2017 were identified from Hospital Episode Statistics data. Time series of quarterly activity were produced for the Cholecystectomy Quality Improvement Collaborative (Chole-QuIC) and all other acute National Health Service hospitals (control group). A negative binomial regression model was used to compare the proportion of patients having surgery within 8 days in the baseline and intervention periods.

Results

Of 13 sites invited to join Chole-QuIC, 12 participated throughout the collaborative, which ran from October 2016 to January 2018. Of 7944 admissions, 1160 patients had a cholecystectomy within 8 days of admission, a significant improvement (P < 0·050) from baseline performance. This represented a relative change of 1·56 (95 per cent c.i. 1·38 to 1·75), compared with 1·08 for the control group. At the individual site level, eight of the 12 Chole-QuIC sites showed a significant improvement (P < 0·050), with four sites increasing their 8-day surgery rate to over 20 per cent of all emergency admissions, well above the mean of 15·3 per cent for control hospitals.

Conclusion

A surgeon-led quality improvement collaborative approach improved care for patients requiring emergency cholecystectomy.

Patient reported outcomes in elective laparoscopic cholecystectomy

Backgrounds/Aims

Traditional outcome measures (e.g., length of hospital stay, morbidity, and mortality) are used to determine the quality of care, but these may not be most important to patients. It is unclear which outcomes matter to patients undergoing elective laparoscopic cholecystectomy (ELC). We aim to identify patient-reported outcome measures (PROM) which patients undergoing ELC valued most.

Methods

A 45-item questionnaire with Four-point Likert-type questions developed from prior literature review, prospectively administered to patients treated with ELC at a tertiary institution in Singapore.

Results

Seventy-five patients participated. Most essential factors were technical skill and experience level of a surgeon, long-term quality of life (QoL), patient involvement in decision-making, communication skill of a surgeon, cleanliness of the ward environment, and standards of nursing care. Least important factors were hospitalization leave duration, length of hospital stay, a family's opinion of the hospital, and scar cosmesis. Employed patients were more likely to find hospitalization leave duration (p<0.001) and procedure duration (p=0.042) important. Younger patients (p=0.048) and female gender (p=0.003) were more likely to perceive scar cosmesis as important.

Conclusions

Patients undergoing ELC value long-term QoL, surgeon technical skill and experience level, patient involvement in decision-making, surgeon communication skill, cleanliness of the ward environment, and nursing care standards. Day-case surgery, medical leave, family opinion of hospital, and scar cosmesis were least important. Understanding what patients value will help guide patient-centric healthcare delivery.

Guidelines on pediatric day surgery of the Italian Societies of Pediatric Surgery (SICP) and Pediatric Anesthesiology (SARNePI)

The Italian Society of Pediatric Surgery (SICP) together with The Italian Society of Pediatric Anesthesia (SARNePI) through a systematic analysis of the scientific literature, followed by a consensus conference held in Perugia on 2015, have produced some evidence based guidelines on the feasibility of day surgery in relation to different pediatric surgical procedures. The main aspects of the pre-operative assessment, appropriacy of operations and discharge are reported.

Deaths Following Cholecystectomy and Herniotomy: An Analysis of Nationwide German Hospital Discharge Data From 2009 to 2013

BACKGROUND

In 2010, 158 000 cholecystectomies and 207 000 herniotomies (without bowel surgery) were performed in Germany as inpatient procedures, generally on a routine, elective basis. Deaths following such operations are rare events. We studied the potential association of death after cholecystectomy or herniotomy with risk factors that could have been detected beforehand, and we examined the types of complications that were documented in these cases.

METHODS

Using nationwide hospital discharge data (DRG statistics) for the years 2009-2013, we analyzed the characteristics of patients who died in the hospital after undergoing a cholecystectomy for cholelithiasis or the repair of an inguinal, femoral, umbilical, or abdominal wall hernia. We compared these data with those of patients who survived and studied the impact of the coded comorbidities on the risk of death.

RESULTS

In Germany, in the years 2009-2013, there were 2957 deaths after a total of 731 000 cholecystectomies (in-hospital mortality, 0.4%) and 1316 deaths after a total of 1 023 000 herniotomies without bowel surgery (0.13%). The patients who died were markedly older than those who did not, and they more commonly had comorbidities. Factors associated with a higher risk of death were age over 65 years, and comorbidities such as congestive heart failure, chronic pulmonary or hepatic disease, or poor nutritional status. Complications were coded much more often for the patients who died than for those who did not.

CONCLUSION

These findings suggest that there is potential for improvement in preoperative risk identification, complication avoidance, and the early recognition and treatment of complications, as well as in safe surgical technique. Measures to lower the mortality associated with herniotomy and cholecystectomy would lessen patients' individual risk and thereby improve patient safety.

Postoperative Use of Anti-TNF-α Agents in Patients with Crohn's Disease and Risk of Reoperation-A Nationwide Cohort Study

BACKGROUND

Approximately 80% of patients with Crohn's disease will require surgery. Surgery for Crohn's disease is not curative, and recurrence is typical. In this cohort study, based on nationwide Danish registries, we examined the association between postoperative treatment with anti-tumor necrosis factor α (anti-TNF-α) agents and reoperation.

METHODS

The association was examined in cohort 1 = patients not treated with anti-TNF-α agents within 6 months before operation, cohort 2 = patients treated with anti-TNF-α agents within 6 months before operation. Within both cohorts, we defined postoperative exposure to anti-TNF-α agents as at least 1 treatment within 6 months after the first operation and the reference cohorts were those not treated. Patients were followed from 6 months after operation and until 5 years. We used Cox proportional-hazards regression to compute adjusted hazard ratios with 95% confidence intervals.

RESULTS

In cohort 1, 31 (1.3%) were treated with anti-TNF-α agents within 6 months after operation and compared with those not treated, the adjusted hazard ratio of reoperation among those treated with anti-TNF-α agents was 3.53 (95% confidence interval: 1.61-7.72). In cohort 2, 63 (16.3%) were treated with anti-TNF-α agents within 6 months after operation, and the corresponding adjusted hazard ratio of reoperation was 2.16 (95% confidence interval: 1.11-4.18).

CONCLUSIONS

Our data suggest that anti-TNF-α treatment within 6 months after the first operation is not associated with a reduction in the need for subsequent operation. Uncontrolled confounding might have influenced our results, and, furthermore, future studies are warranted to clarify whether our study population is different from populations most often associated with postoperative anti-TNF-α treatment.

Bile duct reconstruction following laparoscopic cholecystectomy in England

Objectives

To determine the incidence of bile duct reconstruction (BDR) following laparoscopic cholecystectomy (LC) and to identify associated risk factors.

Background

Major bile duct injury (BDI) requiring reconstruction is a serious complication of cholecystectomy.

Methods

All LC and attempted LC operations in England between April 2001 and March 2013 were identified. Patients with malignancy, a stone in bile duct or those who underwent bile duct exploration were excluded. This cohort of patients was followed for 1 year to identify those who underwent BDR as a surrogate marker for major BDI. Logistic regression was used to identify factors associated with the need for reconstruction.

Results

In total, 572,223 LC and attempted LC were performed in England between April 2001 and March 2013. Five hundred (0.09 %) of these patients underwent BDR. The risk of BDR is lower in patient that do not have acute cholecystitis [odds ratio (OR) 0.48 (95 % CI 0.30–0.76)]. The regular use of on-table cholangiography (OTC) [OR 0.69 (0.54–0.88)] and high consultant caseload >80 LC/year [OR 0.56 (0.39–0.54)] reduced the risk of BDR. Patients who underwent BDR were 10 times more likely to die within a year than those who did not require further surgery (6 vs. 0.6 %).

Conclusions

The rate of BDR following laparoscopic cholecystectomy in England is low (0.09 %). The study suggests that OTC should be used more widely and provides further evidence in support of the provision of LC services by specialised teams with an adequate caseload (>80).

Safety and efficacy of a laparoscopic cholecystectomy in the morbid and super obese patients

BACKGROUND

Although a laparoscopic cholecystectomy (LC) is the gold standard treatment for symptomatic cholelithiasis, its safety and efficacy in the morbidly/super obese patients is unknown. The aim of this study was to investigate the safety and efficacy of an elective LC in the morbid/super obese patients.

METHODS

A retrospective review of the hospital electronic database and medical records was conducted searching for all elective LC from 2010 to 2013. The data collected included patient demographics and body mass index (BMI), length of hospital stay (LOS), duration of surgery (DOS), intra- and post-operative complications, bile duct injuries, performance of an intra-operative cholangiogram, the incidence of open conversion and the seniority of the operator.

RESULTS

A total of 799 patients (76% female) with a mean age of 46 years and BMI of 31 were included in this study. There were significant differences in the median DOS between the three BMI groups; BMI < 26 [64 min; interquartile range (IQR) 54-83]; BMI 26-40 (72 min, IQR 58-91) and BMI > 40 (82 min, IQR 63-104), P < 0.001. There were no statistically significant differences in the LOS, peri-operative complication rates, open conversions or bile duct injuries among the BMI groups.

CONCLUSIONS

This study showed that LC can be performed safely in the morbid/super obese patients.

Mortality after a cholecystectomy: a population-based study

BACKGROUND

The trade-off between the benefits of surgery for gallstone disease for a large population and the risk of lethal outcome in a small minority requires knowledge of the overall mortality.

METHODS

Between 2007 and 2010, 47 912 cholecystectomies for gallstone disease were registered in the Swedish Register for Cholecystectomy and endoscopic retrograde cholangiopancreatography (ERCP) (GallRiks). By linkage to the Swedish Death Register, the 30-day mortality after surgery was determined. The age- and sex-standardized mortality ratio (SMR) was estimated by dividing the observed mortality with the expected mortality rate in the Swedish general population 2007. The Charlson Comorbidity Index (CCI) was estimated by International Classification of Diseases (ICD) codes retrieved from the National Patient Register.

RESULTS

Within 30 days after surgery, 72 (0.15%) patients died. The 30-day mortality was close [SMR = 2.58; 95% confidence interval (CI): 2.02-3.25] to that of the Swedish general population. In multivariable logistic regression analysis, predictors of 30-day mortality were age >70 years [odds ratio (OR) 7.04, CI: 2.23-22.26], CCI > 2 (OR 1.93, CI: 1.06-3.51), American Society of Anesthesiologists (ASA) > 2 (OR 13.28, CI: 4.64-38.02), acute surgery (OR 10.05, CI:2.41-41.95), open surgical approach (OR 2.20, CI: 1.55-4.69) and peri-operative complications (OR 3.27, CI: 1.74-6.15).

DISCUSSION

Mortality after cholecystectomy is low. Co-morbidity and peri-operative complications may, however, increase mortality substantially. The increased mortality risk associated with open cholecystectomy could be explained by confounding factors influencing the decision to perform open surgery.

Bile duct injuries following laparoscopic cholecystectomy

INTRODUCTION

Bile duct injuries occur rarely but are among the most dreadful complications following cholecystectomies.

METHODS

Prospective registration of bile duct injuries occurring in the period 1992-2013 at a tertiary referral hospital.

RESULTS

In total, 67 patients (47 women and 20 men) with a median age of 55 (range 14-86) years had a leak or a lesion of the bile ducts during the study period. Total incidence of postoperative bile leaks or bile duct injuries was 0.9% and for bile duct injuries separately, 0.4%. Median delay from injury to repair was 5 days (range 0-68 days). In 12 patients (18%), the injury was discovered intraoperatively. Bile leak was the major symptom in 59%, and 52% had a leak from the cystic duct or from assumed aberrant ducts in the liver bed of the gall bladder. Following the Clavien-Dindo classification, 39% and 45% were classified as IIIa and IIIb, respectively, 10% as IV, and 6% as V. In all, 31 patients had injuries to the common bile duct or hepatic ducts, and in these patients, 71% were treated with a hepaticojejunostomy. Of patients treated with a hepaticojejunostomy, 56% had an uncomplicated event, whereas 14% later on developed a stricture. Out of 36 patients with injuries to the cystic duct/aberrant ducts, 30 could be treated with stents or sphincterotomies and percutaneous drainage.

CONCLUSION

Half of injuries following cholecystectomies are related to the cystic duct, and most of these can be treated with endoscopic or percutaneous procedures. A considerable number of patients following hepaticojejunostomy will later on develop a stricture.

Ninety-day postdischarge outcomes of inpatient elective laparoscopic cholecystectomy

BACKGROUND

Little information is available about postdischarge adverse events after laparoscopic cholecystectomy.

METHODS

Inpatient and 90-day postdischarge adverse events were identified for Medicare patients discharged in 2009-2010 after undergoing elective laparoscopic cholecystectomy on day 0, 1, or 2 of hospitalization at facilities that performed 20 or more laparoscopic cholecystectomies during the study period. A predictive length of stay (LOS) linear regression model was derived and used to identify patients with prolonged LOS (prLOS) whose risk-adjusted LOS exceeded a 3σ upper limit on a moving average control chart. Rates of inpatient and 90-day fatal and nonfatal adverse events and interrelationships among different outcomes and alternative outcome measures were explored.

RESULTS

Of 89,639 study cases, 0.7% died during their index hospitalization, and 1.3% died within 90 days of discharge. Of live discharges, 8.0% had prLOS, and 42.1% had coded complication. In the 90 days after discharge, 9,416 (10.6%) were readmitted. Patients who were prLOS outliers were more likely to die or be readmitted than nonoutliers (P < .0001; χ(2)).

CONCLUSION

More than 18% of Medicare patients undergoing presumably low-risk elective inpatient laparoscopic cholecystectomy died, had a severe inpatient complication, or were readmitted within 90 days of discharge.

Cholecystectomy in Danish children--a nationwide study

BACKGROUND

An increase in the frequency of cholecystectomy in children has been described during the last decades. Part of the reason is that more cholecystectomies in children are performed for dyskinesia of the gallbladder and not only for gallstone disease. We conducted the first nationwide study to describe outcome of cholecystectomies performed in children in Denmark by using data from the national Danish Cholecystectomy Database (DCD).

METHODS

In the DCD, two data sources were combined: administrative data from the National Patient Registry (NPR) and clinical data entered into the secure Web site by the surgeon immediately after the operation. In the present analysis, we have included children ≤ 15 years from the five year period January 1, 2006, to December 31, 2010.

RESULTS

In the study period 35,444 patients were operated with a cholecystectomy. Of these, 196 (0.5%) were ≤ 15 years. The median age was 14 years, and 82% were girls. Predisposing medical factors for gallstones (despite obesity) were found in only 5%. More than 50% were overweight, and one third were obese. Ninety-seven percent of the operations were completed laparoscopically, and the conversion rate was 0. 5%. Nearly half of the operations (45%) were performed as same day surgery, and 80% of the children stayed in hospital 0-1 day without readmission. 91% were discharged within 3 days and not readmitted. Morbidity was low, and no bile duct lesions occurred. The 30 day mortality was zero.

CONCLUSION

Our nationwide outcome results indicate good quality with 91% of the patients discharged within 3 days without readmission, no bile duct injuries, and no mortality. All patients except two were operated for symptomatic gallstone disease in accordance to the Danish national guidelines. We have not experienced a demand or a need to expand the indications for cholecystectomy beyond gallstone disease.

Cholecystectomy for the elderly: no hesitation for otherwise healthy patients

BACKGROUND

The number of Danish inhabitants older than 65 years is increasing, and cholecystectomy is one of the most common surgical procedures performed for this age group. This study aimed to analyze the role of age as an independent predictor of outcome for elderly cholecystectomy patients.

METHODS

Data from the Danish Cholecystectomy Database (2006-2010) were used. The outcomes of interest were conversion rate for laparoscopic cholecystectomy, outpatient rate, postoperative hospital length of stay, readmission rate, and frequency of additional procedures and death within 30 days postoperatively.

RESULTS

In this study, 697 patients 80 years of age or older and 4,915 patients ages 65-70 years were compared with 8,805 patients ages 50-64 years. Significantly more patients age 80 years or older underwent surgery for acute cholecystitis, and the conversion rate from laparoscopic to open surgery was significantly higher in the oldest group. The older patients had longer postoperative hospital stays, but nearly 30 % of the patients age 80 years or older were admitted for only 0-1 day and not readmitted, and nearly half of the patients were admitted for only 0-3 days without readmission. Also, the mortality rate and the number of patients who underwent additional procedures within 30 days were higher in the oldest group (6 vs 0.1 and 28 vs 15 %, respectively). A subanalysis of the patients age 80 years or older classified as American Society of Anesthesiology 1 and 2 without acute cholecystitis showed that 44 % left the hospital within 1 day and 63 % within 3 days without readmission and that the 30-day mortality rate was only 2 %.

CONCLUSIONS

Age is an independent predictor for worse outcome after cholecystectomy. However, among otherwise healthy patients age 80 years or older who underwent surgery before acute inflammatory complications occurred, 63 % had a fast and uncomplicated course. Thus, it seems fair to recommend elective laparoscopic cholecystectomy when repeated gallstone symptoms have occurred also for the older patient, particularly before the patient experiences acute cholecystitis.

Prevention and treatment of bile duct injuries during laparoscopic cholecystectomy: the clinical practice guidelines of the European Association for Endoscopic Surgery (EAES)

BACKGROUND

Laparoscopic cholecystectomy is one of the most common surgical procedures in Europe (and the world) and has become the standard procedure for the management of symptomatic cholelithiasis or acute cholecystitis in patients without specific contraindications. Bile duct injuries (BDI) are rare but serious complications that can occur during a laparoscopic cholecystectomy. Prevention and management of BDI has given rise to a host of publications but very few recommendations, especially in Europe.

METHODS

A systematic research of the literature was performed. An international expert panel was invited to appraise the current literature and to develop evidence-based recommendations. Statements and recommendations were drafted after a consensus development conference in May 2011, followed by presentation and discussion at the annual congress of the EAES held in Torino in June 2011. Finally, full guidelines were consented and adopted by the expert panel via e-mail and web conference.

RESULTS

A total of 1,765 publications were identified through the systematic literature search and additional submission by panellists; 671 publications were selected as potentially relevant. Only 46 publications fulfilled minimal methodological criteria to support Clinical Practice Guidelines recommendations. Because the level of evidence was low for most of the studies, most statements or recommendations had to be based on consensus of opinion among the panel members. A total of 15 statements and recommendations were developed covering the following topics: classification of injuries, epidemiology, prevention, diagnosis, and management of BDI.

CONCLUSIONS

Because BDI is a rare event, it is difficult to generate evidence for prevention, diagnosis, or the management of BDI from clinical studies. Nevertheless, the panel has formulated recommendations. Due to the currently limited evidence, a European registry should be considered to collect and analyze more valid data on BDI upon which recommendations can be based.