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Quarmby NM, Vo MT, Gananadha S. Is Routine Intraoperative Cholangiogram Necessary in Patients With Mild Acute Biliary Pancreatitis Undergoing Index Admission Cholecystectomy? Am Surg 2024:31348241250050. [PMID: 38686805 DOI: 10.1177/00031348241250050] [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: 05/02/2024]
Abstract
Background: There is controversy about whether intraoperative cholangiogram (IOC) should be performed routinely during laparoscopic cholecystectomy for patients with acute biliary pancreatitis, given significant false positive and negative rates and increased resource utilization. The aim of this study was to clarify the role of IOC in cases of mild biliary pancreatitis in patients undergoing index admission cholecystectomy, its impact on patient outcomes, and the impact of blood tests, imaging, and preoperative intervention on the detection of choledocholithiasis.Methods: A retrospective review of all patients presenting with acute mild biliary pancreatitis between January 2006 and December 2019 was conducted. Data collected included patient demographics, serum chemistry, IOC, and Endoscopic Retrograde Cholangiopancreatography (ERCP) findings, imaging findings, length of stay, operative length, and long-term follow-up outcomes.Results: 284 patients met the inclusion criteria for the study. The overall false positive IOC rate was 7.4%. Worsening bilirubin trend was a positive predictive value (PPV) for positive IOC and ERCP outcomes with a relative risk of 2.93 (P < .01) and 2.32 (P = .013), respectively. Improving preoperative bilirubin trend had a significant negative predictive value in IOC with a relative risk of .59 (P = .02). Positive IOC was shown to significantly increase operative length with a relative risk of 2.03 (P < .001).Discussion: A rising preoperative bilirubin is a predictor of a positive IOC and patients with normalizing bilirubin levels or a preoperative ERCP are less likely to have choledocholithiasis. These features may be used to select patients that would benefit from an IOC for index admission cholecystectomy.
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Affiliation(s)
- Natalie M Quarmby
- Department of Surgery, North Canberra Hospital, Bruce, AU-ACT, Australia
- Canberra Hospital, Garran, AU-ACT, Australia
| | - Minh Tu Vo
- Department of Surgery, North Canberra Hospital, Bruce, AU-ACT, Australia
| | - Sivakumar Gananadha
- Department of Surgery, North Canberra Hospital, Bruce, AU-ACT, Australia
- Canberra Hospital, Garran, AU-ACT, Australia
- Australian National University, Canberra, AU-ACT, Australia
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Temperley HC, O'Sullivan NJ, Grainger R, Bolger JC. Is the use of a routine intraoperative cholangiogram necessary in laparoscopic cholecystectomy? Surgeon 2023; 21:e242-e248. [PMID: 36710125 DOI: 10.1016/j.surge.2023.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 12/20/2022] [Accepted: 01/08/2023] [Indexed: 01/29/2023]
Abstract
INTRODUCTION Although laparoscopic cholecystectomy (LC) has been standard of care for symptomatic gallstone disease for almost 30 years, the use of routine intraoperative cholangiogram (IOC) remains controversial. There are marked variations in the use IOC during LC internationally. Debate has continued about its benefit, in part because of inconsistent benefit, time, and resources required to complete IOC. This literature review is presented as a debate to outline the arguments in favour of and against routine IOC in laparoscopic cholecystectomy. METHODS A standard literature review of PubMed, Medline, OVID, EMBASE, CINHIL and Web of Science was performed, specifically for literature pertaining to the use of IOC or alternative intra-operative methods for imaging the biliary tree in LC. Two authors assembled the evidence in favour, and two authors assembled the evidence against. RESULTS From this controversies piece we found that there is little discernible change in the number of BDIs requiring repair procedures. Although IOC is associated with a small absolute reduction in bile duct injury, there are other confounding factors, including a change in laparoscopic learning curves. Alternative technologies such as intra-operative ultrasound, indocyanine green imaging, and increased access to ERCP may contribute to a reduction in the need for routine IOC. CONCLUSIONS In spite of 30 years of accumulating evidence, routine IOC remains controversial. As technology advances, it is likely that alternative methods of imaging and accessing the bile duct will supplant routine IOC.
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Affiliation(s)
| | | | - Richard Grainger
- Department of Surgery, Tallaght University Hospital, Dublin 24, Ireland
| | - Jarlath C Bolger
- Department of Surgery, Toronto General Hospital/University Health Network, Toronto, ON, Canada; Department of Surgery, Royal College of Surgeons in Ireland, Dublin 2, Ireland
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3
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Tranter-Entwistle I, Simcock C, Eglinton T, Connor S. Prospective cohort study of operative outcomes in laparoscopic cholecystectomy using operative difficulty grade-adjusted CUSUM analysis. Br J Surg 2023; 110:1068-1071. [PMID: 36882185 PMCID: PMC10416680 DOI: 10.1093/bjs/znad046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 01/19/2023] [Accepted: 02/07/2023] [Indexed: 03/09/2023]
Affiliation(s)
| | - Corin Simcock
- Department of Surgery, The University of Otago Medical School, Christchurch, New Zealand
| | - Tim Eglinton
- Department of Surgery, The University of Otago Medical School, Christchurch, New Zealand
- Department of General Surgery, Christchurch Hospital, CDHB, Christchurch, New Zealand
| | - Saxon Connor
- Department of General Surgery, Christchurch Hospital, CDHB, Christchurch, New Zealand
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The artery first technique: re-examining the critical view of safety during laparoscopic cholecystectomy. Surg Endosc 2023:10.1007/s00464-023-09912-z. [PMID: 36792783 DOI: 10.1007/s00464-023-09912-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 01/28/2023] [Indexed: 02/17/2023]
Abstract
INTRODUCTION Significant discrepancies exist between surgeon-documented and actual rates of critical view of safety (CVS) achievement on retrospective review following laparoscopic cholecystectomy. This discrepancy may be due to surgeon utilisation of the artery first technique (AFT), an exception to the CVS first described by Strasberg et al. The present study aims to characterise the use of the AFT, hypothesising it is used as an adjunct in difficult dissections to maximise exposure of the hepato-cystic triangle ensuring safe cholecystectomy. METHODS Prospective digital recording of the operative procedure of patients' undergoing laparoscopic cholecystectomy were undertaken at Christchurch Public Hospital, New Zealand and North Shore Private Hospital, Sydney, Australia. Videos were uploaded to Touch Surgery™ Enterprise. Difficulty was graded, annotated and indications for the AFT quantified using a standardised protocol. RESULTS A total of 275 annotated procedures were included in this study. The AFT was employed in 54 (20%) patients; in 13 (24%) patients for bleeding, in 35 (65%) patients where windows one and two were visible, and in 6 (11%) patients no windows were visible within the hepato-cystic triangle. There were significant differences in utilisation across operative grade and by seniority of operator (p < 0.005). CONCLUSIONS The data presented here demonstrate the AFT is frequently used, particularly with Grade 3 cholecystectomy. However, more data are needed to confirm the utility and safety of this approach. Analysis of the AFT shows that to understand and improve safety in laparoscopic cholecystectomy appreciating how the operation was undertaken and not just that the CVS was achieved is crucial.
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Ng J, Teng R, Izwan S, Chan E, Kumar M, Damodaran Prabha R, Puhalla H. Incidence and management of choledocholithiasis on routine intraoperative cholangiogram: a 5-year tertiary centre experience. ANZ J Surg 2023; 93:139-144. [PMID: 36562109 DOI: 10.1111/ans.18215] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 12/10/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND The incidence of choledocholithiasis on routine intraoperative cholangiogram (IOC) during cholecystectomy is approximately 12%. Cholecystectomy without IOC may lead to undiagnosed choledocholithiasis placing patients at risk of complications such as pancreatitis or cholangitis. This study aims to determine the incidence of choledocholithiasis intraoperatively as well as the associated risk factors and the methods of management. METHODS A retrospective observational analysis of all laparoscopic cholecystectomies with IOC at the Gold Coast Hospital and Health Service from 1 January 2016 to 2 December 2021 was carried out. Patient demographics, operative data and cholangiogram findings were collected from electronic medical systems. RESULTS A total of 3904 cholecystectomies were carried out over the study period. 3520 (90.1%) had an IOC, and 474 (13.4%) had positive IOC findings. 158 (33.3%) of the cases were managed intraoperatively with hyoscine butylbromide with or without intravenous glucagon followed by biliary tree flushing alone, 183 (38.6%) received transcystic bile duct exploration (TCBDE) with a success rate of 83% and 167 (35.2%) received endoscopic retrograde cholangiopancreatography (ERCP). Choledocholithiasis was incidental in 44 (9.28%) patients. CONCLUSION Incidental choledocholithiasis during routine IOC is not uncommon. Management predominantly includes intraoperative TCBDE or postoperatively via an ERCP. This study has not found reliable preoperative factors to predict choledocholithiasis based on preoperative clinical, radiological and biochemical factors. A small proportion of patients received preoperative endoscopic intervention, and the decision-making process requires further investigation.
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Affiliation(s)
- Justin Ng
- Department of General Surgery, Gold Coast University Hospital-Gold Coast Hospital and Health Service, Gold Coast, Queensland, Australia.,Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Queensland, Australia
| | - Roy Teng
- Department of General Surgery, Gold Coast University Hospital-Gold Coast Hospital and Health Service, Gold Coast, Queensland, Australia.,School of Medicine and Dentistry, Griffith University, Gold Coast, Queensland, Australia
| | - Sara Izwan
- Department of General Surgery, Gold Coast University Hospital-Gold Coast Hospital and Health Service, Gold Coast, Queensland, Australia.,School of Medicine and Dentistry, Griffith University, Gold Coast, Queensland, Australia
| | - Erick Chan
- Department of General Surgery, Gold Coast University Hospital-Gold Coast Hospital and Health Service, Gold Coast, Queensland, Australia.,School of Medicine and Dentistry, Griffith University, Gold Coast, Queensland, Australia
| | - Maarisha Kumar
- School of Medicine and Dentistry, Griffith University, Gold Coast, Queensland, Australia
| | - Ramesh Damodaran Prabha
- Department of General Surgery, Gold Coast University Hospital-Gold Coast Hospital and Health Service, Gold Coast, Queensland, Australia
| | - Harald Puhalla
- Department of General Surgery, Gold Coast University Hospital-Gold Coast Hospital and Health Service, Gold Coast, Queensland, Australia.,Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Queensland, Australia.,School of Medicine and Dentistry, Griffith University, Gold Coast, Queensland, Australia
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Tranter-Entwistle I, Eglinton T, Hugh TJ, Connor S. Use of prospective video analysis to understand the impact of technical difficulty on operative process during laparoscopic cholecystectomy. HPB (Oxford) 2022; 24:2096-2103. [PMID: 35961932 DOI: 10.1016/j.hpb.2022.07.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 06/28/2022] [Accepted: 07/19/2022] [Indexed: 01/24/2023]
Abstract
BACKGROUND An understanding of the impact of operative difficulty on operative process in laparoscopic cholecystectomy is lacking. The aim of the present study was to prospectively analyse digitally recorded laparoscopic cholecystectomy to assess the impact of operative technical difficulty on operative process. METHODS Video of laparoscopic cholecystectomy procedures performed at Christchurch Hospital, NZ and North Shore Private Hospital, Sydney Australia were prospectively recorded. Using a framework derived from a previously published standard process video was annotated using a standardized template and stratified by operative grade to evaluate the impact of grade on operative process. RESULTS 317 patients had their laparoscopic cholecystectomy operations prospectively recorded. Seventy one percent of these videos (n = 225) were annotated. Single ICC of operative grade was 0.760 (0.663-0.842 p < 0.010). Median operative time, rate of operative errors significantly increased and rate of CVS decreased with increasing operative grade. Significant differences in operative anatomy, operative process and instrumentation were seen with increasing grade. CONCLUSION Operative technical difficulty is accurately predicted by operative grade and this impacts on operative process with significant implications for both surgeons and patients. Consequently operative grade should be documented routinely as part of a culture of safe laparoscopic cholecystectomy.
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Affiliation(s)
| | - Tim Eglinton
- Department of Surgery, The University of Otago Medical School, Christchurch, New Zealand; Department of General Surgery Christchurch Hospital, Te Whatu Ora, New Zealand
| | - Thomas J Hugh
- Upper Gastrointestinal Surgical Unit, Royal North Shore Hospital and North Shore Private Hospital, St Leonards, NSW, Australia; Northern Clinical School, University of Sydney, Sydney, NSW, Australia
| | - Saxon Connor
- Department of General Surgery Christchurch Hospital, Te Whatu Ora, New Zealand
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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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