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Wightkin SP, Velasco J, Schimpke S, Kremer MJ. Enhancing Intraoperative Cholangiography Interpretation Skills: A Perceptual Learning Approach for Surgical Residents. JOURNAL OF SURGICAL EDUCATION 2024; 81:1267-1275. [PMID: 38960773 DOI: 10.1016/j.jsurg.2024.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Revised: 05/27/2024] [Accepted: 06/01/2024] [Indexed: 07/05/2024]
Abstract
OBJECTIVE Laparoscopic cholecystectomy is a commonly performed surgery with risk of serious complications. Intraoperative cholangiography (IOC) can mitigate these risks by clarifying the anatomy of the biliary tree and detecting common bile duct injuries. However, mastering IOC interpretation is largely through experience, and studies have shown that even expert surgeons often struggle with this skill. Since no formal curriculum exists for surgical residents to learn IOC interpretation, we developed a perceptual learning (PL)-based training module aimed at improving surgical residents' IOC interpretation skills. DESIGN Surgical residents were assessed on their ability to identify IOC characteristics and provide clinical recommendations using an online training module based on PL principles. This research had 2 phases. The first phase involved pre/post assessments of residents trained via the online IOC interpretation module, measuring their IOC image recognition and clinical management accuracy (percentage of correct responses), response time and confidence. During the second phase, we explored the impact of combining simulator-based IOC training with the online interpretation module on same measures as used in the first phase (accuracy, response time, and confidence). SETTING The study was conducted at Rush University Medical College in Chicago. The participants consisted of surgical residents from each postgraduate year (PGY). Residents participated in this study during their scheduled monthly rotation through Rush's surgical simulation center. RESULTS Total 23 surgical residents participated in the first phase. A majority (95.7%) found the module helpful. Residents significantly increased confidence levels in various aspects of IOC interpretation, such as identifying complete IOCs and detecting abnormal findings. Their accuracy in making clinical management decisions significantly improved from pretraining (mean accuracy 68.1 +/- 17.3%) to post-training (mean accuracy 82.3 +/- 10.4%, p < 0.001). Furthermore, their response time per question decreased significantly from 25 +/- 12 seconds to 17 +/- 12 seconds (p < 0.001). In the second phase, we combined procedural simulator training with the online interpretation module. The 20, first year residents participated and 88% found the training helpful. The training group exhibited significant confidence improvements compared to the control group in various aspects of IOC interpretation with observed nonsignificant accuracy improvements related to clinical management questions. Both groups demonstrated reduced response times, with the training group showing a more substantial, though nonsignificant, reduction. CONCLUSION This study demonstrated the effectiveness of a PL-based training module for improving aspects of surgical residents' IOC interpretation skills. The module, found helpful by a majority of participants, led to significant enhancements in clinical management accuracy, confidence levels, and decreased response time. Incorporating simulator-based training further reinforced these improvements, highlighting the potential of our approach to address the lack of formal curriculum for IOC interpretation in surgical education.
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Affiliation(s)
| | - Jose Velasco
- Department of Surgery, Rush University Medical Center, Chicago, Illinois
| | - Scott Schimpke
- Department of Surgery, Rush University Medical Center, Chicago, Illinois; Rush Center for Clinical Skills and Simulation, Rush University Medical Center, Chicago, Illinois
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Hwang F, Bukur M. Contemporary management of common bile duct stone: What you need to know. J Trauma Acute Care Surg 2023; 95:832-838. [PMID: 37697464 DOI: 10.1097/ta.0000000000004128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/13/2023]
Abstract
ABSTRACT Choledocholithiasis is a common presentation of symptomatic cholelithiasis encountered by the acute care surgeon. There is a wide spectrum of variation in management of this disease due to evolutions in laparoscopic and endoscopic techniques. Intricacies in management are related to the timing of diagnosis as well as locally available imaging modalities, surgical expertise, and ancillary advanced endoscopy and interventional radiological support. While individual patient demographics and institutional characteristics will determine management of choledocholithiasis, it is incumbent for the treating surgeon to be well versed in all manners of therapy currently available. The objective of this review is to provide an evidence-based summary of the contemporary management of choledocholithiasis.
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Affiliation(s)
- Franchesca Hwang
- From the Department of Surgery (F.H.), NYU Langone Health, Brooklyn, New York; and Department of Surgery (M.B.), Bellevue Hospital Center, New York, New York
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3
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Marchegiani F, Conticchio M, Zadoroznyj A, Inchingolo R, Memeo R, De'angelis N. Detection and management of bile duct injury during cholecystectomy. Minerva Surg 2023; 78:545-557. [PMID: 36883937 DOI: 10.23736/s2724-5691.23.09866-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2023]
Abstract
INTRODUCTION Cholecystectomy represents one of the most performed surgical procedures. Bile duct injuries (BDIs) are a dangerous complication of this intervention. With the advent of the laparoscopy, the rate of BDIs showed a growing trend that was partially justified by the learning curve of this technique. EVIDENCE ACQUISITION A literature search was conducted on Embase, Medline, and Cochrane databases to identify studies published up to October 2022 that analyzed the intraoperative detection and management of BDIs diagnosed during cholecystectomy. EVIDENCE SYNTHESIS According to the literature, approximately 25% of BDIs is diagnosed during the laparoscopic cholecystectomy. In the clinical suspicion of BDI, an intraoperative cholangiography is performed to confirm it. Complimentary technology, such as near-infrared cholangiography, can be also adopted. Intraoperative ultrasound represents a useful tool to furtherly define the biliary and the vascular anatomy. The proper classification of the type of BDI allows to identify the correct treatment. When a good expertise in hepato-pancreato-biliary surgery is available, a direct repair is performed with good outcomes both in case of simple and complex lesions. When the local resources are limited or there is a lack of dedicated surgical experience, patient referral to a reference center shows better outcomes. In particular, complex vasculo-biliary injuries require a highly specialized treatment. The key elements to transfer the patients are a good documentation of the injury, a proper drainage of the abdomen, and an antibiotic therapy. CONCLUSIONS BDI management requires a proper diagnostic process and prompt treatment to reduce the morbidity and mortality of this feared complication occurring during cholecystectomy.
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Affiliation(s)
- Francesco Marchegiani
- Unit of Colorectal and Digestive Surgery, DIGEST Department, Beaujon University Hospital, AP-HP, University of Paris Cité, Clichy, France
| | - Maria Conticchio
- Unit of Hepato-Pancreato-Biliary Surgery, F. Miulli General Regional Hospital, Acquaviva delle Fonti, Bari, Italy
| | - Alizée Zadoroznyj
- Unit of Colorectal and Digestive Surgery, DIGEST Department, Beaujon University Hospital, AP-HP, University of Paris Cité, Clichy, France
| | - Riccardo Inchingolo
- Unit of Interventional Radiology, F. Miulli General Regional Hospital, Acquaviva delle Fonti, Bari, Italy
| | - Riccardo Memeo
- Unit of Hepato-Pancreato-Biliary Surgery, F. Miulli General Regional Hospital, Acquaviva delle Fonti, Bari, Italy
| | - Nicola De'angelis
- Unit of Colorectal and Digestive Surgery, DIGEST Department, Beaujon University Hospital, AP-HP, University of Paris Cité, Clichy, France -
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4
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Thomas R, Young E, Jayasena W, Raju SE. Significance of intra-operative cholangiogram and its application in suspected duodenal injuries - Case report. Int J Surg Case Rep 2023; 107:108386. [PMID: 37295243 DOI: 10.1016/j.ijscr.2023.108386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 05/31/2023] [Accepted: 06/01/2023] [Indexed: 06/12/2023] Open
Abstract
INTRODUCTION AND IMPORTANCE Intraoperative cholangiogram has always been a critical procedure that allows identification of biliary anatomy, thereby reducing the risks of bile duct injuries. CASE PRESENTATION We present a unique case where the intraoperative cholangiogram highlighted a suspected duodenal injury. CLINICAL DISCUSSION This case discusses the intraoperative steps taken to ensure there was no injury, highlight the importance of cholangiogram interpretation as a skill for all surgeons. CONCLUSION Intraoperative cholangiogram is a crucial procedure to highlight both biliary and non-biliary anatomy and can be used to identify duodenal injuries as was assessed in our case.
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Affiliation(s)
- Rebecca Thomas
- Division of Surgical Specialties & Anaesthetics, Lyell McEwin Hospital, Elizabeth Vale, South Australia, Australia; The University of Adelaide, Faculty of Health and Medical Sciences, Adelaide, South Australia, Australia.
| | - Edward Young
- Division of Surgical Specialties & Anaesthetics, Lyell McEwin Hospital, Elizabeth Vale, South Australia, Australia; The University of Adelaide, Faculty of Health and Medical Sciences, Adelaide, South Australia, Australia.
| | - Warunika Jayasena
- Division of Surgical Specialities and Anaesthetics, Flinders Hospital, Adelaide, South Australia, Australia.
| | - Smita Esther Raju
- The University of Adelaide, Faculty of Health and Medical Sciences, Adelaide, South Australia, Australia; Department of Radiology, Royal Adelaide Hospital, Adelaide, South Australia, Australia.
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5
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Kaldas P, Suthakaran R, Weinberg L, Lee D, Al‐Habbal Y. Evaluating the effect of online surgical education on intraoperative cholangiogram interpretation: a pilot study. ANZ J Surg 2022; 92:2560-2564. [DOI: 10.1111/ans.18027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 08/09/2022] [Accepted: 08/23/2022] [Indexed: 11/28/2022]
Affiliation(s)
- Peter Kaldas
- Department of Surgery Austin Health Melbourne Australia
| | | | - Laurence Weinberg
- Department of Surgery Austin Health Melbourne Australia
- Department of Anaesthesia Austin Health Melbourne Australia
- Department of Critical Care The University of Melbourne, Austin Health Melbourne Australia
| | - Dong‐Kyu Lee
- Department of Anesthesiology and Pain Medicine Dongguk University Ilsan Hospital Goyang Republic of Korea
| | - Yahya Al‐Habbal
- Department of Surgery Austin Health Melbourne Australia
- Department of Surgery Western Health Melbourne Australia
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Cai W, Wang G, Wu H, Li H, Shen C, Wei X, Yu K, Sun Q, Wang Z. Identifying traumatic brain injury (TBI) by ATR-FTIR spectroscopy in a mouse model. SPECTROCHIMICA ACTA. PART A, MOLECULAR AND BIOMOLECULAR SPECTROSCOPY 2022; 274:121099. [PMID: 35257986 DOI: 10.1016/j.saa.2022.121099] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 02/24/2022] [Accepted: 02/26/2022] [Indexed: 06/14/2023]
Abstract
Traumatic brain injury (TBI) is one of the most common mechanical injuries and plays a significant role in forensic practice. For cadavers, however, accurate diagnosis of TBI becomes a more and more challenging task as the level of decomposition increases. Our main purpose was to investigate whether TBI in putrefied mouse cadavers can be identified by Fourier Transform Infrared (FT-IR). The method proposed by Feeney et al. was used to establish the mouse TBI model. Principal component analysis (PCA) and partial least squares discriminant analysis (PLS-DA) modeling were used to distinguish fresh and putrefied brain tissues. Then, we established two PLS-DA models to identify injured area samples in fresh and putrefied brain tissue samples. The accuracy of the two models were 100% and 92.5%. Our preliminary research has proved that the use of FT-IR spectroscopy combined with chemometrics can identify TBI more quickly and accurately in cadavers, providing crucial evidence for judicial proceedings.
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Affiliation(s)
- Wumin Cai
- Department of Forensic Pathology, College of Forensic Medicine, Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Gongji Wang
- Department of Forensic Pathology, College of Forensic Medicine, Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Hao Wu
- Department of Forensic Pathology, College of Forensic Medicine, Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Huiyu Li
- Department of Forensic Pathology, College of Forensic Medicine, Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Chen Shen
- Department of Forensic Pathology, College of Forensic Medicine, Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Xin Wei
- Department of Forensic Pathology, College of Forensic Medicine, Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Kai Yu
- Department of Forensic Pathology, College of Forensic Medicine, Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Qinru Sun
- Department of Forensic Pathology, College of Forensic Medicine, Xi'an Jiaotong University, Xi'an, Shaanxi, China.
| | - Zhenyuan Wang
- Department of Forensic Pathology, College of Forensic Medicine, Xi'an Jiaotong University, Xi'an, Shaanxi, China.
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Vedantam S, Amin S, Maher B, Ahmad S, Kadir S, Niaz SK, Wright M, Tehami N. Increased ERCP volume improves cholangiogram interpretation: a new performance measure for ERCP training? Clin Endosc 2022; 55:426-433. [PMID: 35114744 PMCID: PMC9178142 DOI: 10.5946/ce.2021.239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 10/26/2021] [Accepted: 11/08/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND/AIMS Cholangiogram interpretation is not used as a key performance indicator (KPI) of endoscopic retrograde cholangiopancreatography (ERCP) training, and national societies recommend different minimum numbers per annum to maintain competence. This study aimed to determine the relationship between correct ERCP cholangiogram interpretation and experience. METHODS One hundred fifty ERCPists were surveyed to appropriately interpret ERCP cholangiographic findings. There were three groups of 50 participants each: "Trainees," "Consultants group 1" (performed >75 ERCPs per year), and "Consultants group 2" (performed >100 ERCPs per year). RESULTS Trainees was inferior to Consultants groups 1 and 2 in identifying all findings except choledocholithiasis outside the intrahepatic duct on the initial or completion/occlusion cholangiogram. Consultants group 1 was inferior to Consultants group 2 in identifying Strasberg type A bile leaks (odds ratio [OR], 0.86; 95% confidence interval [CI], 0.77-0.96), Strasberg type B (OR, 0.84; 95% CI, 0.74-0.95), and Bismuth type 2 hilar strictures (OR, 0.81; 95% CI, 0.69-0.95). CONCLUSION This investigation supports the notion that cholangiogram interpretation improves with increased annual ERCP case volumes. Thus, a higher annual volume of procedures performed may improve the ability to correctly interpret particularly difficult findings. Cholangiogram interpretation, in addition to bile duct cannulation, could be considered as another KPI of ERCP training.
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Affiliation(s)
- Shyam Vedantam
- Department of Medicine, University of Miami, Miami, FL, USA
| | - Sunil Amin
- Division of Digestive Health and Liver Diseases, Department of Medicine, University of Miami, Miami, FL, USA
| | - Ben Maher
- Department of Interventional Radiology, University Hospital Southampton NHS Foundation Trust, Southampton, UK
- Southampton Interventional Endoscopy Unit, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Saqib Ahmad
- Department of Gastroenterology, Sherwood Forest Hospitals NHS Foundation Trust, Sutton in Ashfield, UK
| | - Shanil Kadir
- Department of Gastroenterology, Liaquat National Hospital and Medical College, Karachi, Pakistan
| | - Saad Khalid Niaz
- Interventional Endoscopy Unit, Surgical Unit 4, Dow University of Health Sciences, Karachi, Pakistan
| | - Mark Wright
- Southampton Interventional Endoscopy Unit, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Nadeem Tehami
- Southampton Interventional Endoscopy Unit, University Hospital Southampton NHS Foundation Trust, Southampton, UK
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8
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Bansal VK, Misra MC, Agarwal AK, Agrawal JB, Agarwal PN, Aggarwal S, Aslam M, Krishna A, Baksi A, Behari A, Bhattacharjee HK, Bhojwani R, Chander J, Chattopadhyay TK, Chintamani, Chowbey P, Dalvi A, Dash NR, Dhawan IK, Gamangatti S, Garg PK, Gupta NM, Gupta R, Gupta SK, Gupta V, Kaman L, Kapur BML, Kataria K, Khan M, Khanna AK, Khullar R, Kumar A, Kumar A, Kumar S, Kumar S, Lal P, Maurya SD, Moirangthem GS, Pal S, Panwar R, Parshad R, Pottakkat B, Prajapati OP, Puntambekar S, Ranjan P, Rathore YS, Sahni P, Sarangi R, Seenu V, Sharma R, Shukla VK, Singh DP, Singh J, Singh R, Sinha R, Sikora SS, Srivastava A, Srivastava A, Srivastava KN, Thomas S, Verma GR, Wig JD, Kapoor VK. SELSI Consensus Statement for Safe Cholecystectomy—Prevention and Management of Bile Duct Injury—Part B. Indian J Surg 2021. [DOI: 10.1007/s12262-019-01994-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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9
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Askari A, Riaz AA, Brittain R, Zhou J, Irwin S, Talbot M. Benefits of intraoperative cholangiogram for acute cholecystitis. SURGICAL PRACTICE 2021. [DOI: 10.1111/1744-1633.12491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2022]
Affiliation(s)
- Alan Askari
- West Hertfordshire Hospitals NHS Trust Watford UK
| | | | | | - Joel Zhou
- St. George Hospital Sydney New South Wales Australia
| | - Saskia Irwin
- St. George Hospital Sydney New South Wales Australia
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10
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Christou N, Roux-David A, Naumann DN, Bouvier S, Rivaille T, Derbal S, Taibi A, Fabre A, Fredon F, Durand-Fontanier S, Valleix D, Mathonnet M. Bile Duct Injury During Cholecystectomy: Necessity to Learn How to Do and Interpret Intraoperative Cholangiography. Front Med (Lausanne) 2021; 8:637987. [PMID: 33681264 PMCID: PMC7925835 DOI: 10.3389/fmed.2021.637987] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Accepted: 01/14/2021] [Indexed: 12/24/2022] Open
Abstract
Introduction: Biliary duct injury (BDI) is a serious complication during cholecystectomy. Perioperative cholangiography (POC) has recently been generating interest in order to prevent BDI. However, the current literature (including randomized controlled trials) cannot conclude whether POC is protective or not against the risk of BDI. The aim of our study was to investigate whether POC could demonstrate earlier BDI and which criteria are required to make that diagnosis. Methods: We performed a retrospective study between 2005 and 2018 in our French tertiary referral center, which included all patients who had presented following BDI during cholecystectomy. Results: Twenty-two patients were included. Nine patients had POC, whereas 13 did not. When executed, POC was interpreted as normal for three patients and abnormal for six. In this latter group, only two cases had a BDI diagnosed intraoperatively. In other cases, the interpretation was not adequate. Conclusion: BDIs are rare but may reduce patients' quality of life. Our study highlights the surgeon's responsibility to learn how to perform and interpret POC in order to diagnose and manage BDIs and potentially avoid catastrophic consequences.
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Affiliation(s)
- Niki Christou
- Department of Digestive Surgery, University Hospital of Limoges, Limoges, France.,Department of Visceral Surgery, Geneva University Hospitals and Medical School, Geneva, Switzerland.,Department of Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Alexia Roux-David
- Department of Digestive Surgery, University Hospital of Limoges, Limoges, France
| | - David N Naumann
- Department of Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Stephane Bouvier
- Department of Digestive Surgery, University Hospital of Limoges, Limoges, France
| | - Thibaud Rivaille
- Department of Digestive Surgery, University Hospital of Limoges, Limoges, France
| | - Sophiane Derbal
- Department of Digestive Surgery, University Hospital of Limoges, Limoges, France
| | - Abdelkader Taibi
- Department of Digestive Surgery, University Hospital of Limoges, Limoges, France
| | - Anne Fabre
- Department of Digestive Surgery, University Hospital of Limoges, Limoges, France
| | - Fabien Fredon
- Department of Digestive Surgery, University Hospital of Limoges, Limoges, France
| | | | - Denis Valleix
- Department of Digestive Surgery, University Hospital of Limoges, Limoges, France
| | - Muriel Mathonnet
- Department of Digestive Surgery, University Hospital of Limoges, Limoges, France
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11
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Brown AWW, Wilson RB. Legacy of Le Quesne: operative cholangiography in the modern era. ANZ J Surg 2019; 88:819-820. [PMID: 30182411 DOI: 10.1111/ans.14501] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Accepted: 03/08/2018] [Indexed: 01/12/2023]
Affiliation(s)
| | - Robert B Wilson
- General Surgery Department, Liverpool Hospital, Sydney, New South Wales, Australia
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12
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Chehade M, Kakala B, Sinclair JL, Pang T, Al Asady R, Richardson A, Pleass H, Lam V, Johnston E, Yuen L, Hollands M. Intraoperative detection of aberrant biliary anatomy via intraoperative cholangiography during laparoscopic cholecystectomy. ANZ J Surg 2019; 89:889-894. [PMID: 31083792 DOI: 10.1111/ans.15267] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Revised: 04/04/2019] [Accepted: 04/05/2019] [Indexed: 12/27/2022]
Abstract
BACKGROUND Laparoscopic cholecystectomy (LC) is the standard of treatment for symptomatic cholelithiasis. Although intraoperative cholangiography (IOC) is widely used as an adjunct to LC, there is still no worldwide consensus on the value of its routine use. Anatomical studies have shown that variations of the biliary tree are present in approximately 35% of patients with variations in right hepatic second-order ducts being especially common (15-20%). Approximately, 70-80% of all iatrogenic bile duct injuries are a consequence of misidentification of biliary anatomy. The purpose of this study was to assess the adequacy of and the reporting of IOCs during LC. METHODS IOCs obtained from 300 consecutive LCs between July 2014 and July 2016 were analysed retrospectively by two surgical trainees and confirmed by a radiologist. Biliary tree anatomy was classified from IOC films as described by Couinaud (1957) and correlated with documented findings. The accuracy of intraoperative reporting was assessed. Biliary anatomy was correlated to clinical outcome. RESULTS A total of 95% of IOCs adequately demonstrated biliary anatomy. Aberrant right sectoral ducts were identified in 15.2% of the complete IOCs, and 2.6% demonstrated left sectoral or confluence anomalies. Only 20.4% of these were reported intraoperatively. Bile leaks occurred in two patients who had IOCs (0.73%) and two who did not (7.4%). CONCLUSION Surgeons generally demonstrate biliary anatomy well on IOC but reporting of sectoral duct variation can be improved. Further research is needed to determine whether anatomical variation is related to ductal injury.
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Affiliation(s)
- Marthe Chehade
- Upper Gastrointestinal/HPB Surgery, Westmead Hospital, Westmead, New South Wales, Australia
| | - Benedict Kakala
- Upper Gastrointestinal/HPB Surgery, Westmead Hospital, Westmead, New South Wales, Australia.,School of Medicine, Western Sydney University, Penrith, New South Wales, Australia
| | - Jane-Louise Sinclair
- Upper Gastrointestinal/HPB Surgery, Westmead Hospital, Westmead, New South Wales, Australia
| | - Tony Pang
- Upper Gastrointestinal/HPB Surgery, Westmead Hospital, Westmead, New South Wales, Australia.,School of Medicine, The University of Sydney, Sydney, New South Wales, Australia
| | - Rafid Al Asady
- Department of Radiology, Westmead Hospital, Westmead, New South Wales, Australia
| | - Arthur Richardson
- Upper Gastrointestinal/HPB Surgery, Westmead Hospital, Westmead, New South Wales, Australia.,School of Medicine, The University of Sydney, Sydney, New South Wales, Australia
| | - Henry Pleass
- Upper Gastrointestinal/HPB Surgery, Westmead Hospital, Westmead, New South Wales, Australia.,School of Medicine, The University of Sydney, Sydney, New South Wales, Australia
| | - Vincent Lam
- Upper Gastrointestinal/HPB Surgery, Westmead Hospital, Westmead, New South Wales, Australia.,School of Medicine, The University of Sydney, Sydney, New South Wales, Australia
| | - Emma Johnston
- Upper Gastrointestinal/HPB Surgery, Westmead Hospital, Westmead, New South Wales, Australia.,School of Medicine, The University of Sydney, Sydney, New South Wales, Australia
| | - Lawrence Yuen
- Upper Gastrointestinal/HPB Surgery, Westmead Hospital, Westmead, New South Wales, Australia.,School of Medicine, The University of Sydney, Sydney, New South Wales, Australia
| | - Michael Hollands
- Upper Gastrointestinal/HPB Surgery, Westmead Hospital, Westmead, New South Wales, Australia.,School of Medicine, The University of Sydney, Sydney, New South Wales, Australia
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13
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Verma S, Wichmann MW, Gunning T, Beukes E, Maddern G. Intraoperative cholangiogram during laparoscopic cholecystectomy: A clinical trial in rural setting. Aust J Rural Health 2016; 24:415-421. [DOI: 10.1111/ajr.12279] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/20/2015] [Indexed: 12/13/2022] Open
Affiliation(s)
- Shreya Verma
- Department of General Surgery; Mount Gambier Hospital; Mount Gambier South Australia Australia
| | - Matthias W. Wichmann
- Department of General Surgery; Mount Gambier Hospital; Mount Gambier South Australia Australia
| | - Thomas Gunning
- Department of General Surgery; Mount Gambier Hospital; Mount Gambier South Australia Australia
| | - Eben Beukes
- Department of General Surgery; Mount Gambier Hospital; Mount Gambier South Australia Australia
| | - Guy Maddern
- Division of Surgery; Queen Elizabeth Hospital; University of Adelaide; Woodville South Australia Australia
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14
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YU A, DEMIREL D, HALIC T, KOCKARA S. Virtual Intraoperative Cholangiogram Using WebCL. Stud Health Technol Inform 2016; 220:459-464. [PMID: 27046623 PMCID: PMC5039042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
In this paper, we propose a Virtual Intraoperative Cholangiogram (VIC) training platform. Intraoperative Cholangiogram (IC) is an imaging technique of biliary anatomy with using fluorescent fluids sensitive to the X-Rays. The procedure is often employed to diagnose the difficult cases such as abnormal anatomy or choledocholithiasis during the laparoscopic cholecystectomy. The major challenge in cholangiogram is accurate interpretation of the X-Ray image, which requires extensive case training. However, the training platforms that support generation of various IC cases have been lacking. In this study, we developed a web based platform to generate IC images from any virtual bile duct anatomy. As the generation of X-Ray image from 3D scene is a computationally intensive task, we utilized WebCL technology to parallelize the computation for achieving real-time rates. In this work, we present details of our WebCL IC generation algorithm and benchmark results.
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Affiliation(s)
- Alexander YU
- Department of Computer Science, University of Central Arkansas
| | - Doga DEMIREL
- Department of Computer Science, University of Central Arkansas
| | - Tansel HALIC
- Department of Computer Science, University of Central Arkansas
| | - Sinan KOCKARA
- Department of Computer Science, University of Central Arkansas
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Prevot F, Rebibo L, Cosse C, Browet F, Sabbagh C, Regimbeau JM. Effectiveness of intraoperative cholangiography using indocyanine green (versus contrast fluid) for the correct assessment of extrahepatic bile ducts during day-case laparoscopic cholecystectomy. J Gastrointest Surg 2014; 18:1462-8. [PMID: 24916587 DOI: 10.1007/s11605-014-2560-y] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2013] [Accepted: 05/27/2014] [Indexed: 01/31/2023]
Abstract
INTRODUCTION During cholecystectomy, intraoperative cholangiography using contrast fluid (IOC-CF) is still the "gold standard" for biliary tract identification but has many associated pitfalls. A new IOC technique using indocyanine green (IOC-IG) appears to be promising. Here, we studied the effectiveness of IOC-IG (vs IOC-CF) during day-case laparoscopic cholecystectomy. MATERIALS AND METHODS Over a 6-month period, we included 23 patients (with no cirrhosis or risk factors for choledocholithiasis) scheduled for day-case laparoscopic cholecystectomy. The primary efficacy criterion was the "analyzability rate" (i.e., the ability to identify the cystic duct, the cystic duct-hepatic duct junction, and the common bile duct) for the IOC-CF and IOC-IG procedures after dissection. Indocyanine green was infused under general anesthesia. The same near-infrared laparoscopic imaging system was used for IOC-IG and conventional visual inspection. IOC-CF was always attempted after dissection. Each patient served as his/her own control. Cholecystectomies were video-recorded for subsequent off-line, blind analysis. RESULTS The analyzability rate was 74 % for IOC-IG after dissection, 70 % for IOC-CF (p = 0.03), 26 % for conventional visual inspection, and 48 % for IOC-IG before dissection. When each IOC modality (conventional visual inspection, IOC-IG before and after dissection) was considered as a diagnostic test, the accuracy for simultaneous identification of the three anatomic elements was respectively 48, 52, and 74 %. No adverse events occurred during the IOC-IG procedure. CONCLUSION IOC-IG was feasible and safe. Our results suggest that this technique is more effective than IOC-CF for biliary tract identification after dissection and may constitute a powerful diagnostic test for the detection of extrahepatic ducts.
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Affiliation(s)
- F Prevot
- Department of Digestive and Metabolic Surgery, North Hospital, Amiens University Medical Center, Place Victor Pauchet, F-80054, Amiens, Cedex 1, France
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16
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Connor SJ, Perry W, Nathanson L, Hugh TB, Hugh TJ. Using a standardized method for laparoscopic cholecystectomy to create a concept operation-specific checklist. HPB (Oxford) 2014; 16:422-9. [PMID: 23961737 PMCID: PMC4008160 DOI: 10.1111/hpb.12161] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2013] [Accepted: 06/07/2013] [Indexed: 12/12/2022]
Abstract
OBJECTIVES Prevalences of bile duct injury (BDI) following laparoscopic cholecystectomy (LC) remain unacceptably high. There is no standardized method for performing an LC. This study aims to describe a standardized technique for LC that will allow for the development of a concept LC checklist, the use of which, it is hoped, will decrease the prevalence of BDI. METHODS A standardized method for LC was developed based on previously published expert analysis supplemented by video error analysis of operations in which BDI occurred. Established checklist methodology was then used to construct an LC-specific concept checklist. RESULTS A five-step technique for the safe establishment of the critical view was created to guide the development of the checklist. The five steps are: (i) confirm the gallbladder lies in the hepatic principal plane and is retracted to the 10 o'clock position; (ii) confirm Hartmann's pouch is lifted up and toward the segment IV pedicle; (iii) identify Rouvière's sulcus; (iv) confirm the release of the posterior leaf of the peritoneum covering the hepatobiliary triangle, and (v) confirm the critical view with or without intraoperative cholangiography. CONCLUSIONS A standardized approach to LC would allow for the creation of an LC-specific checklist that has the potential to lower the prevalence of BDI.
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Affiliation(s)
- Saxon J Connor
- Department of Surgery, Christchurch HospitalChristchurch, New Zealand,Correspondence Saxon J. Connor, Department of Surgery, Christchurch Hospital, Christchurch 8000, New Zealand. Tel: + 64 3 364 0640. Fax: + 64 3 364 0352. E-mail:
| | - William Perry
- Department of Surgery, Christchurch HospitalChristchurch, New Zealand
| | - Leslie Nathanson
- Department of Surgery, Royal Brisbane and Women's HospitalBrisbane, Qld, Australia
| | - Thomas B Hugh
- Department of Surgery, St Vincent's HospitalSydney, NSW, Australia
| | - Thomas J Hugh
- Department of Gastrointestinal Surgery, Royal North Shore Hospital, University of SydneySydney, NSW, Australia
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Vadlamudi R, Conway J, Mishra G, Baillie J, Gilliam J, Fernandez A, Evans J. Identifying patients most likely to have a common bile duct stone after a positive intraoperative cholangiogram. Gastroenterol Hepatol (N Y) 2014; 10:240-244. [PMID: 24976807 PMCID: PMC4073535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
The false-positive rates of a positive intraoperative cholangiogram (IOC) are as high as 60%. Endoscopic retrograde cholangiopancreatography (ERCP) for stone removal is required after a positive IOC. It is unclear which clinical factors identify patients most likely to have a stone after a positive IOC. This study was conducted to identify factors predictive of common bile duct (CBD) stone(s) on ERCP after a positive IOC. A retrospective review of our endoscopic database identified all ERCP and/or endoscopic ultrasound (EUS) procedures performed for a positive IOC between August 2003 and August 2009. Collected data included patient demographics; indication for cholecystectomy; IOC findings; blood tests before and after cholecystectomy, including liver function tests, complete blood count, and amylase and lipase measurements; and ERCP and/or EUS results. Patients who had a negative EUS for CBD stones and no subsequent ERCP were contacted by phone to see if they eventually required an ERCP. Univariate and multi-variable analyses were performed. A total of 114 patients were included in the study. IOC findings included a single stone, multiple stones, nonpassage of contrast into the duodenum, dilated CBD, and poor visualization of the bile duct. Eighty-four percent of patients had ERCP only, 9% had EUS only, and 7% had EUS followed by ERCP. Sixty-five patients (57%) had CBD stones on ERCP or EUS. Older age, multiple stones, dilated CBD on IOC, and elevated postcholecystectomy bilirubin levels were the clinical variables with statistically significant differences on univariate analysis. On multivariable analysis, older age and elevated postcholecystectomy total bilirubin levels correlated with the presence of CBD stones on ERCP. Fifty-seven percent of patients referred for endoscopic evaluation after a positive IOC had CBD stones on ERCP. Patients with CBD stones after a positive IOC were more likely to be older with elevated post-cholecystectomy total serum bilirubin levels.
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Affiliation(s)
- Raja Vadlamudi
- Dr Vadlamudi is a gastroenterology fellow in the Department of Medicine at SUNY Upstate Medical University in Syracuse, New York. Drs Conway, Mishra, Gilliam, Fernandez, and Evans are affiliated with the Wake Forest School of Medicine in Winston-Salem, North Carolina. Dr Conway is an assistant professor of internal medicine, director of Endoscopic Ultrasound Services and the Advanced Endoscopy Fellowship Program in the Department of Internal Medicine; Dr Mishra is an associate professor of medicine, director of Endoscopy & Clinical Services, and vice chief of the Division of Gastroenterology; Drs Gilliam and Evans are assistant professors of medicine in the Division of Gastroenterology; and Dr Fernandez is an associate professor of surgery in the Department of General Surgery. Dr Baillie is the director of medical gastro-enterology at the Carteret Medical Group in Morehead City, North Carolina
| | - Jason Conway
- Dr Vadlamudi is a gastroenterology fellow in the Department of Medicine at SUNY Upstate Medical University in Syracuse, New York. Drs Conway, Mishra, Gilliam, Fernandez, and Evans are affiliated with the Wake Forest School of Medicine in Winston-Salem, North Carolina. Dr Conway is an assistant professor of internal medicine, director of Endoscopic Ultrasound Services and the Advanced Endoscopy Fellowship Program in the Department of Internal Medicine; Dr Mishra is an associate professor of medicine, director of Endoscopy & Clinical Services, and vice chief of the Division of Gastroenterology; Drs Gilliam and Evans are assistant professors of medicine in the Division of Gastroenterology; and Dr Fernandez is an associate professor of surgery in the Department of General Surgery. Dr Baillie is the director of medical gastro-enterology at the Carteret Medical Group in Morehead City, North Carolina
| | - Girish Mishra
- Dr Vadlamudi is a gastroenterology fellow in the Department of Medicine at SUNY Upstate Medical University in Syracuse, New York. Drs Conway, Mishra, Gilliam, Fernandez, and Evans are affiliated with the Wake Forest School of Medicine in Winston-Salem, North Carolina. Dr Conway is an assistant professor of internal medicine, director of Endoscopic Ultrasound Services and the Advanced Endoscopy Fellowship Program in the Department of Internal Medicine; Dr Mishra is an associate professor of medicine, director of Endoscopy & Clinical Services, and vice chief of the Division of Gastroenterology; Drs Gilliam and Evans are assistant professors of medicine in the Division of Gastroenterology; and Dr Fernandez is an associate professor of surgery in the Department of General Surgery. Dr Baillie is the director of medical gastro-enterology at the Carteret Medical Group in Morehead City, North Carolina
| | - John Baillie
- Dr Vadlamudi is a gastroenterology fellow in the Department of Medicine at SUNY Upstate Medical University in Syracuse, New York. Drs Conway, Mishra, Gilliam, Fernandez, and Evans are affiliated with the Wake Forest School of Medicine in Winston-Salem, North Carolina. Dr Conway is an assistant professor of internal medicine, director of Endoscopic Ultrasound Services and the Advanced Endoscopy Fellowship Program in the Department of Internal Medicine; Dr Mishra is an associate professor of medicine, director of Endoscopy & Clinical Services, and vice chief of the Division of Gastroenterology; Drs Gilliam and Evans are assistant professors of medicine in the Division of Gastroenterology; and Dr Fernandez is an associate professor of surgery in the Department of General Surgery. Dr Baillie is the director of medical gastro-enterology at the Carteret Medical Group in Morehead City, North Carolina
| | - John Gilliam
- Dr Vadlamudi is a gastroenterology fellow in the Department of Medicine at SUNY Upstate Medical University in Syracuse, New York. Drs Conway, Mishra, Gilliam, Fernandez, and Evans are affiliated with the Wake Forest School of Medicine in Winston-Salem, North Carolina. Dr Conway is an assistant professor of internal medicine, director of Endoscopic Ultrasound Services and the Advanced Endoscopy Fellowship Program in the Department of Internal Medicine; Dr Mishra is an associate professor of medicine, director of Endoscopy & Clinical Services, and vice chief of the Division of Gastroenterology; Drs Gilliam and Evans are assistant professors of medicine in the Division of Gastroenterology; and Dr Fernandez is an associate professor of surgery in the Department of General Surgery. Dr Baillie is the director of medical gastro-enterology at the Carteret Medical Group in Morehead City, North Carolina
| | - Adolfo Fernandez
- Dr Vadlamudi is a gastroenterology fellow in the Department of Medicine at SUNY Upstate Medical University in Syracuse, New York. Drs Conway, Mishra, Gilliam, Fernandez, and Evans are affiliated with the Wake Forest School of Medicine in Winston-Salem, North Carolina. Dr Conway is an assistant professor of internal medicine, director of Endoscopic Ultrasound Services and the Advanced Endoscopy Fellowship Program in the Department of Internal Medicine; Dr Mishra is an associate professor of medicine, director of Endoscopy & Clinical Services, and vice chief of the Division of Gastroenterology; Drs Gilliam and Evans are assistant professors of medicine in the Division of Gastroenterology; and Dr Fernandez is an associate professor of surgery in the Department of General Surgery. Dr Baillie is the director of medical gastro-enterology at the Carteret Medical Group in Morehead City, North Carolina
| | - John Evans
- Dr Vadlamudi is a gastroenterology fellow in the Department of Medicine at SUNY Upstate Medical University in Syracuse, New York. Drs Conway, Mishra, Gilliam, Fernandez, and Evans are affiliated with the Wake Forest School of Medicine in Winston-Salem, North Carolina. Dr Conway is an assistant professor of internal medicine, director of Endoscopic Ultrasound Services and the Advanced Endoscopy Fellowship Program in the Department of Internal Medicine; Dr Mishra is an associate professor of medicine, director of Endoscopy & Clinical Services, and vice chief of the Division of Gastroenterology; Drs Gilliam and Evans are assistant professors of medicine in the Division of Gastroenterology; and Dr Fernandez is an associate professor of surgery in the Department of General Surgery. Dr Baillie is the director of medical gastro-enterology at the Carteret Medical Group in Morehead City, North Carolina
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Slim K, Martin G. Does routine intra-operative cholangiography reduce the risk of biliary injury during laparoscopic cholecystectomy? An evidence-based approach. J Visc Surg 2013; 150:321-4. [PMID: 23911201 DOI: 10.1016/j.jviscsurg.2013.06.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
The role of routine intra-operative cholangiography (IOC) during cholecystectomy remains controversial. The purpose of this evidence-based review was to analyze the role of IOC in the prevention and detection of biliary ductal injury during cholecystectomy. The relative rarity of biliary complications means that the randomized trials and meta-analyses that include fewer than 12,000 patients cannot answer the question. Therefore, only six comparative studies were included in this review. The conclusions of these studies were conflicting, half showing a protective effect of routine IOC and the other half showing no effect. Nevertheless, the U.S. and Swedish studies that included the largest number of patients suggested that, while not a panacea, routine IOC could prevent major biliary injuries (one ductal injury per 500 cholecystectomies). Finally, in the context of risk management, we must also emphasize the educational value of teaching young (and not so young) surgeons how to correctly interpret the operative cholangiogram.
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Affiliation(s)
- K Slim
- Service de chirurgie digestive et Unité de chirurgie ambulatoire, CHU Estaing, 1, place Lucie-Aubrac, 63003 Clermont-Ferrand, France.
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