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Petracchi EJ, Olivieri SE, Varela J, Canullan CM, Zandalazini H, Ocampo C, Quesada BM. Use of artificial intelligence in the detection of the critical view of safety during laparoscopic cholecystectomy. J Gastrointest Surg 2024; 28:877-879. [PMID: 38584017 DOI: 10.1016/j.gassur.2024.03.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Revised: 03/08/2024] [Accepted: 03/15/2024] [Indexed: 04/09/2024]
Abstract
BACKGROUND This study aimed to evaluate the use of artificial intelligence (AI) to detect the critical view of safety during elective laparoscopic cholecystectomy. METHODS This was a prospective, observational study evaluating the detection of the critical view of safety with an AI software in a consecutive series of elective laparoscopic cholecystectomies compared with the blinded evaluation of 3 surgeons. The program was created using the digital tools PyCharm (JetBrains), Google Colab Pro (https://colab.google/), and YOLOv8 (Ultralytics). RESULTS A total of 40 consecutive elective laparoscopic cholecystectomies were included in the study. The program was able to detect the critical view of safety in all cases following the experts' blinded opinion. CONCLUSION In this preliminary experience, an AI software was able to detect the critical view of safety in elective laparoscopic cholecystectomies. Its application during nonelective cases, in which the critical view of safety is harder to achieve, might warrant further studies.
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Affiliation(s)
- Enrique J Petracchi
- Division of General Surgery, Cosme Argerich Hospital, Buenos Aires, Argentina
| | - Sean E Olivieri
- Division of General Surgery, Cosme Argerich Hospital, Buenos Aires, Argentina
| | - Jose Varela
- Division of General Surgery, Cosme Argerich Hospital, Buenos Aires, Argentina
| | - Carlos M Canullan
- Division of General Surgery, Cosme Argerich Hospital, Buenos Aires, Argentina
| | - Hugo Zandalazini
- Division of General Surgery, Cosme Argerich Hospital, Buenos Aires, Argentina
| | - Carlos Ocampo
- Division of General Surgery, Cosme Argerich Hospital, Buenos Aires, Argentina
| | - Bernabé M Quesada
- Division of General Surgery, Cosme Argerich Hospital, Buenos Aires, Argentina.
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2
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Vu HQ, Quach DT, Nguyen BH, Le ATQ, Le NQ, Pham HM, Tran NHT, Nguyen DKH, Duong NST, Tran TV, Pham BL. Clinical presentation, management and outcomes of bile duct injuries after laparoscopic cholecystectomy: a 15-year single-center experience in Vietnam. Front Surg 2023; 10:1280383. [PMID: 37886633 PMCID: PMC10598674 DOI: 10.3389/fsurg.2023.1280383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Accepted: 09/27/2023] [Indexed: 10/28/2023] Open
Abstract
Objectives To evaluate the clinical presentation, management, and outcomes of bile duct injuries (BDIs) after laparoscopic cholecystectomy (LC). Methods This is a case series of 28 patients with BDIs after LC treated at a tertiary hospital in Vietnam during the 2006-2021 period. The BDI's clinical presentations, Strasberg classification types, management methods, and outcomes were reported. Results BDIs were diagnosed intraoperatively in 3 (10.7%) patients and postoperatively in 25 (89.3%). The BDI types included Strasberg A (13, 46.4%), D (1, 3.6%), E1 (1, 3.6%), E2 (4, 14.3%), E3 (5, 17.9%), D + E2 (2, 7.1%), and nonclassified (2, 7.1%). Of the postoperative BDIs, the injury manifested as biliary obstruction (18, 72.0%), bile leak (5, 20.0%), and mixed scenarios (2, 8.0%). Regarding diagnostic methods, endoscopic retrograde cholangiopancreatography (ERCP) was more useful in bile leak scenarios, while multislice computed tomography, magnetic resonance cholangiopancreatography, and percutaneous transhepatic cholangiography were more useful in biliary obstruction scenarios. All 28 BDIs were successfully treated. ERCP with stenting was very effective in the majority of Strasberg A BDIs. For more complex BDI types, hepaticocutaneous jejunostomy was a safe and effective approach. The in-hospital morbidities included postoperative pneumonia (2, 10.7%) and biliary-enteric anastomosis leakage (1, 5.4%). There was no cholangitis or anastomotic stenosis during the follow-up after discharge (median 18 months). Conclusions The majority of BDIs are type A and diagnosed postoperatively. ERCP is effective for the majority of Strasberg A BDIs. For major and complex BDIs, hepaticocutaneous jejunostomy is a safe and effective approach.
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Affiliation(s)
- Hung Quang Vu
- Department of General Surgery, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Vietnam
- Department of Hepatobiliary and Pancreatic Surgery, University Medical Center Ho Chi Minh City, Ho Chi Minh City, Vietnam
| | - Duc Trong Quach
- Department of Internal Medicine, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Vietnam
- GI Endoscopy Department, University Medical Center Ho Chi Minh City, Ho Chi Minh City, Vietnam
| | - Bac Hoang Nguyen
- Department of General Surgery, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Vietnam
- Department of Hepatobiliary and Pancreatic Surgery, University Medical Center Ho Chi Minh City, Ho Chi Minh City, Vietnam
| | - Anh-Tuan Quan Le
- Department of General Surgery, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Vietnam
- Department of Hepatobiliary and Pancreatic Surgery, University Medical Center Ho Chi Minh City, Ho Chi Minh City, Vietnam
| | - Nhan Quang Le
- GI Endoscopy Department, University Medical Center Ho Chi Minh City, Ho Chi Minh City, Vietnam
| | - Hai Minh Pham
- Department of Hepatobiliary and Pancreatic Surgery, University Medical Center Ho Chi Minh City, Ho Chi Minh City, Vietnam
| | - Ngoc-Huy Thai Tran
- Department of Hepatobiliary and Pancreatic Surgery, University Medical Center Ho Chi Minh City, Ho Chi Minh City, Vietnam
| | - Dang-Khoa Hang Nguyen
- Department of Hepatobiliary and Pancreatic Surgery, University Medical Center Ho Chi Minh City, Ho Chi Minh City, Vietnam
| | - Ngoc-Sang Thi Duong
- Department of Hepatobiliary and Pancreatic Surgery, University Medical Center Ho Chi Minh City, Ho Chi Minh City, Vietnam
| | - Toan Van Tran
- Department of Hepatobiliary and Pancreatic Surgery, University Medical Center Ho Chi Minh City, Ho Chi Minh City, Vietnam
| | - Binh Long Pham
- Department of Hepatobiliary and Pancreatic Surgery, University Medical Center Ho Chi Minh City, Ho Chi Minh City, Vietnam
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3
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Chemical thromboprophylaxis before skin closure increases bleeding risk after major ventral hernia repair: A multicenter cohort study. Surgery 2022; 172:198-204. [DOI: 10.1016/j.surg.2022.01.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 12/16/2021] [Accepted: 01/16/2022] [Indexed: 11/24/2022]
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4
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Cirocchi R, Panata L, Griffiths EA, Tebala GD, Lancia M, Fedeli P, Lauro A, Anania G, Avenia S, Di Saverio S, Burini G, De Sol A, Verdelli AM. Injuries during Laparoscopic Cholecystectomy: A Scoping Review of the Claims and Civil Action Judgements. J Clin Med 2021; 10:jcm10225238. [PMID: 34830520 PMCID: PMC8622805 DOI: 10.3390/jcm10225238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Revised: 11/04/2021] [Accepted: 11/08/2021] [Indexed: 11/16/2022] Open
Abstract
Background. To define what type of injuries are more frequently related to medicolegal claims and civil action judgments. Methods. We performed a scoping review on 14 studies and 2406 patients, analyzing medicolegal claims related to laparoscopic cholecystectomy injuries. We have focalized on three phases associated with claims: phase of care, location of injuries, type of injuries. Results. The most common phase of care associated with litigation was the improper intraoperative surgical performance (47.6% ± 28.3%), related to a “poor” visualization, and the improper post-operative management (29.3% ± 31.6%). The highest rate of defense verdicts was reported for the improper post-operative management of the injury (69.3% ± 23%). A lower rate was reported in the incorrect presurgical assessment (39.7% ± 24.4%) and in the improper intraoperative surgical performance (21.39% ± 21.09%). A defense verdict was more common in cystic duct injuries (100%), lower in hepatic bile duct (42.9%) and common bile duct (10%) injuries. Conclusions. During laparoscopic cholecystectomy, the most common cause of claims, associated with lower rate of defense verdict, was the improper intraoperative surgical performance. The decision to take legal action was determined often for poor communication after the original incident.
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Affiliation(s)
- Roberto Cirocchi
- Department of Medicine and Surgery, University of Perugia, 06132 Perugia, Italy; (R.C.); (M.L.); (S.A.)
| | - Laura Panata
- Legal Medicine and Insurance Office, Santa Maria della Misericordia Hospital, 06129 Perugia, Italy; (L.P.); (A.M.V.)
| | - Ewen A. Griffiths
- Department of Upper Gastrointestinal Surgery, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Trust, Birmingham B15 2GW, UK;
- Institute of Cancer and Genomic Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TT, UK
| | - Giovanni D. Tebala
- Surgical Emergency Unit, John Radcliffe Hospital, Oxford University NHS Foundation Trust, Oxford OX3 9DU, UK;
| | - Massimo Lancia
- Department of Medicine and Surgery, University of Perugia, 06132 Perugia, Italy; (R.C.); (M.L.); (S.A.)
| | - Piergiorgio Fedeli
- School of Law, Legal Medicine, University of Camerino, 62032 Camerino, Italy;
| | - Augusto Lauro
- Department of Surgical Sciences, Hospital “Policlinico Umberto I”, “Sapienza” University of Rome, 00161 Rome, Italy;
| | - Gabriele Anania
- Department of Medical Science, University of Ferrara, 44121 Ferrara, Italy;
| | - Stefano Avenia
- Department of Medicine and Surgery, University of Perugia, 06132 Perugia, Italy; (R.C.); (M.L.); (S.A.)
| | - Salomone Di Saverio
- Department of General Surgery, ASUR Marche, AV5, Hospital of San Benedetto del Tronto, 63074 San Benedetto del Tronto, Italy;
| | - Gloria Burini
- Department of General and Emergency Surgery, Hospital “Ospedali Riuniti di Ancona”, 60126 Ancona, Italy
- Correspondence: ; Tel.: +39-3465700300
| | - Angelo De Sol
- Department of General Surgery, St. Maria Hospital, 05100 Terni, Italy;
| | - Anna Maria Verdelli
- Legal Medicine and Insurance Office, Santa Maria della Misericordia Hospital, 06129 Perugia, Italy; (L.P.); (A.M.V.)
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5
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Moldovan C, Cochior D, Gorecki G, Rusu E, Ungureanu FD. Clinical and surgical algorithm for managing iatrogenic bile duct injuries during laparoscopic cholecystectomy: A multicenter study. Exp Ther Med 2021; 22:1385. [PMID: 34650633 PMCID: PMC8506945 DOI: 10.3892/etm.2021.10821] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 08/11/2021] [Indexed: 12/15/2022] Open
Abstract
The present study was a multicenter, analytical, nonrandomized research on 108 cases of intraoperative vascular and bile duct lesions during laparoscopic cholecystectomies. We selected these cases from 16,559 cholecystectomies performed entirely laparoscopically or debuted laparoscopically and converted to an open approach. The study included two surgical centers labeled as primary, with extensive experience in hepato-biliary reconstructive surgery, and four other centers labeled as secondary that referred cases to the previous two. Our study analyzed several key parameters such as the percentage of iatrogenic lesions recorded, the variability of the main biliary pathway and conformation as well as its relationship to the adjacent critical anatomical landmarks, the anatomical and physiopathological characteristics of pathology requiring surgical intervention, factors related to laparoscopic surgical technique, the surgical technique used to repair the recorded lesions, the duration of survivability and the rate of the occurring complications. Based on the analysis of these parameters, we developed a descriptive algorithm with visual representation relying on several decisional points to guide the surgeons in choosing the optimal treatment method so that patients will benefit from a favorable clinical path.
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Affiliation(s)
- Cosmin Moldovan
- Faculty of Medicine, 'Titu Maiorescu' University, 040441 Bucharest, Romania.,General Surgery Ward, 'Witting' Clinical Hospital, 010243 Bucharest, Romania
| | - Daniel Cochior
- Faculty of Medicine, 'Titu Maiorescu' University, 040441 Bucharest, Romania.,General Surgery, 'Sanador' Clinical Hospital, 010991 Bucharest, Romania.,General Surgery, 'Monza' Clinical Hospital, 021967 Bucharest, Romania
| | - Gabriel Gorecki
- Medicine Doctoral School, 'Titu Maiorescu' University, 040317 Bucharest, Romania
| | - Elena Rusu
- Faculty of Medicine, 'Titu Maiorescu' University, 040441 Bucharest, Romania
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Lefebvre G, Devenny KA, Héroux DL, Bowman CL, Neilson HK, Mimeault R, Singh SS, Calder LA. Intraoperative injuries from abdominopelvic surgery: an analysis of national medicolegal data. Can J Surg 2021; 64:E127-E134. [PMID: 33666381 PMCID: PMC8064243 DOI: 10.1503/cjs.010219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Background Intraoperative injuries during abdominopelvic surgery can be associated with substantial patient harm. The objective of this study was to describe abdominopelvic intraoperative injuries and their contributing factors among medicolegal cases. Methods This study was a descriptive analysis of medicolegal matters reported to a national body, with subgroup analyses by type of surgery. We reviewed medicolegal matters involving a population-based sample of physicians who were subject to a civil legal action or complaint to a regulatory authority that was closed between 2013 and 2017 in Canada. Results Our analysis included 181 civil legal cases and 88 complaints to a regulatory authority. Among legal cases, 155 patients (85.6%) (median age 47 yr) underwent elective procedures. The most common injury site was the bowel (53 cases [29.3%]). Injuries frequently occurred during dissection (79 [43.6%]) and ligation (38 [21.0%]), were identified postoperatively (138 [76.2%]) and necessitated further surgery (139 [76.8%]). Many patients experienced severe harm (55 [30.4%]) or died (25 [13.8%]). Peer experts in nongynecologic cases were more likely than those in gynecologic cases to include criticisms of a provider in a harmful incident (79 [71.2%] v. 30 [42.9%], p < 0.01). Peer expert criticisms often related to clinical evaluation, decision-making and misidentification of anatomy. Criticisms of nontechnical skills identified documentation and communication deficiencies. Conclusion This study confirms the importance of provider and team training to improve clinical evaluation and decision-making, documentation and communication. Effective protocols may help support clinicians in providing safer surgical care.
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Affiliation(s)
- Guylaine Lefebvre
- From Practice Improvement, Canadian Medical Protective Association, Ottawa, Ont. (Lefebvre, Mimeault); Medical Care Analytics, Canadian Medical Protective Association, Ottawa, Ont. (Devenny, Héroux, Bowman, Neilson, Calder); the Department of Obstetrics and Gynecology, University of Ottawa, Shirley E. Greenberg Women's Health Centre, Ottawa, Ont. (Singh); and the Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ont. (Calder)
| | - Kirsten A Devenny
- From Practice Improvement, Canadian Medical Protective Association, Ottawa, Ont. (Lefebvre, Mimeault); Medical Care Analytics, Canadian Medical Protective Association, Ottawa, Ont. (Devenny, Héroux, Bowman, Neilson, Calder); the Department of Obstetrics and Gynecology, University of Ottawa, Shirley E. Greenberg Women's Health Centre, Ottawa, Ont. (Singh); and the Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ont. (Calder)
| | - Diane L Héroux
- From Practice Improvement, Canadian Medical Protective Association, Ottawa, Ont. (Lefebvre, Mimeault); Medical Care Analytics, Canadian Medical Protective Association, Ottawa, Ont. (Devenny, Héroux, Bowman, Neilson, Calder); the Department of Obstetrics and Gynecology, University of Ottawa, Shirley E. Greenberg Women's Health Centre, Ottawa, Ont. (Singh); and the Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ont. (Calder)
| | - Cara L Bowman
- From Practice Improvement, Canadian Medical Protective Association, Ottawa, Ont. (Lefebvre, Mimeault); Medical Care Analytics, Canadian Medical Protective Association, Ottawa, Ont. (Devenny, Héroux, Bowman, Neilson, Calder); the Department of Obstetrics and Gynecology, University of Ottawa, Shirley E. Greenberg Women's Health Centre, Ottawa, Ont. (Singh); and the Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ont. (Calder)
| | - Heather K Neilson
- From Practice Improvement, Canadian Medical Protective Association, Ottawa, Ont. (Lefebvre, Mimeault); Medical Care Analytics, Canadian Medical Protective Association, Ottawa, Ont. (Devenny, Héroux, Bowman, Neilson, Calder); the Department of Obstetrics and Gynecology, University of Ottawa, Shirley E. Greenberg Women's Health Centre, Ottawa, Ont. (Singh); and the Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ont. (Calder)
| | - Richard Mimeault
- From Practice Improvement, Canadian Medical Protective Association, Ottawa, Ont. (Lefebvre, Mimeault); Medical Care Analytics, Canadian Medical Protective Association, Ottawa, Ont. (Devenny, Héroux, Bowman, Neilson, Calder); the Department of Obstetrics and Gynecology, University of Ottawa, Shirley E. Greenberg Women's Health Centre, Ottawa, Ont. (Singh); and the Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ont. (Calder)
| | - Sukhbir S Singh
- From Practice Improvement, Canadian Medical Protective Association, Ottawa, Ont. (Lefebvre, Mimeault); Medical Care Analytics, Canadian Medical Protective Association, Ottawa, Ont. (Devenny, Héroux, Bowman, Neilson, Calder); the Department of Obstetrics and Gynecology, University of Ottawa, Shirley E. Greenberg Women's Health Centre, Ottawa, Ont. (Singh); and the Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ont. (Calder)
| | - Lisa A Calder
- From Practice Improvement, Canadian Medical Protective Association, Ottawa, Ont. (Lefebvre, Mimeault); Medical Care Analytics, Canadian Medical Protective Association, Ottawa, Ont. (Devenny, Héroux, Bowman, Neilson, Calder); the Department of Obstetrics and Gynecology, University of Ottawa, Shirley E. Greenberg Women's Health Centre, Ottawa, Ont. (Singh); and the Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ont. (Calder)
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7
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Liu DS, Stevens S, Wong E, Fong J, Mori K, Fleming N, Beh PS, Crowe A, Howard T, Slevin M, Jain A, Gill AS, Lee S, Jamel W, Bennet S, Chung C, Ward S, Muralidharan V. Variations in practice of thromboprophylaxis across general surgical subspecialties: a multicentre (PROTECTinG) study of elective major surgeries. ANZ J Surg 2020; 90:2441-2448. [PMID: 33124123 DOI: 10.1111/ans.16374] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Revised: 09/20/2020] [Accepted: 09/21/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Despite guidelines recommending perioperative thromboprophylaxis for patients undergoing general surgery, we have observed significant variations in its practice. This may compromise patient safety. Here, we quantify the heterogeneity of perioperative thromboprophylaxis across all major general surgical operations, and place them in relation to their risk of bleeding and venous thromboembolism. METHODS Retrospective review of all elective major general surgeries performed between 1 January 2018 and 30 June 2019 across seven Victorian hospitals was conducted. RESULTS A total of 5912 patients who underwent 6628 procedures were reviewed. Significant heterogeneity was found in the use of chemoprophylaxis, timing of its initiation, type of anticoagulant administered and application of extended chemoprophylaxis. These variations were observed within the same procedure, and between different surgeries and subspecialties. Contrastingly, there was minimal heterogeneity with the use of mechanical thromboprophylaxis. Oesophago-gastric, liver and colorectal cancer resections had the highest thromboembolic risk. Breast, oesophago-gastric, liver, pancreas and colon cancer resections had the highest bleeding risk. CONCLUSION Perioperative chemoprophylaxis across general surgery is highly variable. This study has highlighted key areas of variance. Our findings also enable surgeons to compare their practices, and provide baseline data to inform future efforts towards optimizing thromboprophylaxis for general surgical patients.
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Affiliation(s)
- David S Liu
- Department of Surgery, Austin Health, Melbourne, Victoria, Australia.,Department of Surgery, Northern Health, Melbourne, Victoria, Australia.,Department of Surgery and Perioperative Medicine, Flinders Medical Centre, Adelaide, South Australia, Australia
| | - Sean Stevens
- Department of Surgery, Austin Health, Melbourne, Victoria, Australia.,Austin Precinct, Department of Surgery, The University of Melbourne, Melbourne, Victoria, Australia
| | - Enoch Wong
- Department of Surgery, Box Hill Hospital, Melbourne, Victoria, Australia
| | - Jonathan Fong
- Department of Surgery, Austin Health, Melbourne, Victoria, Australia
| | - Krinal Mori
- Department of Surgery, Austin Health, Melbourne, Victoria, Australia.,Department of Surgery, Northern Health, Melbourne, Victoria, Australia.,Northern Precinct, Department of Surgery, The University of Melbourne, Melbourne, Victoria, Australia
| | - Nicola Fleming
- Department of Surgery, Austin Health, Melbourne, Victoria, Australia
| | - Pith Soh Beh
- Department of Surgery, Northern Health, Melbourne, Victoria, Australia
| | - Amy Crowe
- Department of Surgery, Box Hill Hospital, Melbourne, Victoria, Australia
| | - Tess Howard
- Department of Surgery, Austin Health, Melbourne, Victoria, Australia
| | - Maeve Slevin
- Department of Surgery, Northern Health, Melbourne, Victoria, Australia
| | - Anshini Jain
- Department of Surgery, Box Hill Hospital, Melbourne, Victoria, Australia
| | - Anna Sonia Gill
- Department of Surgery, Austin Health, Melbourne, Victoria, Australia
| | - Sharon Lee
- Department of Surgery, Northern Health, Melbourne, Victoria, Australia
| | - Wael Jamel
- Department of Surgery, Austin Health, Melbourne, Victoria, Australia
| | - Simon Bennet
- Department of Surgery, Austin Health, Melbourne, Victoria, Australia
| | - Chi Chung
- Department of Surgery, Box Hill Hospital, Melbourne, Victoria, Australia
| | - Salena Ward
- Department of Surgery, Box Hill Hospital, Melbourne, Victoria, Australia.,Monash University Eastern Health Clinical School, Melbourne, Victoria, Australia
| | - Vijayaragavan Muralidharan
- Department of Surgery, Austin Health, Melbourne, Victoria, Australia.,Austin Precinct, Department of Surgery, The University of Melbourne, Melbourne, Victoria, Australia
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- Department of Surgery, Austin Health, Melbourne, Victoria, Australia
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8
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Farooq A, Bae J, Rice D, Moro A, Paredes AZ, Crisp AL, Windholtz M, Sahara K, Tsilimigras DI, Hyer JM, Merath K, Mehta R, Parasidis E, Pawlik TM. Inside the courtroom: An analysis of malpractice litigation in gallbladder surgery. Surgery 2020; 168:56-61. [DOI: 10.1016/j.surg.2020.04.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2019] [Revised: 01/26/2020] [Accepted: 04/07/2020] [Indexed: 01/10/2023]
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9
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Gupta V, Gupta A, Yadav TD, Mittal BR, Kochhar R. Post-cholecystectomy acute injury: What can go wrong? Ann Hepatobiliary Pancreat Surg 2019; 23:138-144. [PMID: 31225415 PMCID: PMC6558122 DOI: 10.14701/ahbps.2019.23.2.138] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2018] [Revised: 02/18/2019] [Accepted: 02/21/2019] [Indexed: 12/14/2022] Open
Abstract
Backgrounds/Aims Most of the emphasis of postcholecystectomy injuries is laid on iatrogenic bilary trauma. However, they can involve a wide spectrum of injuries. Methods We prospectively evaluated 42 patients with postcholecystectomy injuries referred to us from July 2011 to December 2012. Based on spectrum of injuries, we proposed an algorithm of management. Results Injuries occurred following laparoscopy in 20 (2 converted) patients and open in 22 patients. Mean time of detection of injury was 4.32±2.33 days. The nature of drainage was bilious in 36, bile with blood in 2, only blood in 2, and enteric in 2. Nine had organ failure at presentation. Six (14%) needed re-operation. Source of hemorrhage was from right hepatic artery in three and small bowel mesentry in 1. Enteric injuries were one each to duodenum and colon. Six patient (14%) died. Advancing age and organ failure were the predictors of mortality. Persistant biliary fistula was seen in 5 (14%). Ten had lateral leaks that closed at 28.89±2.34 days. Twenty-two formed stricture which was successfully managed with definitive hepaticojejunostomy. Conclusions Post cholecystectomy acute injury does not limit itself to bile duct or vascular injury but it can traumatize adjacent hollow viscus or mesentery. It is important to diagnose and intervene enteric injury early. Presentation and management for such injury should be followed as per the proposed algorithm.
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Affiliation(s)
- Vikas Gupta
- Department of General Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ashish Gupta
- Department of General Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Thakur Deen Yadav
- Department of General Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Bhagwant Rai Mittal
- Department of Nuclear Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Rakesh Kochhar
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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10
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Tonolini M, Ierardi AM, Patella F, Carrafiello G. Early cross-sectional imaging following open and laparoscopic cholecystectomy: a primer for radiologists. Insights Imaging 2018; 9:925-941. [PMID: 30390275 PMCID: PMC6269337 DOI: 10.1007/s13244-018-0663-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Revised: 09/16/2018] [Accepted: 09/27/2018] [Indexed: 12/12/2022] Open
Abstract
Abstract Performed on either an elective or urgent basis, cholecystectomy currently represents the most common abdominal operation due to the widespread use of laparoscopy and the progressively expanded indications. Compared to traditional open surgery, laparoscopic cholecystectomy minimised the duration of hospitalisation and perioperative mortality. Albeit generally considered safe, cholecystectomy may result in adverse outcomes with non-negligible morbidity. Furthermore, the incidence of worrisome haemorrhages and biliary complications has not been influenced by the technique shift. Due to the growing medico-legal concerns and the vast number of cholecystectomies, radiologists are increasingly requested to investigate recently operated patients. Aiming to increase familiarity with post-cholecystectomy cross-sectional imaging, this paper provides a brief overview of indications and surgical techniques and illustrates the expected early postoperative imaging findings. Afterwards, most iatrogenic complications following open, converted, laparoscopic and laparo-endoscopic rendezvous cholecystectomy are reviewed with examples, including infections, haematoma and active bleeding, residual choledocholithiasis, pancreatitis, biliary obstruction and leakage. Multidetector computed tomography (CT) represents the “workhorse” modality to rapidly investigate the postoperative abdomen in order to provide a reliable basis for an appropriate choice between conservative, interventional or surgical treatment. Emphasis is placed on the role of early magnetic resonance cholangiopancreatography (MRCP) and additional gadoxetic acid-enhanced MRCP to provide a non-invasive anatomic and functional assessment of the operated biliary tract. Teaching Points • Having minimised perioperative mortality and hospital stay, laparoscopy has now become the first-line approach to performing cholecystectomy, even in patients with acute cholecystitis. • Laparoscopic, laparo-endoscopic rendezvous, converted and open cholecystectomy remain associated with non-negligible morbidity, including surgical site infections, haemorrhage, residual lithiasis, pancreatitis, biliary obstruction and leakage. • Contrast-enhanced multidetector computed tomography (CT) is increasingly requested early after cholecystectomy and represents the “workhorse” modality that rapidly provides a comprehensive assessment of the operated biliary tract and abdomen. • Magnetic resonance cholangiopancreatography (MRCP) is the best modality to provide anatomic visualisation of the operated biliary tract and is indicated when biliary complications are suspected. • Additional gadoxetic acid (Gd-EOB-DTPA)-enhanced MRCP non-invasively provides functional biliary assessment, in order to confirm and visualise bile leakage.
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Affiliation(s)
- Massimo Tonolini
- Department of Radiology, "Luigi Sacco" University Hospital, Via G.B. Grassi 74, 20157, Milan, Italy.
| | - Anna Maria Ierardi
- Diagnostic and Interventional Radiology Department, ASST Santi Paolo e Carlo, Via A di Rudinì 8, 20142, Milan, Italy
| | - Francesca Patella
- Diagnostic and Interventional Radiology Department, ASST Santi Paolo e Carlo, Via A di Rudinì 8, 20142, Milan, Italy
| | - Gianpaolo Carrafiello
- Diagnostic and Interventional Radiology Department, ASST Santi Paolo e Carlo, Via A di Rudinì 8, 20142, Milan, Italy
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11
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Künzli BM, Spohnholz J, Braumann C, Shrikhande SV, Uhl W. Clinical Impact of Iatrogenic Small Bowel Perforation Secondary to Laparoscopic Cholecystectomy: A Single-center Experience. Surg Laparosc Endosc Percutan Tech 2018; 28:309-313. [PMID: 30067585 DOI: 10.1097/sle.0000000000000561] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Bowel, vascular, and biliary injuries during laparoscopic cholecystectomy (LC) have to be addressed with high priority. The focus of this study was on small bowel injury (SBI) and its impact on clinical management. METHODS We report 5 cases of SBI in a retrospective database of 2062 consecutive LC between January 2004 and December 2017. RESULTS We report isolated iatrogenic SBI in 0.24% (5 of 2062) after LC. We identified 3 cases with SBI associated with the technique of Hasson or related problems with intraoperative relaxation toward the end of the LC. All 5 patients needed at least 1 reoperation. There was no mortality in this series and all patients with iatrogenic SBI got discharged from the clinic in good health. Nevertheless, 3 of 5 patients (60%) with SBI filed a law suit. CONCLUSIONS Isolated iatrogenic SBI is a rare but dreaded complication after LC with high impact on patient's health and prone for medicolegal claims. Strict precaution on thorough relaxation throughout the operation, meticulous handling of closing technique of the fascial layer and "eternal vigilance" are mandatory to reduce risks of SBI after LC.
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Affiliation(s)
- Beat M Künzli
- Department of Surgery, University Hospital Bochum, Bochum, Germany
| | | | - Chris Braumann
- Department of Surgery, University Hospital Bochum, Bochum, Germany
| | | | - Waldemar Uhl
- Department of Surgery, University Hospital Bochum, Bochum, Germany
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12
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Siqueira OHK, Oliveira KJ, Carvalho ACG, da Nóbrega ACL, Medeiros RF, Felix-Patrício B, Áscoli FO, Olej B. Effect of tamoxifen on fibrosis, collagen content and transforming growth factor-β1, -β2 and -β3 expression in common bile duct anastomosis of pigs. Int J Exp Pathol 2017; 98:269-277. [PMID: 29205609 DOI: 10.1111/iep.12250] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2017] [Accepted: 09/01/2017] [Indexed: 12/14/2022] Open
Abstract
End-to-end anastomosis in the treatment for bile duct injury during laparoscopic cholecystectomy has been associated with stricture formation. The aim of this study was to experimentally investigate the effect of oral tamoxifen (tmx) treatment on fibrosis, collagen content and transforming growth factor-β1, -β2 and -β3 expression in common bile duct anastomosis of pigs. Twenty-six pigs were divided into three groups [sham (n = 8), control (n = 9) and tmx (n = 9)]. The common bile ducts were transected and anastomosed in the control and tmx groups. Tmx (40 mg/day) was administered orally to the tmx group, and the animals were euthanized after 60 days. Fibrosis was analysed by Masson's trichrome staining. Picrosirius red was used to quantify the total collagen content and collagen type I/III ratio. mRNA expression of transforming growth factor (TGF)-β1, -β2 and -β3 was quantified using real-time polymerase chain reaction (qRT-PCR). The control and study groups exhibited higher fibrosis than the sham group, and the study group showed lower fibrosis than the control group (P = 0.011). The control and tmx groups had higher total collagen content than the sham group (P = 0.003). The collagen type I/III ratio was higher in the control group than in the sham and tmx groups (P = 0.015). There were no significant differences in the mRNA expression of TGF-β1, -β2 and -β3 among the groups (P > 0.05). Tmx decreased fibrosis and prevented the change in collagen type I/III ratio caused by the procedure.
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Affiliation(s)
| | - Karen Jesus Oliveira
- Department of Physiology and Pharmacology, Fluminense Federal University, Niterói, Rio de Janeiro, Brazil
| | | | | | - Renata Frauches Medeiros
- Department of Physiology and Pharmacology, Fluminense Federal University, Niterói, Rio de Janeiro, Brazil
| | - Bruno Felix-Patrício
- Department of Natural Science, Fluminense Federal University, Rio das Ostras, Rio de Janeiro, Brazil
| | - Fábio Otero Áscoli
- Department of Physiology and Pharmacology, Fluminense Federal University, Niterói, Rio de Janeiro, Brazil
| | - Beni Olej
- Department of Clinical Medicine, Fluminense Federal University, Niterói, Rio de Janeiro, Brazil
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13
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Gordon-Weeks A, Samarendra H, de Bono J, Soonawalla Z, Silva M. Surgeons opinions of legal practice in bile duct injury following cholecystectomy. HPB (Oxford) 2017; 19:721-726. [PMID: 28526400 DOI: 10.1016/j.hpb.2017.04.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Revised: 04/17/2017] [Accepted: 04/21/2017] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Litigation for bile duct injury following laparoscopic cholecystectomy places financial strain on the health service, causes significant patient morbidity and adversely affects the patient and surgeon. Claimants argue that the injury itself is evidence of negligence. METHODS A questionnaire addressing views on BDI causation was sent to members of AUGIS working in the National Health Service, UK. Response themes and responses were compared between groups of surgeons. RESULTS Of 117 respondents, 45% experienced BDI and 22% had medicolegal experience. 47% of respondents identified factors outside the surgeons control as being relevant to BDI. Those that had experienced BDI from their own surgery were less likely to identify surgeon/systems errors as the primary cause for BDI than those that had not (34% vs 74%, p < 0.001). Medicolegal expert surgeons were more likely to report that substandard technique should be presumed (50% vs 19%, p = 0.002), however, 25% of medicolegal experts indicated that not all BDIs caused by their own surgery could have been avoided. CONCLUSION A significant number of experienced surgeons indicated that BDI following LC should not be assumed to result from surgeon negligence or institutional failure. This suggests that negligence should not be inferred from the act of BDI alone.
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Affiliation(s)
| | | | - John de Bono
- Serjeants' Inn Chambers, 85 Fleet Street, London EC4Y 1AE, UK
| | - Zahir Soonawalla
- Department of Hepatobiliary Surgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Michael Silva
- Department of Hepatobiliary Surgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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14
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Pochhammer J, Lang S, Scuffi B, Schäffer M, Smaxwil CA. Are routine ultrasound examinations helpful in the detection of bleeding complications following laparoscopic inguinal hernia repair? JOURNAL OF CLINICAL ULTRASOUND : JCU 2017; 45:145-149. [PMID: 27696438 DOI: 10.1002/jcu.22397] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/17/2016] [Revised: 07/22/2016] [Accepted: 08/05/2016] [Indexed: 06/06/2023]
Abstract
PURPOSE Intraabdominal bleeding is a dreaded complication after laparoscopic transabdominal preperitoneal inguinal hernia repairs. Routine postoperative sonographic (US) examination and hemoglobin measurement have been suggested to identify bleeding after surgery. We retrospectively assessed the value of these tests. METHODS A total of 995 consecutive patients admitted for laparoscopic inguinal hernia repair to a single teaching hospital were analyzed. US examinations were performed postoperatively on the operative day to identify intraabdominal bleeding. In addition, hemoglobin measurements were obtained on the first postoperative day. RESULTS Postoperative US examinations were performed on 971 patients (97.6%). Of these, 945 were examined within 24 hours of surgery. Reoperation was necessary in 1.1% (11/995) of the patients because of a persistent seroma in five cases, intraabdominal or inguinal bleeding or hematomas in five cases, and a trocar hernia in one case. In none of the 11 patients requiring reoperation did US examination or hemoglobin measurement indicate acute bleeding or hematoma. CONCLUSIONS Routine postoperative US examination and hemoglobin measurement within the first 24 hours of surgery are not suitable for identifying patients with intraabdominal bleeding who require a reoperation. Instead, US examination and hemoglobin measurement should be part of the patient workup when there is a clinical suspicion of a postoperative complication. © 2016 Wiley Periodicals, Inc. J Clin Ultrasound 45:145-149, 2017.
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Affiliation(s)
- Julius Pochhammer
- Marienhospital Stuttgart, Department of Visceral, General and Thoracic Surgery, Stuttgart, Germany
| | - Stefanie Lang
- Marienhospital Stuttgart, Department of Visceral, General and Thoracic Surgery, Stuttgart, Germany
| | - Bettina Scuffi
- Marienhospital Stuttgart, Department of Visceral, General and Thoracic Surgery, Stuttgart, Germany
| | - Michael Schäffer
- Marienhospital Stuttgart, Department of Visceral, General and Thoracic Surgery, Stuttgart, Germany
| | - Constantin A Smaxwil
- Diakonissenkrankenhaus Stuttgart, Department of Endocrine Surgery, Stuttgart, Germany
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15
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Abbasoğlu O, Tekant Y, Alper A, Aydın Ü, Balık A, Bostancı B, Coker A, Doğanay M, Gündoğdu H, Hamaloğlu E, Kapan M, Karademir S, Karayalçın K, Kılıçturgay S, Şare M, Tümer AR, Yağcı G. Prevention and acute management of biliary injuries during laparoscopic cholecystectomy: Expert consensus statement. ULUSAL CERRAHI DERGISI 2016; 32:300-305. [PMID: 28149133 DOI: 10.5152/ucd.2016.3683] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/11/2016] [Accepted: 09/13/2016] [Indexed: 12/17/2022]
Abstract
Gallstone disease is very common and laparoscopic cholecystectomy is one of the most common surgical procedures all over the world. Parallel to the increase in the number of laparoscopic cholecystectomies, bile duct injuries also increased. The reported incidence of bile duct injuries ranges from 0.3% to 1.4%. Many of the bile duct injuries during laparoscopic cholecystectomy are not due to inexperience, but are the result of basic technical failures and misinterpretations. A working group of expert hepatopancreatobiliary surgeons, an endoscopist, and a specialist of forensic medicine study searched and analyzed the publications on safe cholecystectomy and biliary injuries complicating laparoscopic cholecystectomy under the organization of Turkish Hepatopancreatobiliary Surgery Association. After a series of e-mail communications and two conferences, the expert panel developed consensus statements for safe cholecystectomy, management of biliary injuries and medicolegal issues. The panel concluded that iatrogenic biliary injury is an overwhelming complication of laparoscopic cholecystectomy and an important issue in malpractice claims. Misidentification of the biliary system is the major cause of biliary injuries. To avoid this, the "critical view of safety" technique should be employed in all the cases. If biliary injury is identified intraoperatively, reconstruction should only be performed by experienced hepatobiliary surgeons. In the postoperative period, any deviation from the expected clinical course of recovery should alert the surgeon about the possibility of biliary injury.
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Affiliation(s)
- Osman Abbasoğlu
- Turkish Association of Hepatopancreatobiliary Surgery Study Group, Ankara, Turkey
| | - Yaman Tekant
- Turkish Association of Hepatopancreatobiliary Surgery Study Group, Ankara, Turkey
| | - Aydın Alper
- Turkish Association of Hepatopancreatobiliary Surgery Study Group, Ankara, Turkey
| | - Ünal Aydın
- Turkish Association of Hepatopancreatobiliary Surgery Study Group, Ankara, Turkey
| | - Ahmet Balık
- Turkish Association of Hepatopancreatobiliary Surgery Study Group, Ankara, Turkey
| | - Birol Bostancı
- Turkish Association of Hepatopancreatobiliary Surgery Study Group, Ankara, Turkey
| | - Ahmet Coker
- Turkish Association of Hepatopancreatobiliary Surgery Study Group, Ankara, Turkey
| | - Mutlu Doğanay
- Turkish Association of Hepatopancreatobiliary Surgery Study Group, Ankara, Turkey
| | - Haldun Gündoğdu
- Turkish Association of Hepatopancreatobiliary Surgery Study Group, Ankara, Turkey
| | - Erhan Hamaloğlu
- Turkish Association of Hepatopancreatobiliary Surgery Study Group, Ankara, Turkey
| | - Metin Kapan
- Turkish Association of Hepatopancreatobiliary Surgery Study Group, Ankara, Turkey
| | - Sedat Karademir
- Turkish Association of Hepatopancreatobiliary Surgery Study Group, Ankara, Turkey
| | - Kaan Karayalçın
- Turkish Association of Hepatopancreatobiliary Surgery Study Group, Ankara, Turkey
| | - Sadık Kılıçturgay
- Turkish Association of Hepatopancreatobiliary Surgery Study Group, Ankara, Turkey
| | - Mustafa Şare
- Turkish Association of Hepatopancreatobiliary Surgery Study Group, Ankara, Turkey
| | - Ali Rıza Tümer
- Turkish Association of Hepatopancreatobiliary Surgery Study Group, Ankara, Turkey
| | - Gökhan Yağcı
- Turkish Association of Hepatopancreatobiliary Surgery Study Group, Ankara, Turkey
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16
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Giraldo P, Sato L, Martínez-Sánchez JM, Comas M, Dwyer K, Sala M, Castells X. Eleven-year descriptive analysis of closed court verdicts on medical errors in Spain and Massachusetts. BMJ Open 2016; 6:e011644. [PMID: 27577585 PMCID: PMC5013385 DOI: 10.1136/bmjopen-2016-011644] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVES To evaluate and compare the characteristics of court verdicts on medical errors allegedly harming patients in Spain and Massachusetts from 2002 to 2012. DESIGN, SETTING AND PARTICIPANTS We reviewed 1041 closed court verdicts obtained from data on litigation in the Thomson Reuters Aranzadi Westlaw databases in Spain (Europe), and 370 closed court verdicts obtained from the Controlled Risk and Risk Management Foundation of Harvard Medical Institutions (CRICO/RMF) in Massachusetts (USA). We included closed court verdicts on medical errors. The definition of medical errors was based on that of the Institute of Medicine (USA). We excluded any agreements between parties before a judgement. RESULTS Medical errors were involved in 25.9% of court verdicts in Spain and in 74% of those in Massachusetts. The most frequent cause of medical errors was a diagnosis-related problem (25.1%; 95% CI 20.7% to 31.1% in Spain; 35%; 95% CI 29.4% to 40.7% in Massachusetts). The proportion of medical errors classified as high severity was 34% higher in Spain than in Massachusetts (p=0.001). The most frequent factors contributing to medical errors in Spain were surgical and medical treatment (p=0.001). In Spain, 98.5% of medical errors resulted in compensation awards compared with only 6.9% in Massachusetts. CONCLUSIONS This study reveals wide differences in litigation rates and the award of indemnity payments in Spain and Massachusetts; however, common features of both locations are the high rates of diagnosis-related problems and the long time interval until resolution.
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Affiliation(s)
- Priscila Giraldo
- Risk Management Foundation of Harvard Medical Institutions, Cambridge, Massachusetts, USA
- Epidemiology and Evaluation Department, Hospital del Mar, Barcelona, Spain
- IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain
- Escuela Superior de Enfermería del Mar, Centro adscrito a la Universitat Pompeu Fabra, Barcelona, Spain
- Programa de Doctorado en Metodología de la Investigación Biomédica y Salud Pública, Universitat Autónoma de Barcelona, Barcelona, Spain
- Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Madrid, Spain
| | - Luke Sato
- Risk Management Foundation of Harvard Medical Institutions, Cambridge, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Jose M Martínez-Sánchez
- Tobacco Control Unit, Cancer Prevention and Control Program, Institut Català d'Oncologia, L'Hospitalet de Llobregat, Barcelona, Spain
- Cancer Prevention and Control Group, Institut d'Investigació Biomèdica de Bellvitge—IDIBELL, L'Hospitalet de Llobregat, Barcelona, Spain
- Biostatistics Unit, Department of Basic Sciences, Universitat Internacional de Catalunya, Sant Cugat del Vallès, Spain
- Public Health Advocacy Institute, Northeastern University School of Law, Boston, Massachusetts, USA
| | - Mercè Comas
- Epidemiology and Evaluation Department, Hospital del Mar, Barcelona, Spain
- IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain
- Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Madrid, Spain
| | - Kathy Dwyer
- Risk Management Foundation of Harvard Medical Institutions, Cambridge, Massachusetts, USA
| | - Maria Sala
- Epidemiology and Evaluation Department, Hospital del Mar, Barcelona, Spain
- IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain
- Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Madrid, Spain
- Universitat Autónoma de Barcelona (UAB), Barcelona, Spain
| | - Xavier Castells
- Epidemiology and Evaluation Department, Hospital del Mar, Barcelona, Spain
- IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain
- Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Madrid, Spain
- Universitat Autónoma de Barcelona (UAB), Barcelona, Spain
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17
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Routine ultrasound and blood tests after laparoscopic cholecystectomy-are they worthwhile? A diagnostic accuracy study. Langenbecks Arch Surg 2016; 401:489-94. [PMID: 27023218 DOI: 10.1007/s00423-016-1411-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2015] [Accepted: 03/17/2016] [Indexed: 02/06/2023]
Abstract
PURPOSE Delayed recognition of complications can have life-threatening sequelae and is a leading cause of medical litigation. Minimal evidence exists for benefits of postoperative surveillance. This study investigated whether ultrasound (US) and blood tests can detect complications after laparoscopic cholecystectomy. METHODS A series of 772 laparoscopic cholecystectomies performed between February 2008 and October 2009 was retrospectively analyzed. Routine US was performed within 6 h postoperatively, and a blood sample was taken at the second postoperative day. RESULTS Postoperative US was performed in 722 patients. Fluid accumulation was documented in 104 patients; only two of these patients had clinically significant findings requiring treatment. The best predictor of infectious complications was elevated postoperative C-reactive protein (≥123 mg/L), with an area under the curve (AUC) of 0.94 and a number needed to misdiagnose (NNM) of 8.7. To predict postoperative choledocholithiasis, a combination of total bilirubin, aspartate aminotransferase and alkaline phosphatase elevations, with cutoff values of 1.3 mg/dL, 37 IU/L, and 136 IU/L, respectively, attained the highest accuracy with a NNM of 29.5. Ultrasonographic detection of bile duct dilation further improved specificity, while lowering sensitivity. CONCLUSIONS The value of early routine postoperative US is low, unless there is clinical suspicion of complications. Routine blood tests have a high sensitivity for infectious complications and a high specificity for remnant biliary duct stones. Therefore, we recommend avoiding routine US postoperatively and performing routine postoperative blood tests. We also recommend facilitating easy access to postoperative US, as it can aid the decision to take therapeutic measures in symptomatic patients.
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18
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Viste A, Horn A, Øvrebø K, Christensen B, Angelsen JH, Hoem D. Bile duct injuries following laparoscopic cholecystectomy. Scand J Surg 2015; 104:233-7. [PMID: 25700851 DOI: 10.1177/1457496915570088] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2014] [Accepted: 12/12/2014] [Indexed: 12/22/2022]
Abstract
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.
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Affiliation(s)
- A Viste
- Department of Acute and Gastrointestinal Surgery, Haukeland University Hospital, Bergen, Norway Department of Clinical Medicine K1, University of Bergen, Bergen, Norway
| | - A Horn
- Department of Acute and Gastrointestinal Surgery, Haukeland University Hospital, Bergen, Norway
| | - K Øvrebø
- Department of Acute and Gastrointestinal Surgery, Haukeland University Hospital, Bergen, Norway
| | - B Christensen
- Department of Acute and Gastrointestinal Surgery, Haukeland University Hospital, Bergen, Norway
| | - J-H Angelsen
- Department of Acute and Gastrointestinal Surgery, Haukeland University Hospital, Bergen, Norway
| | - D Hoem
- Department of Acute and Gastrointestinal Surgery, Haukeland University Hospital, Bergen, Norway
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Karakaya MA, Koç O, Ekiz F, Ağaçhan AF. The retrospective documentation of legal cases with bile duct injury that were submitted for consideration to İstanbul Forensic Medicine Institute by the courts between 2008-2012. Turk J Surg 2014; 30:211-3. [PMID: 25931931 DOI: 10.5152/ucd.2014.2753] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2014] [Accepted: 06/28/2014] [Indexed: 11/22/2022]
Abstract
OBJECTIVE The aim was to evaluate the parameters that were considered by Forensic Medicine in bile duct injury as well as the issues that the physicians were found to be faulty. MATERIAL AND METHODS The following parameters were investigated in 21 files that were referred to Istanbul Forensic Medicine Institute with request of expert opinion between 2008-2012; expert decisions, patient's age, gender, written patient consent, diagnosis, type of first surgery, surgical complications, timing of complication diagnosis within the scope of complication management, patient's referral timing, troubleshooting procedures and mortality rate. RESULTS Physicians were found to be faulty in all files. The reason for physician fault was failure to show the necessary professional care and attention in one (4.7%) file, late recognition of injury and late transfer of the patient in 20 (95.3%) files. Written consent had not been obtained in any of the files. Thirteen patients were female (61.9%) and 8 (30.1%) were male, with a mean age of 43.3 years. Nineteen patients had cholelithiasis (90.4%), and two patients (9.5%) had a mass in the head of the pancreas. Cholecystectomy was performed laparoscopically in 15 patients (78.9%), and with open surgery in 4 patients (21.1%). The Whipple procedure was performed in two patients. The diagnosis was made during the operation in one patient (4.7%), and in the post-operative period in 20 patients (95.3%). The time to diagnosis after surgery was between 3-6 days. All of the patients had been referred to third level health care facilities. The timing of transfer was 1 day in the patient who was diagnosed during the operation, and ranged between 4-10 days in those who were diagnosed postoperatively. Reasons for late referral were delays related to pending test results in 12 patients, vague signs in 3 patients, and following-up patients with the thought that the biliary fistula will heal by itself in 5 patients. Mortality was not observed in any of the examined files. CONCLUSION The issues where physicians were most frequently found to be faulty were failure to obtain written patient consent, late recognition of injury and late transfer of the patient.
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Affiliation(s)
- M Arif Karakaya
- Department of General Surgery, Forensic Medicine Institute, İstanbul, Turkey
| | - Okay Koç
- Clinic of Gastroenterology Surgery, Diyarbakır Training and Research Hospital, Diyarbakır, Turkey
| | - Feza Ekiz
- Department of General Surgery, İstanbul University İstanbul Faculty of Medicine, İstanbul, Turkey
| | - A Feran Ağaçhan
- Clinic of General Surgery, Kartal Dr. Lütfi Kırdar Training and Research Hospital, İstanbul, Turkey
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Siqueira OHK, Herani Filho B, Paula RED, Ascoli FO, Nóbrega ACLD, Carvalho ACG, Pires ARC, Gaglionone NC, Cunha KSG, Granjeiro JM. Tamoxifen decreases the myofibroblast count in the healing bile duct tissue of pigs. Clinics (Sao Paulo) 2013; 68:101-6. [PMID: 23420165 PMCID: PMC3552444 DOI: 10.6061/clinics/2013(01)oa16] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2012] [Accepted: 09/21/2012] [Indexed: 12/11/2022] Open
Abstract
OBJECTIVE The aim of this study was to evaluate the effect of oral tamoxifen treatment on the number of myofibroblasts present during the healing process after experimental bile duct injury. METHODS The sample consisted of 16 pigs that were divided into two groups (the control and study groups). Incisions and suturing of the bile ducts were performed in the two groups. Tamoxifen (20 mg/day) was administered only to the study group. The animals were sacrificed after 30 days. Quantification of myofibroblasts in the biliary ducts was made through immunohistochemistry analysis using anti-alpha smooth muscle actin of the smooth muscle antibody. Immunohistochemical quantification was performed using a digital image system. RESULTS In the animals treated with tamoxifen (20 mg/day), there was a significant reduction in immunostaining for alpha smooth muscle actin compared with the control group (0.1155 vs. 0.2021, p = 0.046). CONCLUSION Tamoxifen reduced the expression of alpha smooth muscle actin in the healing tissue after bile duct injury, suggesting a decrease in myofibroblasts in the scarred area of the pig biliary tract. These data suggest that tamoxifen could be used in the prevention of biliary tract stenosis after bile duct surgeries.
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Real-time near-infrared (NIR) fluorescent cholangiography in single-site robotic cholecystectomy (SSRC): a single-institutional prospective study. Surg Endosc 2012; 27:2156-62. [PMID: 23271272 DOI: 10.1007/s00464-012-2733-2] [Citation(s) in RCA: 105] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2012] [Accepted: 12/01/2012] [Indexed: 02/07/2023]
Abstract
BACKGROUND Bile duct injury is a rare but serious complication of laparoscopic cholecystectomy and the primary cause is misinterpretation of biliary anatomy. This may occur more frequently with a single-incision approach due to difficulties in exposing and visualizing the triangle of Calot. Intraoperative cholangiography was proposed to overcome this problem, but due to multiple issues, it is not used routinely. Indocyanine green (ICG) near-infrared (NIR) fluorescent cholangiography is non invasive and provides real-time biliary images during surgery, which may improve the safety of single-incision cholecystectomy. This study aims to evaluate the efficacy and safety of this technique during single-site robotic cholecystectomy (SSRC). METHODS Patients presenting with symptomatic biliary gallstones without suspicion of common bile duct stones underwent SSRC with ICG-NIR fluorescent cholangiography using the da Vinci Fluorescence Imaging Vision System. During patient preparation, 2.5 mg of ICG was injected intravenously. During surgery, the biliary anatomy was imaged in real time, which guided dissection of Calot's triangle. Perioperative outcomes included biliary tree visualizations, operative time, conversion and complications rates, and length of hospital stay. RESULTS There were 45 cases between July 2011 and January 2012. All procedures were completed successfully; there were no conversions and at least one structure was visualized in each patient. The rates of visualization were 93 % for the cystic duct, 88 % for the common hepatic duct, and 91 % for the common bile duct prior to Calot's dissection; after Calot's dissection, the rates were 97 % for all three ducts. Mean hospital stay was 1.1 days and there were no bile duct injuries or any other major complications. CONCLUSION Real-time high-resolution fluorescent imaging to identify the biliary tree anatomy during SSRC using the da Vinci Fluorescence Imaging Vision System was safe and effective.
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Ausania F, Holmes LR, Ausania F, Iype S, Ricci P, White SA. Intraoperative cholangiography in the laparoscopic cholecystectomy era: why are we still debating? Surg Endosc 2012; 26:1193-200. [PMID: 22437958 DOI: 10.1007/s00464-012-2241-4] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2011] [Accepted: 03/01/2012] [Indexed: 12/14/2022]
Abstract
Laparoscopic cholecystectomy is now one of the most frequently performed abdominal surgical procedures in the world. The most common major complication is bile duct injury, which can have catastrophic repercussions for patients and it has been suggested that intraoperative cholangiography may reduce the rate of bile duct injury. Whether this procedure should be performed routinely is still an active subject of debate. We discuss the available evidence and likely implications for the future.
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Documenting correct assessment of biliary anatomy during laparoscopic cholecystectomy. Surg Endosc 2011; 26:79-85. [PMID: 21792718 PMCID: PMC3242940 DOI: 10.1007/s00464-011-1831-x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2010] [Accepted: 06/13/2011] [Indexed: 01/12/2023]
Abstract
Background Correct assessment of biliary anatomy can be documented by photographs showing the “critical view of safety” (CVS) but also by intraoperative cholangiography (IOC). Methods Photographs of the CVS and IOC images for 63 patients were presented to three expert observers in a random and blinded fashion. The observers answered questions pertaining to whether the biliary anatomy had been conclusively documented. Results The CVS photographs were judged to be “conclusive” in 27%, “probable” in 35%, and “inconclusive” in 38% of the cases. The IOC images performed better and were judged to be “conclusive” in 57%, “probable” in 25%, and “inconclusive” in 18% of the cases (P < 0.001 compared with the photographs). The observers indicated that they would feel comfortable transecting the cystic duct based on the CVS photographs in 52% of the cases and based on the IOC images in 73% of the cases (P = 0.004). The interobserver agreement was moderate for both methods (kappa values, 0.4–0.5). For patients with a history of cholecystitis, both the CVS photographs and the IOC images were less frequently judged to be sufficient for transection of the cystic duct (P = 0.006 and 0.017, respectively). Conclusion In this series, IOC was superior to photographs of the CVS for documentation of the biliary anatomy during laparoscopic cholecystectomy. However, both methods were judged to be conclusive only for a limited proportion of patients, especially in the case of cholecystitis. This study highlights that documenting assessment of the biliary anatomy is not as straightforward as it seems and that protocols are necessary, especially if the images may be used for medicolegal purposes. Documentation of the biliary anatomy should be addressed during training courses for laparoscopic surgery.
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Raval MV, Lautz TB, Browne M. Bile Duct Injuries During Pediatric Laparoscopic Cholecystectomy: A National Perspective. J Laparoendosc Adv Surg Tech A 2011; 21:113-8. [DOI: 10.1089/lap.2010.0425] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Mehul V. Raval
- Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, Illinois
- Division of Pediatric Surgery, Department of Surgery, Feinberg School of Medicine, Northwestern University, Children's Memorial Hospital, Chicago, Illinois
| | - Timothy B. Lautz
- Division of Pediatric Surgery, Department of Surgery, Feinberg School of Medicine, Northwestern University, Children's Memorial Hospital, Chicago, Illinois
| | - Marybeth Browne
- Division of Pediatric Surgery, Department of Surgery, Feinberg School of Medicine, Northwestern University, Children's Memorial Hospital, Chicago, Illinois
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Skidmore FD. Medicolegal implications of laparoscopic technique. Ann R Coll Surg Engl 2010; 92:271. [PMID: 20501010 DOI: 10.1308/003588410x12664192076179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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