Gallbladder adhesion degree as predictor of conversion surgery, common bile duct injury and resurgery in laparoscopic cholecystectomy: A cross-sectional study

Background

The gold-standard treatment for cholecystectomy, laparoscopic cholecystectomy, has remarkably variable outcomes and conversion rates. We investigated the gallbladder adhesion degree as a predictor of conversion surgery, common bile duct injury, and resurgery.

Methods

We reviewed 157 medical records and video recordings of laparoscopic cholecystectomy on patients with cholelithiasis with or without cholecystitis at three hospitals in Yogyakarta, Indonesia from January 2016 to December 2018. The degree of gallbladder adhesion is classified into 4 categories: no adhesion, <50% adhesion, 50%-buried GB, and completely buried GB.

Results

One hundred fifty seven patients were involved in this study, of whom 58 were males and 99 females with average age 49.2. Eighty-one patients out of 157 patients (51.6%) had gallbladder adhesion comprising of 61/157 (38.9%) with <50% adhesion and 20/157 (12.7%) 50%-buried GB. There is one incidence each of conversion surgery, CBD injury, and resurgery. The degree of GB adhesion has low degree of correlation with conversion surgery, CBD injury, and resurgery wirh r value of 0.156, 0.041, and 0.156 respectively. There is significant correlation between the degree of GB adhesion and conversion surgery and resurgery with p value of 0.032, and 0.032 respectively. There is no significant correlation between degree of GB adhesion and CBD injury with p value of 0.453.

Conclusion

The degree of GB adhesion has low degree of correlation with conversion, CBD injury and resurgery. This study also showed that patients with high degree of gallbladder adhesion are still eligible for laparoscopic procedure performed by an experienced surgeon.

Comparative analysis of reliability and clinical effects of the critical view of safety approach used in laparoscopic cholecystectomy in the pediatric population

PURPOSE

With the increase in indications for cholecystectomy in children, the frequency of laparoscopic cholecystectomy procedures and related problems has increased. The Critical View of Safety (CVS) is the target-specific method for identifying the cystic duct during laparoscopic cholecystectomy to prevent common bile duct injury. We hypothesize that the use of CVS is reliable in the pediatric population.

METHODS

Data of 91 patients under 18 years of age who underwent elective laparoscopic cholecystectomy were retrospectively analyzed. Patients were divided into two groups depending on whether CVS was applied. The descriptive characteristics and complications of the two groups were compared.

RESULTS

CVS was applied to 41 patients. When the groups were compared in terms of operation time, postoperative length of stay, idiopathic gallbladder perforation, dropping stone, and presence of surgical site infection, no statistical significant difference was found. However, the time to start oral feeding was shorter in CVS group (p = 0.01).

CONCLUSION

We believe CVS is a reliable method to ensure safe cystic channel identification in the pediatric population. New studies are warranted on the effectiveness of CVS for safely performing laparoscopic cholecystectomy in children, as the procedure is being performed more frequently in the pediatric population.

Recovery from a biliary stricture of a common bile duct ligature injury: A case report

BACKGROUND

Cholecystectomy is a common elective procedure for cholecystic diseases, including cholecystitis and cholelithiasis. Common bile duct injury is a major complication in both open and laparoscopic cholecystectomy (LC). The number of cholecystectomies performed has increased due to popularization and application of the laparoscopic technique, which has led to an increase in the number of bile duct injuries.

CASE SUMMARY

A 65-year-old man presented to the General Surgery Department with a complaint of repeated right upper quadrant pain for 2 years that had worsened over the previous day. The patient had a history of gallstones and hypertension. A LC was performed; it was found that a biliary stricture of 53 h duration was caused by a ligature injury of the common bile duct during the LC. Another laparoscopic exploration was performed, and the stricture was released.

CONCLUSION

LC is a common surgical procedure, but if a complication occurs, it is important for the surgeon to consider another exploratory surgery.

An Update on Iatrogenic Biliary Injuries: Identification, Classification, and Management

Common bile duct injury is a feared complication of cholecystectomy, with an incidence of 0.1% to 0.6%. A majority of injuries go unnoticed at index operation, and postoperative diagnosis can be difficult. Patient presentation can vary from vague abdominal pain to uncontrolled sepsis and peritonitis. Diagnostic evaluation typically begins with ultrasound or CT scan in the acute setting, and source control is paramount at time of presentation. In a stable patient, hepatobiliary iminodiacetic acid scan can be useful in identifying an ongoing bile leak, which requires intervention. A variety of diagnostic techniques define biliary anatomy. Treatment often requires a multidisciplinary approach.

Characterization of common bile duct injury after laparoscopic cholecystectomy in a high-volume hospital system. Surg Endosc. 2018;32:1184-1191. [PMID: 28840410 DOI: 10.1007/s00464-017-5790-8]

BACKGROUND

Despite the popularity of laparoscopic cholecystectomy, rates of common bile duct injury remain higher than previously observed in open cholecystectomy. This retrospective chart review sought to determine the prevalence of, and risk factors for, biliary injury during laparoscopic cholecystectomy within a high-volume healthcare system.

METHODS

800 of approximately 3000 cases between 2009 and 2015 were randomly selected and retrospectively reviewed. A single reviewer examined all operative notes, thereby including all cases of BDI regardless of ICD code or need for a second procedure. Biliary injuries were classified per Strasberg et al. (J Am Coll Surg 180:101-125, 1995). Logistic regression models were utilized to identify univariable and multivariable predictors of biliary injuries.

RESULTS

31.0% of charts stated that the Critical View of Safety was obtained, and 12.4% of charts correctly described the critical view in detail. Three patients (0.4%) had a cystic duct leak, and 4 (0.5%) had a common bile duct injury. Of the four CBDI, three patients had a partial transection of the CBD and one had a partial stricture. Patients who suffered BDI were more likely to have had lower hemoglobin, urgent surgery, choledocholithiasis, or acutely inflamed gallbladder. Multivariable analysis of BDI risk factors showed higher preoperative hemoglobin to be independently protective against CBDI. Acutely inflamed gallbladder and choledocholithiasis were independently predictive of CBDI.

CONCLUSIONS

The rate of CBDI in this study was 0.5%. Acutely inflamed conditions were risk factors for biliary injury. Multivariable analysis suggests a protective effect of higher preoperative hemoglobin. There was no correlation of CVS with prevention of biliary injury, although only 12.4% of charts could be verified as following the technique correctly. Better implementation of CVS, and increased caution in patients with perioperative inflammatory signs, may be important for preventing bile duct injury. Additionally, counseling patients with acute inflammation on increased risk is important.

Intraoperative cholangiography during cholecystectomy among hospitalized medicare beneficiaries with non-neoplastic biliary disease

BACKGROUND

Prior studies of Medicare beneficiaries with both neoplastic and non-neoplastic indications for cholecystectomy demonstrated a reduced risk of common bile duct (CBD) injury when intraoperative cholangiography (IOC) was used. We sought to determine the association between IOC and CBD injury during inpatient cholecystectomy for non-neoplastic biliary disease and compare survival among those with or without CBD injury.

METHODS

Retrospective study of patients ≥66 who underwent inpatient cholecystectomy (2005-2010) for gallstones, cholecystitis, cholangitis, or gallbladder obstruction. The association between IOC and CBD injury was analyzed using multivariable logistic regression and survival after cholecystectomy was analyzed using multivariable Cox regression.

RESULTS

Among 472,367 patients who underwent cholecystectomy, 0.3% had a CBD injury. IOC was associated with increased CBD injury (adjusted OR 1.41[1.27-1.57]). CBD injury was associated with increased hazards of death (adjusted HR 1.37[1.25-1.51]).

CONCLUSIONS

IOC in patients with non-neoplastic biliary disease was associated with increased odds of CBD injury. This likely reflects its selective use in patients at higher risk of CBD injury or as a confirmatory test when an injury is suspected.

Long-term outcomes of patients with common bile duct injury following laparoscopic cholecystectomy

INTRODUCTION

Common bile duct (CBD) injury is a serious and dreaded complication of cholecystectomy. A paucity of data assessing long-term outcomes exists. This study aimed to determine long-term mortality and liver transplantation rates following CBD injury requiring operative intervention.

METHODS

Patients were identified via the New York State (NYS) Planning and Research Cooperative System longitudinal administrative database which captures patient-level data from every inpatient and outpatient hospital discharge in NYS. In total, 125 patients with CBD injuries were identified following 156,958 laparoscopic cholecystectomies for cholelithiasis performed in NYS from 2005 to 2010. Patients were then tracked by unique identifier to obtain rate of liver transplantation. Follow-up ranged from 4 to 9 years from surgery.

RESULTS

There were 125 patients with CBD injuries detected. No mortalities occurred within 30 days. All-cause mortality was 20.8 % (n = 26) with mean time to death 1.64 ± 1.08 years. One patient who underwent hepaticoenterostomy required a liver transplant 4.3 years after surgery. Significant factors predictive of all-cause mortality included: age >61, Medicare insurance, male gender, White race, diabetes, hypertension and pulmonary complications following surgery. Overall 30-day morbidity, timing to and type of operative intervention did not influence mortality.

CONCLUSION

Considerable long-term mortality, 20.8 %, is associated with common bile duct injury requiring operative intervention. This was an increase of 8.8 % above the cohort's expected age-adjusted rate of death. The mortality rate is appreciably higher than quoted previously. No difference was demonstrated by type of repair required. Liver transplant rate was 0.8 %. These data have significant implications for patient and family counseling both prior to cholecystectomy and following CBD injury.

Innovation and the difficult gallbladder: tread lightly

Innovation has advanced the treatment of biliary disease significantly, but further progress is needed to improve safety. An uncommonly used technique is described, which could potentially prevent serious complications for the difficult gallbladder.

[Bile duct lesions repaired with peritoneal tube grafts]

BACKGROUND

A significant number of people suffer iatrogenic bile duct injury during laparoscopic cholescystectomy. Biliary-digestive bypass may be complicated by stenosis and biliary sepsis, affecting both quality of life and life expectancy. To avoid bypass synthetic grafts have been used, which are expensive.

OBJECTIVE

Evaluating autologous implantation of peritoneus as alternative of bile duct repair.

METHODS

Under general anesthesia, ten New Zealand adult rabbits were operated, common bile duct approached and sectioned underneath the cystic duct followed by a liver biopsy. An autologous graft was built of peritoneum and graft-bile duct proximal and distal end-to-end anastomosis done. Animals were followed-up by weekly bilirrubin and transferases. Rabbits were scheduled euthanized and a liver biopsy done for histological examinations.

RESULTS

Autologous graft was easy to create and all rabbits survived. They did not develop jaundice or alterations in their normal habits. At necropsy, autologous grafts were removed and no signs of occlusion were noticed. Moderate short-term liver damage was observed but long-term damage was negligible. Bileoma and pyogenic liver abscess were observed in two animals, respectively.

DISCUSSION

Our results favourably match well-known procedures used for bile duct repair, especially in cases of severe injury (Bismuth-Strasberg E1-3): it seems less complicated than biliary-digestive bypass, not as expensive as synthetic grafts, and much easier to build than human amnion graft.

CONCLUSION

Interposing an autologous graft of peritoneum is an easy-to-create surgical procedure and circumferential bile duct injuries were adequately repaired.