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Laparoscopic Common Bile Duct Exploration in Patients with a Previous History of Biliary Tract Surgery
Published on: February 10, 2023
Characterization of common bile duct injury after laparoscopic cholecystectomy in a high-volume hospital system
Julia F Kohn1,2, Alexander Trenk3, Kristine Kuchta3
1University of Illinois at Chicago College of Medicine, Chicago, IL, USA. Kohn3@uic.edu.
Insights
Laparoscopic cholecystectomy has a 0.5% common bile duct injury rate. Acutely inflamed gallbladders and choledocholithiasis increase risk, while higher hemoglobin may be protective.
Area of Science:
- Surgical outcomes research
- Gastrointestinal surgery
- Patient safety in surgery
Background:
- Laparoscopic cholecystectomy is popular but has higher common bile duct injury (CBDI) rates than open procedures.
- Biliary tract injuries (BDI) during laparoscopic cholecystectomy require investigation to improve patient safety.
- A high-volume healthcare system provides a robust setting to study BDI prevalence and risk factors.
Purpose of the Study:
- To determine the prevalence of biliary tract injuries during laparoscopic cholecystectomy.
- To identify risk factors associated with biliary injuries in this patient population.
- To evaluate the effectiveness of the Critical View of Safety (CVS) in preventing BDI.
Main Methods:
- Retrospective chart review of 800 randomly selected laparoscopic cholecystectomy cases (2009-2015).
- Inclusion of all BDI cases regardless of coding or need for secondary procedures.
- Classification of injuries per Strasberg et al. and logistic regression for risk factor identification.
Main Results:
- The common bile duct injury (CBDI) rate was 0.5% (4 cases).
- Risk factors for BDI included lower hemoglobin, urgent surgery, choledocholithiasis, and acutely inflamed gallbladder.
- Higher preoperative hemoglobin was independently protective against CBDI; acute inflammation and choledocholithiasis were predictive.
Conclusions:
- The CBDI rate in this study was 0.5%, with acute inflammation and choledocholithiasis as significant risk factors.
- Higher preoperative hemoglobin demonstrated a protective effect against CBDI.
- Improved Critical View of Safety (CVS) implementation and caution in inflamed cases may reduce BDI; patient counseling is advised.
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.
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