Reinterventions following laparoscopic cholecystectomy and bile duct exploration. A review of prospective data from 5740 patients

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Abstract

Background

Complications following laparoscopic cholecystectomy (LC) and common bile duct exploration (CBDE) for the management of gallstones or choledocholithiasis impact negatively on patients’ quality of life and may lead to reinterventions. This study aims to evaluate the causes and types of reintervention following index admission LC with or without CBDE.

Methods

A prospectively maintained database of LC and CBDE performed by a single surgeon was analysed. Preoperative factors, difficulty grading and perioperative complications requiring reintervention and readmissions were examined.

Results

Reinterventions were required in 112 of 5740 patients (2.0%), 89 (1.6%) being subsequent to complications. The reintervention cohort had a median age of 64 years, were more likely to be females ( p < 0.0023) and to be emergency admissions (67.9%, p < 0.00001) with obstructive jaundice (35.7%, p < 0.00001). 46.4% of the reintervention cohort had a LC operative difficulty grade IV or V and 65.2% underwent a CBDE. Open conversion was predictive of the potential for reintervention ( p < 0.00001). The most common single cause of reintervention was retained stones (0.5%) requiring ERCP followed by bile leakage (0.3%) requiring percutaneous drainage, ERCP and relaparoscopy. Relaparoscopy was necessary in 17 patients and open surgery in 13, 6 of whom not resulting from complications. There were 5 deaths.

Conclusion

This large series had a low incidence of reinterventions resulting from complications in spite of a high workload of index admission surgery for biliary emergencies and bile duct stones. Surgical or endoscopic reinterventions following LC alone occurred in only 0.8%. The most common form of reintervention was ERCP for retained CBD stones. This important outcome parameter of laparoscopic biliary surgery can be optimised through early diagnosis and timely reintervention for complications.

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Most cited references 37

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Iatrogenic bile duct injury: a population-based study of 152 776 cholecystectomies in the Swedish Inpatient Registry.

Magnus Nilsson, A Waage (2006)

Older age, male sex, and low yearly hospital volume of cholecystectomy may increase the risk of bile duct injury (BDI), whereas the use of intraoperative cholangiography may decrease the risk. The incidence of BDI at cholecystectomy may have increased after the introduction of laparoscopic cholecystectomy. Nationwide population-based study of all cholecystectomies registered in the Swedish Inpatient Registry from 1987 through 2001. All hospitals performing inpatient cholecystectomies in Sweden. Cholecystectomies were identified using International Classification of Diseases, Ninth and 10th Revisions surgical procedure codes. After exclusion of patients with hepatobiliary and pancreatic malignancies, patients with codes indicating reconstructive bile duct operations within 1 year after cholecystectomy were considered BDI cases. Risk factors for BDI were analyzed using multivariate logistic regression. The incidence proportion of BDI was calculated by dividing the number of cases by the number of cholecystectomies. Relative risks were estimated using odds ratios with 95% confidence intervals, and incidence proportion was used to describe incidence. Among 152 776 cholecystectomies, 613 reconstructed BDIs (0.40%) were identified. Older age and male sex were positively associated with BDI, whereas intraoperative cholangiography was negatively associated with BDI. The incidence proportion of BDI was 0.40% from 1987 to 1990, decreased to 0.32% from 1991 to 1995, and increased to 0.47% from 1996 to 2001. The mean yearly hospital volume did not affect the risk of BDI. Older age and male sex increased the risk of BDI, whereas intraoperative cholangiography was protective. There was a small to moderate long-term increase in the risk of BDI after the introduction of laparoscopic cholecystectomy compared with the pre-laparoscopic era.

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Effect of intended intraoperative cholangiography and early detection of bile duct injury on survival after cholecystectomy: population based cohort study

Björn Törnqvist, Cecilia Strömberg, Gunnar Persson … (2012)

Objectives To determine whether the routine use of intraoperative cholangiography can improve survival from complications related to bile duct injuries. Design Population based cohort study. Setting Prospectively collected data from the Swedish national registry of gallstone surgery and endoscopic retrograde cholangiopancreatography, GallRiks. Multivariate analysis done by Cox regression. Population All cholecystectomies recorded in GallRiks between 1 May 2005 and 31 December 2010. Main outcome measures Evidence of bile duct injury, rate of intended use of intraoperative cholangiography, and rate of survival after cholecytectomy. Results During the study, 51 041 cholecystectomies were registered in GallRiks and 747 (1.5%) iatrogenic bile duct injuries identified. Patients with bile duct injuries had an impaired survival compared with those without injury (mortality at one year 3.9% v 1.1%). Kaplan-Meier analysis showed that early detection of a bile duct injury, during the primary operation, improved survival. The intention to use intraoperative cholangiography reduced the risk of death after cholecystectomy by 62% (hazard ratio 0.38 (95% confidence interval 0.31 to 0.46)). Conclusions The high incidence of bile duct injury recorded is probably from GallRiks’ ability to detect the entire range of injury severities, from minor ductal lesions to complete transections of major ducts. Patients with bile duct injury during cholecystectomy had impaired survival, and early detection of the injury improved survival. The intention to perform an intraoperative cholangiography reduced the risk of death after cholecystectomy.

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Randomised trial of laparoscopic exploration of common bile duct versus postoperative endoscopic retrograde cholangiography for common bile duct stones.

M. Rhodes, L. Sussman, L. Cohen … (1998)

The management of stones in the common bile duct in the laparoscopic era is controversial. The three major options are preoperative endoscopic retrograde cholangiography (ERCP), laparoscopic exploration of the common bile duct (LECBD), or postoperative ERCP. Between August, 1995, and August, 1997, 471 laparoscopic cholecystectomies were done in our department. In 427 (91%), satisfactory peroperative cholangiography was obtained. In 80 (17%) of these cases there were stones in the common bile duct, 40 patients were randomised to LECBD and 40 to postoperative ERCP. If LECBD failed, patients had either open exploration of the common bile duct or postoperative ERCP. If one postoperative ERCP failed, the procedure was repeated until the common bile duct was cleared of stones or an endoprosthesis was placed to prevent stone impaction. The primary endpoints were duct-clearance rates, morbidity, operating time, and hospital stay. Analyses were by intention to treat. Age and sex distribution of patients was similar in the randomised groups. Duct clearance after the first intervention was 75% in both groups. By the end of treatment, duct clearance was 100% in the laparoscopic group compared with 93% in the ERCP group. Duration of treatment was a median of 90 min (range 25-310) in the laparoscopic group (including ERCPs for failed LECBD) compared with 105 min (range 60-255) in the postoperative ERCP group (p = 0.1, 95% CI for difference -5 to 40). Hospital stay was a median of 1 day (range 1-26) in the laparoscopic group compared with 3.5 days (range 1-11) in the ERCP group (p = 0.0001, 95% CI 1-2). LECBD is as effective as ERCP in clearing the common bile duct of stones. There is a non-significant trend to shorter time in the operating theatre and a significantly shorter hospital stay in patients treated by LECBD.

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Author and article information

Contributors

Ahmad H. M. Nassar:

ORCID: http://orcid.org/0000-0001-7878-7024

Ahmad.nassar@glasgow.ac.uk , anassar@doctors.org.uk

Journal

Journal ID (nlm-ta): Surg Endosc

Journal ID (iso-abbrev): Surg Endosc

Title: Surgical Endoscopy

Publisher: Springer US (New York )

ISSN (Print): 0930-2794

ISSN (Electronic): 1432-2218

Publication date (Electronic): 2 June 2021

Publication date PMC-release: 2 June 2021

Publication date (Print): 2022

Volume: 36

Issue: 5

Pages: 2809-2817

Affiliations

[1 ]GRID grid.416071.5, ISNI 0000 0004 0624 6378, Laparoscopic Biliary Surgery Service, , University Hospital Monklands, ; Airdrie, Scotland, UK

[2 ]GRID grid.416071.5, ISNI 0000 0004 0624 6378, University Hospital Monklands, ; Airdrie, Scotland, ML6 0JS UK

Author information

Ahmad H. M. Nassar http://orcid.org/0000-0001-7878-7024

Article

Publisher ID: 8568

DOI: 10.1007/s00464-021-08568-x

PMC ID: 9001563

PubMed ID: 34076762

SO-VID: cdcfcb97-9628-4f37-9719-ccd6e65e3fc3

License:

Open AccessThis article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.

History

Date received : 12 January 2021

Date accepted : 18 May 2021

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ScienceOpen disciplines: Surgery

Keywords: laparoscopic cholecystectomy,reintervention,complications,bile duct exploration

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ScienceOpen disciplines: Surgery

Keywords: laparoscopic cholecystectomy, reintervention, complications, bile duct exploration

Reinterventions following laparoscopic cholecystectomy and bile duct exploration. A review of prospective data from 5740 patients

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International Journal of Applied Technology in Medical Sciences

Most cited references 37

Iatrogenic bile duct injury: a population-based study of 152 776 cholecystectomies in the Swedish Inpatient Registry.

Effect of intended intraoperative cholangiography and early detection of bile duct injury on survival after cholecystectomy: population based cohort study

Randomised trial of laparoscopic exploration of common bile duct versus postoperative endoscopic retrograde cholangiography for common bile duct stones.

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