S. Cassaro1,2, A. Meshesha2, S. Kesavaramanujam2, N. Atherton1,2 1University Of California – Irvine,Surgery,Orange, CA, USA 2Kaweah Delta Health Care District,Acute Care And Trauma Surgery,Visalia, CA, USA
Introduction:
Biliary duct injury (BDI) is a dreaded complication of cholecystectomy. The incidence of BDI during laparoscopic cholecystectomy (LC) is not exactly known. Major BDI is defined as an injury requiring biliary repair or reconstruction and is reported to occur in 0.1 to 0.55% of the cases. Since approximately 750,000 patients undergo LC each year in the US, it can be inferred that at least 750 patients sustain a major BDI every year.
Methods:
We reviewed the most recent five years of NSQIP data to assess the incidence and 30-day outcomes of major BDI after LC. The 2010-2014 NSQIP database of 158,278 cases of LC was searched for diagnostic and procedural codes associated with BDI.
Results:
The query returned a total of 33 cases of LC that listed one of the selected procedural codes either as additional procedure at the time of the initial surgery, or as reoperation.
A BDI was repaired during the initial procedure in 19 cases. An IOC was performed during the LC in ten of the patients. Six of the patients were men and 13 women. The injury was repaired with a bilio-enteric anastomosis in eleven patients, using a Roux-en-Y loop in nine. The remaining nine injuries were repaired primarily in eight patients and with an end-to-end reconstruction in one. The average postoperative length of stay after repair was 6.5 days (range 1 to 16 days), and there were no readmissions. One of the patients who underwent biliary diversion died within thirty days from the procedure.
Fourteen patients underwent BDI repair within 30 days from the index procedure, which included an only in two cases. Eleven of the patients were women and three were men. Seven of these patients were discharged on the day of the initial procedure, while the other seven remained hospitalized after the index LC for an average of 7 days (range 1 to 16 days). A bilio-enteric diversion was used to repair the injury in six patients, and a Roux-en-Y reconstruction was the technique selected in all but one of the cases. A direct ductal repair was performed in the other eight patients. There were no postoperative deaths in this group.
Conclusion:
There is substantial evidence that the incidence of major BDI after LC is between 0.1 and 0.5%, and the vast majority of those injuries should be identifiable within thirty days of the index procedure.
NSQIP is designed to capture all the significant events occurring in the thirty days following each procedure tracked, but a query of NSQIP data for codes associated with major BDI after LC yields results that are grossly inconsistent with the expected ones and reflect a BDI incidence lower than 0.002%.
In its current format NSQIP data are inadequate to benchmark the risk of major BDI injury after LC, and may grossly underestimate the incidence of such occurrence. The implementation of procedure-specific registries for commonly performed surgical interventions such as LC may provide better data quality.