Beyond the Learning Curve: Bile Duct Injuries Following Laparoscopic Cholecystectomy Normalize to Open in the Modern Era

Caitlin Halbert, DO, Jie Yang, Ziqi Meng, Maria Altieri, MD, Mark Talamini, MD, Aurora Pryor, MD, Dana Telem, MD. Stony Brook University

INTRODUCTION

Early reports of higher complication rates, specifically bile duct injuries, raised concerns over the safety of laparoscopy over open cholecystectomy. This study aims to ascertain the rate, management and perioperative outcomes of bile duct injury in an era beyond the laparoscopic learning curve.

METHODS

Following IRB and New York State (NYS) approval, the NYS Planning and Research Cooperative System (SPARCS) longitudinal administrative database was used to identify patients. SPARCS captures patient level data from every inpatient and outpatient hospital discharge in NYS. From 2008 to 2010, 73,646 patients were identified who had undergone laparoscopic cholecystectomy for symptomatic cholelithiasis or acute or chronic cholecystitis.

Patients with malignancy, liver disease, pancreatitis, biliary dyskinesia, open procedure, age <18, and incidental cholecystectomy as part of another procedure were excluded. Preoperative, intraoperative and postoperative variables were recorded. Patients were then tracked with unique identifiers within the first postoperative year for common bile duct (CBD) injury. Common bile duct injury was identified by ICD-9 and CPT diagnosis and procedure codes for patients who subsequently underwent hepatectomy, hepaticojejunostomy, or other bile duct surgery within this time period.

RESULTS

Of the 73,646 patients who underwent laparoscopic cholecystectomy from 2008 to 2010, 77 patients with biliary injuries were identified at a rate of 0.1%. Patients with CBD injury were predominantly >45 years old (67%), female (77.9%) and white (55%).

Of the 77 patients with biliary injuries, 22 (28.6%) underwent hepatectomy, 22 (28.6%) underwent hepaticoenterostomy, 22 (28.6%) underwent primary repair of the bile duct, and 11 (14.2%) required a combination of aforementioned complex procedures.

Fifteen (19%) patients who had suffered a CBD injury were repaired on the same day as their initial procedure. Of the remaining 62 patients, 17 were repaired within 7 days, 8 repaired between 7-21 days and 37 patients over 21 days from injury. Mean length of hospital stay was 8, 12 and 10 days, respectively, and did not significantly differ by timing of repair.

For the subsequent procedure, 38 (49%) patients remained at their index hospital of procedure, while 39 (51%) patients were transferred to another facility. Patients who were transferred to another institution were more likely to require higher complexity operations including hepatectomy (38.4% vs. 18.4%, p=0.07) and hepaticoenterostomy (41% vs. 15.8%, p=0.02), versus primary duct repair (8% vs. 50%, p=0.001). A total of 51 (66%) patients experienced a perioperative complication. No difference in perioperative morbidity was demonstrated by secondary operation performed at index versus nonindex hospital (71.1% vs. 61.5%, p=0.37).

CONCLUSION

In NYS, the rate of bile duct injury has decreased to 0.1% and mirrors the historical figures quoted for open cholecystectomy. This improvement likely reflects increased experience and movement beyond the “learning curve”. Nonetheless, injuries to the CBD are still significant in nature, with the majority of patients requiring hepaticoenterostomy or hepatectomy. Additionally, perioperative morbidity remains high in patients requiring reparative operation. Interestingly, only half of patients with biliary injuries were transferred to other facilities for repair. However, the more complex the case the more likely the patient was to be transferred.

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