National Trend in Intraoperative Cholangiogram and Common Bile Duct Injury During Cholecystectomy

Roman Grinberg, MD, John N Afthinos, MD, Karen E Gibbs, MD. Staten Island University Hospital

Introduction: Common bile duct injury (CBDI) is a serious, and perhaps the most dreaded, complication following cholecystectomy. The early phase of laparoscopic cholecystectomy (LC) adoption brought about significant awareness and strategies for avoiding and/or recognizing this injury due to initially high CBDI rates. Advances in visualization, training and equipment, including intraoperative cholangiogram (IOC), have been theorized to reduce this injury rate to “acceptable” levels. We sought to evaluate the prevalence and overall trend of CBDI and IOC utilization in a large patient population database.

Methods: The Nationwide Inpatient Sample (NIS) Database was queried for all cholecystectomies performed for benign gallbladder disease from 2005 to 2010. Malignancy, pancreatic diseases and revisional procedures of bilio-enteric anastomoses were excluded. The rate of CBDI and IOC was calculated for the laparoscopic, open (OC) and laparoscopic converted to open (CO) groups. Multivariate regression analysis was performed to I dentify risk factors for CBDI.

Results: We identified 361318 patients, of which 312511 (87%) underwent LC, 18753 (5%) underwent open cholecystectomy and 30054 (8%) were converted to open. A total of 632 CBDI were identified (0.2%). The LC group had 259 (0.08%), the open group 164 (0.88%) and the converted group 209 (0.70%). All three were statistically different from each other (p < 0.0001). The average IOC rate was 32.8%. IOC was an independent risk factor for CBDI with odds ratios of 4.4, 2.9, and 4.4 in LC, OC and CO, respectively.

Conclusion: IOCs are performed in approximately one-third of cholecystectomy cases. Overall, the CBDI rate was 0.2%. The injury rate was unchanged over the study period. The LC cohort had the lowest rate of CBDI, while the open group had the highest. There is likely a selection bias involved in this trend, as the vast majority of procedures are performed laparoscopically. In addition, it appears that many IOCs are performed in response to concern for CBDI.