Patrick J Worth, MD, Taranjeet Kaur, MBBS, Brian S Diggs, PhD, Brett C Sheppard, MD, John G Hunter, MD, James P Dolan, MD. Oregon Health & Science University
Bile duct injury (BDI) after laparoscopic cholecystectomy (LC) continues to have significant cost impact on our health care system, and can represent a significant source of morbidity for patients. We undertook a population-based assessment of the national experience with bile duct injury between 2001 and 2011 and compared this to our report for the prior decade.
We utilized the Nationwide Inpatient Sample (NIS) for the years 2001 to 2011. All patients who underwent laparoscopic cholecystectomy or laparoscopic partial cholecystectomy were extracted for analysis. Within this group, patients undergoing operative (non-endoscopic) biliary reconstruction were selected and those undergoing a procedure likely to involve biliary tree revision for benign or malignant conditions were excluded. Data was analyzed using methods that accounted for the hierarchical, stratified random sampling utilized in the NIS. Both univariate and multivariate modeling was performed to explore the relationship between patient and institutional characteristics and BDI after LC.
In the period from 2001 to 2011, 4,987,032 cholecystectomies were performed, 3,741,260 of which were attempted laparoscopically. Over this period, the annual rate of LCs increased from 71.1% in 2001 to 79.0% in 2011 (p < .0001). The average mortality rate was 0.47%, and decreased from 0.56% to 0.38% (p = .0015) over the same interval. In 2001, 0.11% of LCs were associated with biliary reconstruction as compared to 0.09% in 2011 (p = 0.15). Reconstruction rates ranged from 0.08 to 0.12% over the period of study with an average in-hospital mortality rate of 4.4%. In comparison to prior data from 1991 to 2000, LC rates in the study period have increased from an average of 68.3% to 75.06% (p <0.001). Need for biliary reconstruction has decreased from an average rate of 0.13% to 0.10% (p = 0.03). Mortality rates from laparoscopic cholecystectomy have remained consistent (0.10%, p = 0.57) as well as mortality related to biliary reconstruction (4.4%, p = 0.50). Logistic regression of this data associated admission from clinic as well as treatment at an urban teaching hospital with need for biliary reconstruction after LC. This is similar to our findings from the prior decade. Over this period, we did not find that emergent admission or race was associated with increased odds of BDI, which differs from our prior analysis.
The percentage of LCs continues to increase in the first decade of the 21st century. Although rates of BDI have decreased, the need for reconstruction continues to be associated with a significant mortality rate. Mortality in patients with biliary injury continues to have a ten-fold increase over uncomplicated cases. Our analysis suggests that mortality related to biliary reconstruction is higher than previously published series, and may reflect the complexity managing biliary injury as well as the higher likelihood of these patients to have comorbid conditions.