BACKGROUND: Common bile duct(CBD) injury is a serious complication of laparoscopic cholecystectomy(LC). The use of intraoperative cholangiogram(IOC) may decrease the rate of CBD injury by confirming biliary tract anatomy prior to transection, but this effect has not been clearly defined, quantified or cost-analyzed.
METHODS: A retrospective population-based study was conducted using the Washington State hospital discharge database to determine the effect of IOC use and surgical experience on CBD injury. All discharge reports from 1991-1998 were searched for ICD9 procedure codes consistent with LC. This group was then evaluated for ICD9 procedure codes consistent with CBD reconstruction within 90 days of LC.
RESULTS: 30,630 LCs and 76 major CBD injuries(2.5/1000)were identified in this analysis. There was a 10% decrease in the rate of injury per year after 1991(p=0.05). There were no significant differences between injured and non-injured patients based on demographics (age, sex) disease acuity (previous admissions, CBD stone, cholangitis, acute disease, ER admission), payer status(Medicare, Medicaid, private), or hospital variables (teaching, rural, profit). CBD injury occurred in 3.2/1000 of LCs in the early case order(<20) of surgeons compared with 1.7/1000 at later points(p=0.01), RR=1.81 (95% CI=1.44,2.88). The rate of injury in LCs performed without IOC was 3.3/1000 compared to 1.9/1000 in LCs with IOC (p=0.02), RR=1.7 (95%CI=1.1,2.6). Surgeon's experience and IOC use were independent predictors of injury. These effects were maintained in logistic regression models designed to account for confounding variables. During the first 36 LCs performed by surgeons the risk of CBD injury was significantly higher if no IOC was used, RR=2.2 (95% CI=1.31,3.74). Surgeons who used IOC in greater than 75% of LCs had an injury rate of 2.2/1000 compared to 3.2/1000 among surgeons with IOC use in <15% of LCs(p=0.33), but among more routine cholangiographers there was a higher rate of injury when an IOC was not used. The charge associated with the avoidance of a CBD injury would be ,057 overall, and ,000 per injury averted for surgeons within their first 36 LCs.
DISCUSSION: IOC use significantly reduces the likelihood of CBD injury during LC. This effect is magnified during the early experience of surgeons. The data suggest that systemic use of IOC may decrease the rate of CBD injury. This would be particularly cost beneficial if directed towards surgeons at increased risk for injury.
