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Background:
Bile duct injury during cholecystectomy is a dreaded complication. Regarding prevention, the identification of patient and procedure-related risk factors are essential. The protective effect of intraoperative cholangiogam has been controversial and widely debated due to lack of conclusive studies. The aim of this study is to identify risk factors for bile duct injury at cholecystectomy using the highly valid Swedish national registry for gallstone surgery, GallRiks, where more than 90% of the Swedish cholecystectomies are registered.
Methods:
All cholecystectomies in GallRiks, from the start of the registry on May 1 2005 until December 31 2010 were included. Patient, institutional and procedure related risk factors for iatrogenic bile duct injury were analysed using multivariate logistic regression. The intention to use intraoperative cholangiogram was defined as performed or attempted cholangiogram, thus using the intention-to-do approach.
Results:
Among 51 041 cholecystectomies, 747 (1.46%) bile duct injuries ranging from minor to major lesions were identified. Patients with acute cholecystitis had a 25% increased risk of bile duct injury compared to patients without cholecystitis (OR 1.25 (95% CI 1.04 to 1.49)) Additionally, the risk of severe bile duct injuries (transections of major ducts with loss of ductal tissue or lesions above the hepatic confluence) were doubled among patients with acute cholecystitis (OR 2.13 (95% CI 0.96 to 4.75)). The intention to use intraoperative cholangiogram reduced the overall risk of bile duct injury by 25% (OR 0.75 (95% CI 0.62 to 0.92)) and the risk of severe bile duct injuries by 66% (OR 0.44 (95% CI 0.30 to 0.63)). The association between intended intraoperative cholangiogram and the reduction in risk of bile duct injury were most prominent among patients with ongoing acute cholecystitis. This group had a risk reduction of 56% (OR 0.44 (95% CI 0.30 to 0.63)).
Conclusions:
In this study, using the highly valid Swedish national registry for gallstone surgery, risk factors for iatrogenic bile duct injury during cholecystectomy were analysed. Patients with acute cholecystitis were at higher risk for bile duct injury. Intention to use intraoperative cholangiogram reduced bile duct injury rates in general and severe injuries in particular. The most noticeable protective effect of intraoperative cholangiogram was seen among patients with acute cholecystitis. The main contribution of this study is the intention-to-do data on intraoperative cholangiogram, and the results suggest that routine use of intraoperative cholangiogram at cholecystectomy may be beneficial.