Bile duct injuries, 1989-1993 : A statewide experience. Discussion

Objective : To review the incidence of major bile duct injuries (MBDI) during the shift from open (OC) to laparoscopic cholecystectomy (LC). Design : Cohort analysis ; minimum 15-month patient follow-up. Setting : Acute care Connecticut hospitals. Patients : Medical records of 30 211 patients with cholecystectomy (OC or LC) reviewed ; 47 cases of MBDI confirmed. Main Outcome Measure : Rate of MBDI. Results : The incidence of MBDI in Connecticut hospitals rose from 0.04% in 1989 to 0.24% in 1991, then decreased to 0.11% in 1993. The increase was due to increased numbers of cholecystectomies and the initial increased risk of injury with LC. The 1990-through-1993 trend of decreasing incidence of LC MBDI was statistically significant (P=.02). By 1993, the difference between LC and OC was no longer significant (P=.81). Acute cholecystitis (odds ratio, 3.3) and gallstone pancreatitis (odds ratio, 3.6) increased the risk of MBDI during LC (P<.001). The LC MBDI more commonly were ductal excision or transections and often were not diagnosed intraoperatively. Intraoperative cholangiography facilitated intraoperative recognition and repair. Most patients (89%) underwent definitive management of the MBDI at the hospital of origin ; of those, 5% required further interventions. Conclusions : Surgeries for acute cholecystitis and gallstone pancreatitis are associated with an increased risk for MBDI. Ductal anatomy, the timing of recognition of injury, and the method of repair dictate patient outcomes. Most patients are successfully managed at the hospital of origin, with good long-term results. Late bile duct strictures appear rare.