Sunday, October 26, 2003

Best of the Web Wednesday had a link entitled "What Would Gallbladders Do Without Experts" which leads to this article about a paper in this week's Journal of the American Medical Association. The same group of authors published another article describing a decrease in common bile duct injuries (CBDI) when intraoperative cholangiography (IOC)is used.
The main point of the paper is this:

Thirty-three percent of all patients died within the 9.2-year follow-up period (median survival, 5.6 years; interquartile range, 3.2-7.4 years), with 55.2% of patients without and 19.5% with a CBD injury remained alive.

I haven't had the opportunity to read the article but just based on the abstract, I have the following concerns:
Given the incidence of CBDI is higher with laparoscopic cholecystectomy than with open (0.7 percent versus 0.4 percent) how many of these were done laparoscopicaly?
How many of these deaths were directly related to their CBDI? (sepsis, cholangitis, liver failure). Given the population (Medicare beneficiaries) the deaths may be from other causes. The A=true,B=true but unrelated scenario from medical school tests.
These patients may have had more severe gallbladder disease than your routine biliary colic and with the resultant inflammation may have obscured the normal anatomy, with CBDI occurring.

Regardless of the reasoning, CBDI is one of the most common sources of
liability suits against general surgeons in the U.S. today. I had one in training that was recognized at the time of surgery, and repaired primarily. My indications for IOC and conversion to open cholecystectomy are pretty low, but some guidelines are useful...

Anatomy is obscured due to inflammation or other causes..
You have been working for 45 minutes without making progress...
You have bleeding which has required more than five clips to control...
Suspicion of malignancy..

Some advocate the use of dome-down cholecystectomy to avoid CBDI, but it has not gained widepsread acceptance.

The title of this post comes from a lecture I had as a first-year medical student where an attorney described when he would get a high-dollar case, such as a CBDI, he would call his wife and tell her to "book a cruise"
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