Laparoscopic cholecystectomy, intraoperative cholangiograms, and common duct injuries

摘要

In the late 1980s, laparoscopic cholecystectomy was quickly adopted because it reduced the morbidity associated with the operation and had a relatively straightforward learning curve. However, compared with the open procedure, laparoscopic cholecystectomy was also as-sociated with an increased incidence of common duct injuries, generally due to misinterpretation of the biliary anatomy during the operation. Common duct injuries can have devastating consequences. Although common duct injury rates have decreased slightly through the years, they have not been eliminated and remain a serious risk. Observational studies of intraopera-tive cholangiography (which involves placing a catheter into the cystic duct, injecting contrast material, and obtaining radiographs) have examined whether intraoperative cholangiography may reduce the risk of common duct injury during cholecystectomy, but the results of these studies have not been consistent. In this issue of JAMA, Sheffield and coauthors8 used an instrumental variable analysis to estimate the association between intraoperative cholangiography use and common duct injury. Examining Texas Medicare data, they found 40.4% of 92 932 patients undergoing laparoscopic cholecystectomy had an intraoperative cholangiogram. Common duct injury occurred in 0.21% of patients who underwent intraoperative cholangiography and in 0.36% of patients who did not.