ContextCommon bile duct (CBD) injury during cholecystectomy is a significant
source of patient morbidity, but its impact on survival is unclear.ObjectiveTo demonstrate the relation between CBD injury and survival and to identify
the factors associated with improved survival among Medicare beneficiaries.Design, Setting, and PatientsRetrospective study using Medicare National Claims History Part B data
(January 1, 1992, through December 31, 1999) linked to death records and to
the American Medical Association's (AMA's) Physician Masterfile. Records with
a procedure code for cholecystectomy were reviewed and those with an additional
procedure code for repair of the CBD within 365 days were defined as having
a CBD injury.Main Outcome MeasureSurvival after cholecystectomy, controlling for patient (sex, age, comorbidity
index, disease severity) and surgeon (procedure year, case order, surgeon
specialty) characteristics.ResultsOf the 1 570 361 patients identified as having had a cholecystectomy
(62.9% women), 7911 patients (0.5%) had CBD injuries. The entire population
had a mean (SD) age of 71.4 (10.2) years. 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. The adjusted hazard ratio (HR) for death during the
follow-up period was significantly higher (2.79; 95% confidence interval [CI];
2.71-2.88) for patients with a CBD injury than those without CBD injury. The
hazard significantly increased with advancing age and comorbidities and decreased
with the experience of the repairing surgeon. The adjusted hazard of death
during the follow-up period was 11% greater (HR, 1.11; 95% CI, 1.02-1.20)
if the repairing surgeon was the same as the injuring surgeon.ConclusionsThe association between CBD injury during cholecystectomy and survival
among Medicare beneficiaries is stronger than suggested by previous reports.
Referring patients with CBD injuries to surgeons or institutions with greater
experience in CBD repair may represent a system-level opportunity to improve
outcome.

https://jamanetwork.com/journals/jama/articlepdf/197531/JOC30964.pdf

Bile duct injury during cholecystectomy and survival in medicare beneficiaries.

https://www.giejournal.org/article/S0016-5107(03)80058-5/pdf

Biliary sphincterotomy plus dilation with a large balloon for bile duct stones that are difficult to extract

Background: Laparoscopic cholecystectomy is the standard of care for symptomatic cholelithiasis, but it is associated with a higher incidence of bile duct injury than the open approach. Methods: A review was performed of the English language literature on the management of bile duct injury listed on Medline databases. Results and conclusion: There is consensus that careful dissection and correct interpretation of the anatomy avoids the complication of bile duct injury during cholecystectomy. Routine intraoperative cholangiography is associated with a lower incidence and early recognition of bile duct injury. Early detection and repair is associated with an improved outcome, and the minimum standard of care after the recognition of a bile duct injury is immediate referral to a surgeon experienced in bile duct injury repair. Surgery provides the mainstay of treatment, with proximal hepaticojejunostomy Roux en Y being the operation of choice; a selective role for endoscopic or radiological treatment exists. The outcome after bile duct injury remains poor, especially in relation to the initial expectation of the cholecystectomy. Patients are often committed to a decade of follow-up.

https://www.dkmic.de/fileadmin/bibliothek/literatur/galle/9_bile_duct_injury.pdf

Bile duct injury in the era of laparoscopic cholecystectomy.

Importance Subtotal cholecystectomy (SC) is a procedure that removes portions of the gallbladder when structures of the Calot triangle cannot be safely identified in “difficult gallbladders.” Objective To conduct a systematic review and meta-analysis to evaluate current studies and present an evidence-based assessment of the outcomes for the techniques available for SC. Data Sources A literature search of the PubMed/MEDLINE (1954 to November 2013) and EMBASE (1974 to November 2013) databases was conducted. Search criteria included the words subtotal , partial , insufficient or incomplete , and cholecystectomy . Study Selection Inclusion criteria were all randomized, nonrandomized, and retrospective studies with data on SC techniques and outcomes. Exclusion criteria were studies that reported data on SC along with other interventions (eg, cholecystostomy) without the possibility to discriminate results specific to SC. Data Extraction and Synthesis This systematic review was performed using the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Main Outcomes and Measures The primary outcome of the study was the occurrence of common bild duct injury. Secondary outcomes included the occurrence of other SC-related morbidities, such as hemorrhage, subhepatic collection, bile leak, retained stones, postoperative endoscopic retrograde cholangiopancreatography, wound infection, reoperation, and mortality. Results Thirty articles were included. Subtotal cholecystectomy was typically performed using the laparoscopic technique (72.9%), followed by the open (19.0%) and laparoscopic converted to open (8.0%) techniques. The most common indications were severe cholecystitis (72.1%), followed by cholelithiasis in liver cirrhosis and portal hypertension (18.2%) and empyema or perforated gallbladder (6.1%). Morbidity rates were relatively low (postoperative hemorrhage, 0.3%; subhepatic collections, 2.9%; bile duct injury, 0.08%; and retained stones, 3.1%); the rate for bile leaks was higher (18.0%). Reoperations were necessary in 1.8% of the cases; the 30-day mortality rate was 0.4%. The laparoscopic approach produced less risk of subhepatic collection (odds ratio [OR], 0.4; 95% CI, 0.2-0.9), retained stones (OR, 0.5; 95% CI, 0.3-0.9), wound infection (OR, 0.07; 95% CI, 0.04-0.2), reoperation (OR, 0.5; 95% CI, 0.3-0.9), and mortality (OR, 0.2; 95% CI, 0.05-0.9) but more bile leaks (OR, 5.3; 95% CI, 3.9-7.2) compared with the open approach. Conclusions and Relevance Subtotal cholecystectomy is an important tool for use in difficult gallbladders and achieves morbidity rates comparable to those reported for total cholecystectomy in simple cases. The various technical differences appear to influence outcomes only for the laparoscopic approach.

https://jamanetwork.com/journals/jamasurgery/articlepdf/2084862/soi140063.pdf

Subtotal Cholecystectomy for “Difficult Gallbladders”: Systematic Review and Meta-analysis

https://www.giejournal.org/article/S0016-5107(07)02658-2/pdf

Large-diameter biliary orifice balloon dilation to aid in endoscopic bile duct stone removal: a multicenter series

In this paper, we present a validation of public transport origin–destination (OD) matrices obtained from smartcard and GPS data. These matrices are very valuable for management and planning but have not been validated until now. In this work, we verify the assumptions and results of the method using three sources of information: the same database used to make the estimations, a Metro OD survey in which the card numbers are registered for a group of users, and a sample of volunteers. The results are very positive, as the percentages of correct estimation are approximately 90% in all cases.

Validating travel behavior estimated from smartcard data

The increase of laparoscopic cholecystectomy has resulted in an increase of bile duct injuries. The purpose of this article is to define the types of injury, their occurrence and frequency, and their management by endoscopic and surgical techniques. Three investigations were included in the present study. 1. A 3-year retrospective study among 29 hospitals with 25,007 laparoscopic cholecystectomies. 2. An 8-year prospective study at our institution of 6488 patients. 3. A prospective endoscopic study of 94 patients with injuries and strictures of the common bile duct (CBD) after laparoscopic cholecystectomy. A special classification for bile duct injuries was developed. Among 25,007 patients from 29 hospitals, a total of 74 lesions were detected with an incidence of 0.29%. At our institution, 20 cases were seen (0.29%) with type I, II, and III injuries. The 94 cases managed by endoscopic procedure were submitted to endoscopic retrograde cholangiopancreatography (ERCP) and papillotomy, with placement of several stents 5 to 10 F during 8 months. The results of this procedure have been excellent to good in 76% of the cases up to 3 years of follow-up. According to our previous and present experience, bile duct injuries after laparoscopic procedure are two times higher than after open procedure. The best treatment is the prevention of these injuries by careful surgical technique. If they occur, the best moment to repair them is during surgery. If they are noticed after the operation, endoscopic or surgical procedures can be employed.

Treatment of common bile duct injuries during laparoscopic cholecystectomy: endoscopic and surgical management.

Advances in cannulation techniques and instruments have helped in difficult bile duct cannulation and thus stone extraction. For small common bile duct (CBD) stones, endoscopic papillary balloon dilatation has been proposed as an alternative to endoscopic papillotomy (EPT). The technique must undergo further evaluation before recom- mending its routine use. For most patients with bile duct stones, EPT remains the method of choice. Out of 8204 patients treated in three surgical endoscopy centers (Chile, Germany, and India), 86% to 91% of all CBD stones could be extracted subsequently after EPT using a Dormia basket; 4% to 7% required mechanical lithotripsy (ML) before removal and 3% to 10% of the patients needed other sophisticated techniques, such as electrohydraulic lithotripsy (EHL), laser-induced shock-wave litho- tripsy (LISL), or extracorporeal shock-wave lithotripsy (ESWL). The local expertise and availability of equipment determines the choice of method used. In general, EHL or LISL is used for impacted CBD stones including stones in Mirizzi syndrome refractory to ML. ESWL is best suited for intrahepatic stones. Permanent stenting can be offered to poor risk patients instead of extensive procedures to clear the bile duct. Using currently available nonsurgical techniques, fewer than 1% of all patients with bile duct stones still require surgical intervention.

Advances in Therapeutic Endoscopic Treatment of Common Bile Duct Stones

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 To obtain travel information from smartcard data is a growing tendency. Many researchers have foreseen the opportunity of obtaining high quality information at very low cost, and therefore have developed tools to obtain valuable information from the original data generated as a side-product of the operation of transit systems. However, most authors recognize that the process of estimating destination, route and activities from smartcard data involves several assumptions, and the results need to be validated. We have conducted such validation for the set of methodologies used to input boarding position, alighting stop and route chosen for the case of Transantiago (public transport system in Santiago, Chile). To do so, we have used three sources of information: information from the same database used to make the estimations (endogenous validation), information from a detailed origin-destination survey applied to a sample of 300,000 metro users, where a small percentage of them provided their smartcard id for validation purposes, and personal interviews to a small sample of volunteers who provided all their travel and personal information. The endogenous validation was mainly used to detect errors and improve the methodology. The large sample of OD surveys was used to compare the route chosen by the users within the Metro network with the route assigned by the model (minimum cost). The small sample of metro users who answer the OD survey and also provided their card id, and the sample of volunteers were used to validate the more strong assumptions of the model: alighting estimation and purpose assignment. The results of this exploratory validation analysis are very promising. The endogenous validation showed very reasonable estimations, and helped to detect some errors that can be easily corrected with slight modifications to the previous methodology. Both the OD survey and the personal interviews showed that the estimation of the boarding site is very precise, and that the estimation of alighting stop is reasonably good in estimating the exact alighting site, and reach levels over 95% of accuracy at a more aggregate level.

Claudio Navarrete

Papers

Validating travel behavior estimated from smartcard data

Treatment of common bile duct injuries during laparoscopic cholecystectomy: endoscopic and surgical management.

Advances in Therapeutic Endoscopic Treatment of Common Bile Duct Stones

Validating travel behavior estimated from smartcard data