S. Patil1, S. H. Fletcher1, F. C. Nance1, R. S. Chamberlain1,2,3 1Saint Barnabas Medical Center,General Surgery,Livingston, NJ, USA 2University Of Medicine And Dentistry Of New Jersey,Newark, NJ, USA 3Saint George’s University,Grenada, Grenada, Grenada
Introduction: Bile duct injury (BDI) during cholecystectomy is a serious complication associated with high morbidity and mortality. This study aimed to determine and analyze the trends and clinical outcomes in BDI and factors influencing BDI in the US over 22 years.
Methods: Data on patients undergoing Open Cholecystectomy (OC) and Laparoscopic Cholecystectomy (LC), as a primary procedure were abstracted from Nationwide Inpatient Sample (NIS) database (1988-2010). Demographic, clinical and hospital characteristics were analyzed as shown in Table 1. BDI rates were compared across two study periods, First (1988-1997) and Second (1998-2010), for both OC and LC. Categorical variables were compared using the Chi-square test and the Student’s t-test was used to compare continuous variables. Multivariate analysis was performed to identify factors influencing BDI.
Results: 1,756,962 (34.0% OCs and 66.0% LCs) cholecystectomy were performed with 9,464 (0.5%) BDIs (1.35% OC and 0.13% LC). OCs decreased by 88.3% with corresponding BDIs decreased by 22.9%. LCs increased by 22.4% with corresponding BDIs decreased by 45%. BDI patients were significantly older in both OC and LC. Overall males had higher BDI for both OC and LC. In OC the overall BDI rates increased in the second study period for all the variables analyzed, except for African Americans, CBD obstruction and in private (for profit) hospitals. Among OC with BDI there was decreased LOS from admission to OC, and discharge to short term hospital, nursing home, and home health care. Among the LC group, the overall BDI rates remained unchanged or decreased in the second study period for all the variables analyzed, except for elective admission and non-inflammatory diagnosis. Among LC with BDI there was increased LOS from admission to LC and discharges with home health care. For both OC and LC with BDI there was increase in the primary repair rates and total charges with decrease in biliary-enteric anastomosis, overall LOS and mortality. On multivariate analysis, age > 50 years, males, OC, large bedsize, urban, teaching hospitals, Northeast US, non-inflammatory diagnosis and patients with CBD stones had increased risk of BDI.
Conclusion: Several independent risk factors for BDI have been identified as outlined above. Notably, obesity is not a risk factor for BDI. LC during acute attack is associated with fewer BDI then a delayed approach. Increased BDI in the absence of inflammation at diagnosis may indicate chronic disease state with dense adhesions. BDI in LC appears to be less complex considering high number of primary repairs. Primary repair appears to be the preferred treatment for both OC and LC BDIs, however long term success remains unknown. Increased morbidity and mortality in OC needs critical attention. Increasing mortality in LC with no BDI needs further evaluation.
