University of Illinois at Chicago College of Medicine, Chicago, IL, USA.
Department of Surgery, Section of Minimally Invasive Surgery, NorthShore University HealthSystem, Evanston, IL, USA.
Surg Endosc. 2018 Mar;32(3):1184-1191. doi: 10.1007/s00464-017-5790-8. Epub 2017 Aug 24.
Despite the popularity of laparoscopic cholecystectomy, rates of common bile duct injury remain higher than previously observed in open cholecystectomy. This retrospective chart review sought to determine the prevalence of, and risk factors for, biliary injury during laparoscopic cholecystectomy within a high-volume healthcare system.
800 of approximately 3000 cases between 2009 and 2015 were randomly selected and retrospectively reviewed. A single reviewer examined all operative notes, thereby including all cases of BDI regardless of ICD code or need for a second procedure. Biliary injuries were classified per Strasberg et al. (J Am Coll Surg 180:101-125, 1995). Logistic regression models were utilized to identify univariable and multivariable predictors of biliary injuries.
31.0% of charts stated that the Critical View of Safety was obtained, and 12.4% of charts correctly described the critical view in detail. Three patients (0.4%) had a cystic duct leak, and 4 (0.5%) had a common bile duct injury. Of the four CBDI, three patients had a partial transection of the CBD and one had a partial stricture. Patients who suffered BDI were more likely to have had lower hemoglobin, urgent surgery, choledocholithiasis, or acutely inflamed gallbladder. Multivariable analysis of BDI risk factors showed higher preoperative hemoglobin to be independently protective against CBDI. Acutely inflamed gallbladder and choledocholithiasis were independently predictive of CBDI.
The rate of CBDI in this study was 0.5%. Acutely inflamed conditions were risk factors for biliary injury. Multivariable analysis suggests a protective effect of higher preoperative hemoglobin. There was no correlation of CVS with prevention of biliary injury, although only 12.4% of charts could be verified as following the technique correctly. Better implementation of CVS, and increased caution in patients with perioperative inflammatory signs, may be important for preventing bile duct injury. Additionally, counseling patients with acute inflammation on increased risk is important.
尽管腹腔镜胆囊切除术已广泛应用，但胆总管损伤的发生率仍高于开放胆囊切除术。本回顾性图表研究旨在确定在高容量医疗保健系统中腹腔镜胆囊切除术中胆道损伤的发生率和危险因素。
在 2009 年至 2015 年期间，随机选择了约 3000 例病例中的 800 例进行回顾性分析。一位单一的审查员检查了所有手术记录，因此包括了所有胆管损伤的病例，无论 ICD 代码或是否需要进行第二次手术。胆管损伤按 Strasberg 等人的分类方法（J Am Coll Surg 180:101-125, 1995）进行分类。利用逻辑回归模型确定胆管损伤的单变量和多变量预测因素。
31.0%的图表表明获得了安全关键视图，12.4%的图表详细描述了关键视图。3 名患者（0.4%）出现胆囊管漏，4 名患者（0.5%）发生胆总管损伤。在 4 例 CBDI 中，3 例患者胆总管部分横断，1 例患者胆总管部分狭窄。发生胆管损伤的患者术前血红蛋白水平较低、手术紧急、胆总管结石或胆囊急性炎症的可能性更高。对胆管损伤危险因素的多变量分析显示，术前血红蛋白较高可独立预防 CBDI。急性胆囊炎和胆总管结石是 CBDI 的独立预测因素。
本研究中 CBDI 的发生率为 0.5%。急性炎症状态是胆管损伤的危险因素。多变量分析表明术前血红蛋白较高有保护作用。尽管只有 12.4%的图表可以证实正确遵循了该技术，但 CVS 与预防胆管损伤之间没有相关性。更好地实施 CVS，并在围手术期有炎症迹象的患者中更加谨慎，可能对预防胆管损伤很重要。此外，告知急性炎症患者增加风险也很重要。
