胆管损伤（BDI）在腹腔镜胆囊切除术的先进时代。
Bile duct injuries (BDI) in the advanced laparoscopic cholecystectomy era.
机构信息
Dwight D. Eisenhower Army Medical Center (DDEAMC), Fort Gordon, GA, USA.
General Surgery Department, Dwight D. Eisenhower Army Medical Center (DDEAMC), 300 East Hospital Road, Fort Gordon, GA, 30905, USA.
出版信息
Surg Endosc. 2019 Mar;33(3):724-730. doi: 10.1007/s00464-018-6333-7. Epub 2018 Jul 13.
BACKGROUND
Laparoscopic cholecystectomy is the most commonly performed laparoscopic procedure. It is superior in nearly every regard compared to open cholecystectomies. The one significant aspect where the laparoscopic approach is inferior regards the association with bile duct injuries (BDI). The BDI rate with laparoscopic cholecystectomy is approximately 0.5%; nearly triple the rate compared to the open approach. We propose that 0.5% BDI rate with the laparoscopic approach is no longer accurate.
METHODS
The National Surgical Quality Improvement Program (NSQIP) registry was retrospectively reviewed. All laparoscopic cholecystectomies performed between 2012 and 2016 were extracted. A total of 217,774 cases meeting inclusion criteria were analyzed. The primary data points were the overall BDI incidence rate and time of diagnosis. BDI were identified by ICD-9 and ICD-10 codes. Secondary data points were variables associated with BDI.
RESULTS
The BDI rate was 0.19%. 77% of cases were diagnosed after the index surgical admission. Intra-operative cholangiography (IOC) use was associated with a higher BDI rate and higher identification rate of a BDI intraoperatively (P value < 0.0001). Resident teaching cases were protective with a RR score of 0.56 (P value < 0.0001). The presence of cholecystitis increased the risk of a BDI with a RR score of 1.20 (P value < 0.0001). There was a low conversion rate of 0.04% however converted cases had a nearly hundredfold increase in BDI at 15% (P value < 0.0001).
CONCLUSIONS
The performance of laparoscopic cholecystectomies in North America is no longer associated with higher BDI rates compared to open. IOC use still is not protective against BDI, and cholecystitis continues to be a risk factor for BDI. When a cholecystectomy requires conversion from a laparoscopic to an open approach the BDI increases a hundredfold; which may raise the concern if this approach is still a safe bailout method for a difficult laparoscopic dissection.
背景
腹腔镜胆囊切除术是最常见的腹腔镜手术。与开腹胆囊切除术相比，它在几乎所有方面都具有优势。但在与胆管损伤（BDI）相关的方面，腹腔镜手术存在一个明显的劣势。腹腔镜胆囊切除术的 BDI 发生率约为 0.5%；几乎是开腹手术的三倍。我们认为，腹腔镜手术 0.5%的 BDI 发生率已经不再准确。
方法
回顾性分析国家外科质量改进计划（NSQIP）登记处的数据。提取了 2012 年至 2016 年间进行的所有腹腔镜胆囊切除术。分析了符合纳入标准的 217774 例病例。主要数据点是总体 BDI 发生率和诊断时间。BDI 通过 ICD-9 和 ICD-10 代码确定。次要数据点是与 BDI 相关的变量。
结果
BDI 发生率为 0.19%。77%的病例在指数手术入院后被诊断。术中胆管造影（IOC）的使用与更高的 BDI 发生率和更高的术中 BDI 检出率相关（P 值<0.0001）。住院医师教学病例的保护作用 RR 评分 0.56（P 值<0.0001）。胆囊炎的存在使 BDI 的风险增加了 1.20 倍（P 值<0.0001）。转换率较低，为 0.04%，但转换病例的 BDI 发生率增加了近 100 倍，达到 15%（P 值<0.0001）。
结论
北美腹腔镜胆囊切除术的 BDI 发生率不再高于开腹手术。IOC 的使用仍然不能预防 BDI，胆囊炎仍然是 BDI 的一个危险因素。当胆囊切除术需要从腹腔镜转为开腹时，BDI 会增加近 100 倍，这可能会引起人们对这种方法作为困难腹腔镜手术的安全救援方法是否仍然安全的担忧。
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