Gross Abby, Said Sayf Al-Deen, Wehrle Chase J, Hong Hanna, Quick Joseph, Larson Sarah, Hossain Mir Shanaz, Naffouje Samer, Walsh R Matthew, Augustin Toms
Quality Improvement & Patient Safety, Digestive Disease Institute, Cleveland Clinic, Cleveland, Ohio.
Department of General Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, Ohio.
JAMA Surg. 2025 Feb 1;160(2):145-152. doi: 10.1001/jamasurg.2024.5216.
There is sparse literature on whether routine cholangiography (RC) vs selective cholangiography (SC) during cholecystectomy is associated with improved perioperative outcomes, regardless of whether an intraoperative cholangiogram (IOC) is performed.
To compare perioperative outcomes of cholecystectomy between surgeons who routinely vs selectively perform IOC.
DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort study was conducted from January 2015 through June 2023 and took place within the Cleveland Clinic Enterprise, which includes 18 hospitals and 9 ambulatory surgery centers in 2 states (Ohio and Florida). Participants included adult patients who underwent cholecystectomy for benign biliary disease. Data analysis was conducted between July 2023 and August 2024.
Routine cholangiography, defined as more than 70% of cholecystectomies performed with IOC per surgeon over the study period.
MAIN OUTCOME(S) AND MEASURE(S): The primary outcome was major bile duct injury (BDI). Hierarchical mixed-effects models with patients nested in hospitals adjusted for individual- and surgeon-level characteristics were used to assess the odds of major BDI and secondary outcomes (minor BDI, operative duration, and perioperative endoscopic retrograde cholangiopancreatography [ERCP]).
A total of 134 surgeons performed 28 212 cholecystectomies with 10 244 in the RC cohort (mean age, 52.71 [SD, 17.78] years; 7102 female participants [69.33%]) and 17 968 in the SC cohort (mean age, 52.33 [SD, 17.72] years; 12 135 female participants [67.54%]). Overall, 26 major BDIs (0.09%) and 105 minor BDIs (0.34%) were identified. Controlling for patient and surgeon characteristics nested in hospitals, RC was associated with decreased odds of major BDI (odds ratio [OR], 0.16; 95% CI, 0.15-0.18) and minor BDI (OR, 0.83; 95% CI, 0.77-0.89) compared with SC. Major BDIs were recognized intraoperatively more often in the RC cohort than the SC cohort (76.9% vs 23.0%; difference, 53.8%; 95% CI, 15.9%-80.2%). Lastly, RC was not significantly associated with increased perioperative ERCP utilization (OR, 1.01; 95% CI, 0.90-1.14) or negative ERCP rate (RC, 27 of 844 [3.2%] vs SC, 57 of 1570 [3.6%]; difference, -0.3%; 95% CI, -1.9% to 1.0%).
In this study, RC was associated with decreased odds of major and minor BDI, as well as increased intraoperative recognition of major BDI when it occurred. RC could be considered as a health systems strategy to minimize BDI, acknowledging the overall low prevalence but high morbidity from these injuries.
关于胆囊切除术期间常规胆管造影（RC）与选择性胆管造影（SC）是否与改善围手术期结局相关的文献较少，无论是否进行术中胆管造影（IOC）。
比较常规与选择性进行IOC的外科医生行胆囊切除术的围手术期结局。
设计、设置和参与者：这项回顾性队列研究于2015年1月至2023年6月进行，在克利夫兰诊所企业内开展，该企业包括俄亥俄州和佛罗里达州的18家医院和9个门诊手术中心。参与者包括因良性胆道疾病接受胆囊切除术的成年患者。数据分析于2023年7月至2024年8月进行。
常规胆管造影，定义为在研究期间每位外科医生进行的胆囊切除术中超过70%伴有IOC。
主要结局是主要胆管损伤（BDI）。采用将患者嵌套在医院中的分层混合效应模型，对个体和外科医生水平的特征进行调整，以评估主要BDI和次要结局（次要BDI、手术持续时间和围手术期内镜逆行胰胆管造影术[ERCP]）的发生几率。
共有134名外科医生进行了28212例胆囊切除术，其中RC队列10244例（平均年龄52.71[标准差，17.78]岁；女性参与者7102例[69.33%]），SC队列17968例（平均年龄52.33[标准差，17.72]岁；女性参与者12135例[67.54%]）。总体而言，共识别出26例主要BDI（0.09%）和105例次要BDI（0.34%）。在控制了嵌套在医院中的患者和外科医生特征后，与SC相比，RC与主要BDI发生几率降低（优势比[OR]，0.16；95%置信区间，0.15 - 0.18）和次要BDI发生几率降低（OR，0.83；95%置信区间，0.77 - 0.89）相关。与SC队列相比，RC队列中更多的主要BDI在术中被识别（76.9%对23.0%；差异，53.8%；95%置信区间，15.9% - 80.2%）。最后，RC与围手术期ERCP使用率增加（OR，1.01；95%置信区间，0.90 - 1.14）或ERCP阴性率增加无显著关联（RC，844例中的27例[3.2%]对SC，1570例中的57例[3.6%]；差异， - 0.3%；95%置信区间， - 1.9%至1.0%）。
在本研究中，RC与主要和次要BDI发生几率降低相关，并且在发生主要BDI时术中识别率增加。考虑到这些损伤总体患病率低但发病率高，RC可被视为一种卫生系统策略，以尽量减少BDI。
