Comparative Safety of Robotic-Assisted vs Laparoscopic Cholecystectomy.

Importance: Robotic-assisted cholecystectomy is rapidly being adopted into practice, partly based on the belief that it offers specific technical and safety advantages over traditional laparoscopic surgery. Whether robotic-assisted cholecystectomy is safer than laparoscopic cholecystectomy remains unclear. Objective: To determine the uptake of robotic-assisted cholecystectomy and to analyze its comparative safety vs laparoscopic cholecystectomy. Design, Setting, and Participants: This retrospective cohort study used Medicare administrative claims data for nonfederal acute care hospitals from January 1, 2010, to December 31, 2019. Participants included 1 026 088 fee-for-service Medicare beneficiaries 66 to 99 years of age who underwent cholecystectomy with continuous Medicare coverage for 3 months before and 12 months after surgery. Data were analyzed August 17, 2022, to June 1, 2023. Exposure: Surgical technique used to perform cholecystectomy: robotic-assisted vs laparoscopic approaches. Main Outcomes and Measures: The primary outcome was rate of bile duct injury requiring definitive surgical reconstruction within 1 year after cholecystectomy. Secondary outcomes were composite outcome of bile duct injury requiring less-invasive postoperative surgical or endoscopic biliary interventions, and overall incidence of 30-day complications. Multivariable logistic analysis was performed adjusting for patient factors and clustered within hospital referral regions. An instrumental variable analysis was performed, leveraging regional variation in the adoption of robotic-assisted cholecystectomy within hospital referral regions over time, to account for potential confounding from unmeasured differences between treatment groups. Results: A total of 1 026 088 patients (mean [SD] age, 72 [12.0] years; 53.3% women) were included in the study. The use of robotic-assisted cholecystectomy increased 37-fold from 211 of 147 341 patients (0.1%) in 2010 to 6507 of 125 211 patients (5.2%) in 2019. Compared with laparoscopic cholecystectomy, robotic-assisted cholecystectomy was associated with a higher rate of bile duct injury necessitating a definitive operative repair within 1 year (0.7% vs 0.2%; relative risk [RR], 3.16 [95% CI, 2.57-3.75]). Robotic-assisted cholecystectomy was also associated with a higher rate of postoperative biliary interventions, such as endoscopic stenting (7.4% vs 6.0%; RR, 1.25 [95% CI, 1.16-1.33]). There was no significant difference in overall 30-day complication rates between the 2 procedures. The instrumental variable analysis, which was designed to account for potential unmeasured differences in treatment groups, also showed that robotic-assisted cholecystectomy was associated with a higher rate of bile duct injury (0.4% vs 0.2%; RR, 1.88 [95% CI, 1.14-2.63]). Conclusions and Relevance: This cohort study's finding of significantly higher rates of bile duct injury with robotic-assisted cholecystectomy compared with laparoscopic cholecystectomy suggests that the utility of robotic-assisted cholecystectomy should be reconsidered, given the existence of an already minimally invasive, predictably safe laparoscopic approach.

Assessment of a novel biliary-specific near-infrared fluorescent dye (BL-760) for intraoperative detection of bile ducts and biliary leaks during hepatectomy in a preclinical swine model.

OBJECTIVES: Postoperative bile leakage is a common complication of hepatobiliary surgery and frequently requires procedural intervention. Bile-label 760 (BL-760), a novel near-infrared dye, has emerged as a promising tool for identifying biliary structures and leakage, owing to its rapid excretion and strong bile specificity. This study aimed to assess the intraoperative detection of biliary leakage using intravenously administered BL-760 compared with intravenous (IV) and intraductal (ID) indocyanine green (ICG). MATERIALS AND METHODS: Laparotomy and segmental hepatectomy with vascular control were performed on two 25-30 kg pigs. ID ICG, IV ICG, and IV BL-760 were administered separately, followed by an examination of the liver parenchyma, cut liver edge, and extrahepatic bile ducts for areas of leakage. The duration of intra- and extrahepatic fluorescence detection was assessed, and the target-to-background (TBR) of the bile ducts to the liver parenchyma was quantitatively measured. RESULTS: In Animal 1, after intraoperative BL-760 injection, three areas of leaking bile were identified within 5 min on the cut liver edge with a TBR of 2.5-3.8 that was not apparent to the naked eye. In contrast, after IV ICG administration, the background parenchymal signal and bleeding obscured the areas of bile leakage. A second dose of BL-760 demonstrated the utility of repeated injections, confirming two of the three previously visualized areas of bile leakage and revealing one previously unseen leak. In Animal 2, neither ID ICG nor IV BL-760 injections showed obvious areas of bile leakage. However, fluorescence signals were observed within the superficial intrahepatic bile ducts after both injections. CONCLUSIONS: BL-760 enables the rapid intraoperative visualization of small biliary structures and leaks, with the benefits of fast excretion, repeatable intravenous administration, and high-fluorescence TBR in the liver parenchyma. Potential applications include the identification of bile flow in the portal plate, biliary leak or duct injury, and postoperative monitoring of drain output. A thorough assessment of the intraoperative biliary anatomy could limit the need for postoperative drain placement, a possible contributor to severe complications and postoperative bile leak.

Outcome assessment of biliary stricture repair following cholecystectomy in a tertiary care centre.

PURPOSE: Bile duct injuries (BDIs) are the potential grievous complications of cholecystectomy that result in substantial morbidity and mortality. Outcomes of BDI management depend on multiple factors such as the type and extent of injury, timing of repair, and surgical expertise. The present retrospective study was conducted to analyse the risk factors associated with the BDI repair outcomes. METHODS: The data of patients having primary or recurrent bile duct stricture following BDI from 1985 to 2018 were retrospectively evaluated. RESULTS: A total of 268 patients underwent hepaticojejunostomy (HJ). Of the total, 218 patients had primary bile duct stricture, and 50 patients had HJ stricture. The most commonly performed procedure for primary BDI was Roux-en-Y HJ (RYHJ), followed by right hepatectomy, right posterior sectionectomy, and left hepatectomy. All patients with strictured HJ underwent RYHJ, except one who underwent a right hepatectomy. Outcome assessment using the McDonald grading system showed that 62%, 27%, 5%, and 6% of patients with primary bile duct stricture had grade A, grade B, grade C, and grade D complications, respectively, with a mortality rate of 3.21%, whereas 46%, 34%, and 18% patients with strictured HJ had grade A, grade B, and grade C complications, respectively, with a mortality rate of 2%. High-up biliary strictures, early repair, and blood loss > 350 mL are the surrogate markers for failure of repair. CONCLUSION: Management of BDI needs a multidisciplinary approach. The outcomes of both primary biliary stricture and strictured HJ can be improved with management of patients in a tertiary care centre. However, attempts to repair within 2 weeks of injury, Strasberg E4 and E5, and blood loss of > 350 mL may have an adverse effect on the outcome of HJ.

Intraoperative Time-Out to Promote the Implementation of the Critical View of Safety in Laparoscopic Cholecystectomy: A Video-Based Assessment of 343 Procedures.

BACKGROUND: The critical view of safety (CVS) is poorly adopted in surgical practices, although it is recommended ubiquitously to prevent major bile duct injuries during laparoscopic cholecystectomy (LC). This study aimed to investigate whether performing a short intraoperative time-out can improve CVS implementation. STUDY DESIGN: In this before vs after study, surgeons performing LCs at an academic center were invited to use a 5-second long time-out to verify CVS before dividing the cystic duct (5-second rule). The primary aim was to compare the rate of CVS achievement for LC performed in the year before vs the year after implementation of the 5-second rule. The CVS achievement rate was computed after exclusion of bailout procedures using a mediated video-based assessment made by 2 independent reviewers. Clinical outcomes, LC workflows, and postoperative reports were also compared. RESULTS: Three hundred and forty-three of 381 LC performed between December 2017 and November 2019 (171 before and 172 after implementation of the 5-second rule) were analyzed. The 5-second rule was associated with a significantly increased rate of CVS achievement (15.9% vs 44.1% before vs after the 5-second rule, respectively; p < 0.001). Significant differences were also observed with respect to the rate of bailout procedures (8.2% vs 15.7%; p = 0.04), median time (hours:minutes:seconds) to clip the cystic duct or artery (00:17:26; interquartile range 00:11:48 to 00:28:35 vs 00:23:12; interquartile range 00:14:29 to 00:31:45 duration; p = 0.007), and the rate of postoperative CVS reporting (1.3% vs 28.8%; p < 0.001). Postoperative morbidity was comparable (1.8% vs 2.3%; p = 0.68). CONCLUSIONS: Performing a short intraoperative time-out was associated with an improved CVS achievement rate. Systematic intraoperative cognitive aids should be studied to sustain the uptake of guidelines.

Routine versus selective intraoperative cholangiography during cholecystectomy: systematic review, meta-analysis and health economic model analysis of iatrogenic bile duct injury.

BACKGROUND: Bile duct injury (BDI) is a severe complication following cholecystectomy. Early recognition and treatment of BDI has been shown to reduce costs and improve patients' quality of life. The aim of this study was to assess the effect and cost-effectiveness of routine versus selective intraoperative cholangiography (IOC) in cholecystectomy. METHODS: A systematic review and meta-analysis, combined with a health economic model analysis in the Swedish setting, was performed. Costs per quality-adjusted life-year (QALY) for routine versus selective IOC during cholecystectomy for different scenarios were calculated. RESULTS: In this meta-analysis, eight studies with more than 2 million patients subjected to cholecystectomy and 9000 BDIs were included. The rate of BDI was estimated to 0.36 per cent when IOC was performed routinely, compared with to 0.53 per cent when used selectively, indicating an increased risk for BDI of 43 per cent when IOC was used selectively (odds ratio 1.43, 95 per cent c.i. 1.22 to 1.67). The model analysis estimated that seven injuries were avoided annually by routine IOC in Sweden, a population of 10 million. Over a 10-year period, 33 QALYs would be gained at an approximate net cost of €808 000 , at a cost per QALY of about €24 900. CONCLUSION: Routine IOC during cholecystectomy reduces the risk of BDI compared with the selective strategy and is a potentially cost-effective intervention.

Biliary Enteric Reconstruction After Biliary Injury: Delayed Repair Is More Costly Than Early Repair.

BACKGROUND: Bile duct injury (BDI) during cholecystectomy requiring biliary enteric reconstruction (BER) is associated with increased risk of postoperative mortality and substantive increases in costs of care. The impact of the timing of repair on overall costs of care is poorly understood. MATERIALS AND METHODS: The Healthcare Cost and Utilization Project Florida State databases (2006-2015) were queried to identify patients undergoing BER within 1-y of cholecystectomy performed for benign biliary disease. Patients were then categorized by the time interval between cholecystectomy to BER: early (≤3 d), intermediate (4 d to 6 wk), or delayed (>6 wk). By repair timing strategy, 1-y outcomes were aggregated, including charges, inpatient costs, aggregate length of stay, and inpatient mortality. RESULTS: Of 563,887 patients undergoing cholecystectomy, 1168 required a BER (0.21%) within 1-y of cholecystectomy. Early BER was performed in 560 patients (47.9%), intermediate BER in 439 patients (37.6%), and delayed BER in 169 (14.5%) patients. On multivariable analysis adjusting for patient, procedure, and facility factors, intermediate BER demonstrated an increased risk of mortality (odds ratio 2.04, 95% confidence interval [CI]: 1.16-3.56) and increased aggregate inpatient cost (+$12,472; 95% CI: $6421-$18,524) relative to early BER. There was no notable difference in adjusted risk of inpatient mortality between the early and delayed BER cohorts (odds ratio 0.90; 95% CI: 0.32-1.25), but delayed BER was associated with increased aggregate inpatient costs (+$45,111; 95% CI: $36,813-$53,409). CONCLUSIONS: When compared with delayed BER, early repair was associated with shorter aggregate inpatient hospitalization without increased postoperative mortality. Intermediate timing of repair is associated with increased costs and risk of mortality.

A comprehensive evaluation of the long-term clinical and economic impact of minor bile duct injury.

BACKGROUND: Outcomes after Strasberg grade E bile duct injury have been widely reported. However, there are comparatively few reports of outcomes after Strasberg A to D bile duct injury. Therefore, the aim of this study was to comprehensively evaluate the long-term clinical and economic impact of Strasberg A to D bile duct injury. METHODS: Patients with Strasberg A to D bile duct injury were identified from a prospectively collected and maintained database. Long-term biliary complication rates, as well as treatment costs were then estimated, and compared across Strasberg injury grades. RESULTS: A total of N = 120 patients were identified, of whom N = 49, 13, 20, and 38 had Strasberg grade A, B, C, and D bile duct injury, respectively. Surgical repair was most commonly performed in Strasberg grade D injuries (74% vs 8%-20% in lower grades, P < .001). By 5 years post bile duct injury, the estimated long-term biliary complication rate was 40% in Strasberg grade D injuries, compared with 15% in Strasberg grade A (P = .022). A significant difference in total treatment and follow-up costs was also detected (P < .001), being highest in Strasberg grade D injuries (mean £11,048/US$14,252 per patient) followed by the Strasberg grade B group (mean £10,612/US$13,689 per patient). DISCUSSION: Strasberg grade A to D injuries lead to considerable long-term morbidity and cost. Strasberg grade D injuries are typically managed surgically and result in the highest complication rate and treatment costs. Strasberg grade B injuries lead to a similar complication rate and treatment cost but are often managed without surgery.

Adverse outcomes and short-term cost implications of bile duct injury during cholecystectomy.

BACKGROUND: Bile duct injury (BDI) is an uncommon but major complication of cholecystectomy that has a poorly defined magnitude of effect on hospital costs. This study sought to calculate the healthcare costs, length of stay, and discharge status associated with bile duct injury in patients undergoing cholecystectomy in the United States. METHODS: The Premier Healthcare Database, which comprises hospital-billing records from over 700 hospitals in the United States, was queried for all patients undergoing cholecystectomy between January 2010 and March 2018. BDI was defined by ICD-9-CM and ICD-10-CM codes. Patient demographics, clinical characteristics, and operative information were extracted. Hospital costs, length of stay, and discharge status were compared between BDI and non-BDI patients. Propensity score matching was used to minimize confounding factors. Multivariable regression models were used to estimate the association between BDI and the outcomes variables. RESULTS: A total of 1,168,288 cholecystectomies were identified. BDI occurred in 878 patients (0.08%). Laparoscopy was the most common approach (> 95%). The majority of BDI occurred during inpatient admissions (71.0%). BDI patients had higher index admission hospital costs ($18,771 vs. $12,345, p < 0.0001), increased rate of discharge to an institutional post-acute care facility (odds ratio 3.89, 95% CI 2.92-5.19, p < 0.0001), and increased risk of readmission within 30 days after discharge (odds ratio 1.86, 95% CI 1.52-2.28, p < 0.0001), compared to patients without BDI. Among inpatient cholecystectomies, BDI was associated with increased length of stay (8.6 days vs. 4.8 days, p < 0.0001). CONCLUSION: BDI is associated with significantly increased hospital costs, length of stay, 30-day readmission, and discharge to an institutional post-acute care facility.

A comprehensive evaluation of the long-term economic impact of major bile duct injury.

BACKGROUND: Complications and litigation after bile duct injury (BDI) result in clinical and economic burden. The aim of this study was to comprehensively evaluate the long-term clinical and economic impact of major BDI. METHOD: Patients with long-term follow-up after Strasberg E BDI were identified. Costs of treatment and litigation were the primary outcome. Relationships between these outcomes and repair factors, like timing of repair and surgeon expertise, were secondary outcomes. RESULTS: Among 139 patients with a median follow up of 10.7 years, 40% of patients developed biliary complications. Repairs by non-specialist surgeons had significantly higher follow up and treatment costs than those by specialists (£25,814 vs. £14,269, p < 0.001). Estimated litigation costs were higher in delayed than immediate repairs (£23,295 vs. £12,864). As such, the lowest average costs per BDI are after immediate specialist repair and the highest after delayed non-specialist repair (£27,133 vs. £49,109, ×1.81 more costly, p < 0.001). Repair by a non-specialist surgeon (HR: 4.00, p < 0.001) and vascular injury (HR: 2.35, p = 0.013) were significant independent predictors of increased complication rates. CONCLUSION: Costs of major BDI are considerable. They can be reduced by immediate on-table repair by specialist surgeons. This must therefore be considered the standard of care wherever possible.

Financial Aspects of Bile Duct Injuries.

BACKGROUND Major bile duct injury is the most worrisome complication of cholecystectomy. There is no detailed data about the incidence or treatment-related costs of bile duct injuries in Turkey. We aimed to determine prevalence and therapeutic costs of patients with major biliary duct injuries managed in our department, and further estimate a projection of these parameters at the national level. MATERIAL AND METHODS All patients admitted due to bile duct injury during cholecystectomy from 2011 to 2014 were included. Healthcare costs were calculated by summing of their all treatment-related costs in Istanbul Medical Faculty. We collected 2014-2015 data on number of patients diagnosed with cholecystitis in Turkey, the number of cholecystectomies, and the number of the interventions performed following these initial surgeries, which were obtained from the Turkish Social Security Institution. RESULTS Forty-nine patients were enrolled and bilioenteric diversion was performed in 39 patients: 20.4% of patients had Bismuth II, 38.8% had Bismuth III, and 40.8% had Bismuth IV biliary stricture. Comparison of stricture types with total costs, days of hospitalization, and outpatient clinic costs revealed significant differences. Mean total cost of corrective surgeries was 9199 TRY. We estimated that 1.5% to 2.4% of patients who underwent cholecystectomy in Turkey have bile duct injury (including 0.3% with major bile duct injury). CONCLUSIONS New preventive strategies should be used to avoid bile duct injuries, which have a huge financial impact on the national economy.

Routine intraoperative cholangiography during cholecystectomy is a cost-effective approach when analysing the cost of iatrogenic bile duct injuries.

BACKGROUND: The total cost of bile duct injuries (BDIs) in an unselected national cohort of patients undergoing cholecystectomy are unknown. The aim was to evaluate costs associated with treatment of cholecystectomy-related BDIs and to calculate cost effectiveness of routine vs. on-demand intraoperative cholangiography (IOC). METHODS: Data from Swedish patients suffering a BDI during a 5 year period were analysed. Questionnaires to investigate loss-of-production and health status (EQ-5D) were distributed to patients who suffered a BDI during cholecystectomy and who underwent uneventful cholecystectomy (matched control group). Costs per quality-adjusted-life-year (QALY) gained by intraoperative diagnosis were estimated for two strategies: routine versus on-demand IOC during cholecystectomy. RESULTS: Intraoperative diagnosis, immediate intraoperative repair, and minor BDI were all associated with reduced direct treatment costs compared to postoperative diagnosis, delayed repair, and major BDI (all p < 0.001). No difference was noted in loss-of-production for minor versus major BDIs or between different treatment strategies. The cost per QALY gained with routine intraoperative cholangiography (ICER-incremental cost-effectiveness ratio) to achieve intraoperative diagnosis was €50,000. CONCLUSIONS: Intraoperative detection and immediate intraoperative repair is the superior strategy with less than half the cost and superior functional patient outcomes than postoperative diagnosis and delayed repair. The cost per QALY gained (ICER) using routine IOC was considered reasonable.

Single-incision laparoscopic cholecystectomy: does it work? A systematic review.

BACKGROUND: Single-incision laparoscopic cholecystectomy (SILC) has been widely introduced into the clinical practice, but the real clinical benefits for patients still remain a matter of debate. We conducted a systematic review, according to the PRISMA guidelines comparing clinical and peri-operative outcomes of SILC and conventional laparoscopic cholecystectomy (CLC). METHOD: A literature search, including only randomised controlled trials (RCTs), was performed via PubMed, Google Scholar, Cochrane Library and Embase database. The reviewers extracted data from the manuscripts of selected articles including patient demographics, operative time, morbidity rate, post-operative length of stay, conversion rate, cost data, pain and satisfaction with cosmetic results. RESULT: Seventeen RCTs matching the inclusion criteria were finally selected for the analysis. A total of 1293 patients were involved in the review, including 663 (51.3 %) patients who have undergone SILC and 630 (48.7 %) patients who have undergone CLC. Post-operative pain was significantly worse in SILC patients in four studies, in CLC patients in four studies, while in the remnants seven studies, no differences in pain scores were found. Data on satisfaction for post-operative cosmetics were significantly better for SILC patients in all studies but two. Operating time was significantly longer in SILC group while there is no statistically significant difference in conversion rate. Morbidity rate was similar in both groups, as was the incidence of bile duct injuries. Costs were significantly higher in SILC group. SILC was considered a more challenging procedure in all studies. CONCLUSION: The role of SILC is still controversial. Until now, no real significant benefit has been proven: overall satisfaction is the only clear advantage of SILC, and this is mainly related to cosmetic results. Indications to SILC are mainly limited to patients with uncomplicated disease, with BMI ≤ 30 kg/m(2), whose surgery is unlikely to be converted to an open or multiport approach.

A cost analysis of operative repair of major laparoscopic bile duct injuries.

BACKGROUND: Major bile duct injuries occur infrequently after laparoscopic cholecystectomy, but may result in life-threatening complications. Few data exist on the financial implications of duct repair. This study calculated the costs of operative repair in a cohort of patients who underwent reconstruction of the bile duct after major ductal injury. OBJECTIVE: To calculate the total in-hospital cost of surgical repair of patients referred with major bile duct injuries. METHODS: A prospective database was reviewed to identify all patients referred to the University of Cape Town Private Academic Hospital, South Africa, between 2002 and 2013 for assessment and repair of major laparoscopic bile duct injuries. The detailed clinical records and billing information were evaluated to determine all costs from admission to discharge. Total costs for each patient were adjusted for inflation between the year of repair and 2013. Results. Forty-four patients (33 women, 11 men; median age 48 years, range 30 - 78) underwent reconstruction of a major bile duct injury. First-time repairs were performed at a median of 24.5 days (range 1 - 3,662) after initial surgery. Median hospital stay was 15 days (range 6 - 86). Mean cost of repair was ZAR215,711 (range ZAR68,764 - 980,830). Major contributors to cost were theatre expenses (22%), admission to intensive care (21%), radiology (17%) and specialist fees (12%). Admission to a general ward (10%), consumables (7%), pharmacy (5%), endoscopy (3%) and laboratory costs (3%) made up the balance. CONCLUSIONS: The cost of repair of a major laparoscopic bile duct injury is substantial owing to prolonged hospitalisation, complex surgicalintervention and intensive imaging requirements.

Iatrogenic bile duct injury. A significant surgical problem. Assessment of treatment outcomes in the department's own material.

UNLABELLED: Iatrogenic bile duct injuries (BDI) are still a challenging diagnostic and therapeutic problem. With the introduction of the laparoscopic technique for the treatment of cholecystolithiasis, the incidence of iatrogenic BDI increased. The aim of the study was a retrospective analysis of 69 patients treated at the department due to iatrogenic BDI in the years 2004-2014. MATERIAL AND METHODS: In this paper, we presented the results of a retrospective analysis of 69 patients treated at the Department due to iatrogenic BDI in the years 2004-2014. The data were analysed in terms of age, sex, type of biliary injury, clinical symptoms, the type of repair surgery, the time between the primary surgery and the BDI management, postoperative complications and duration of hospital stay. RESULTS: 82.6% of BDI occurred during laparoscopic cholecystectomy, 8.7% occurred during open cholecystectomy, whereas 6 cases of BDI resulted from surgeries conducted for other indications. In order to assess the degree of BDI, Bismuth and Neuhaus classifications were used (for open and laparoscopic cholecystectomy respectively). 84.1% of patients with confirmed BDI, were transferred to the Department from other hospitals. The average time between the primary surgery and reoperation was 6.2 days (SD 4). The most common clinical symptom was biliary fistula observed in 78.3% of patients. In 28 patients, unsuccessful attempts to manage BDI were made prior to the admission to the Department in other centres. The repair procedure was mainly conducted by laparotomy (82.6%) and by the endoscopic approach (15.9%). Hepaticojejunostomy was the most common type of reconstruction following BDI (34.7%). CONCLUSIONS: The increase in the rate of iatrogenic bile duct injury remains a challenging surgical problem. The management of BDI should be multidisciplinary treatment. Referring patients with both suspected and confirmed iatrogenic BDI to tertiary centres allows more effective treatment to be implemented.

Postoperative biliary adverse events following orthotopic liver transplantation: assessment with magnetic resonance cholangiography.

Biliary adverse events following orthotopic liver transplantation (OLT) are relatively common and continue to be serious causes of morbidity, mortality, and transplant dysfunction or failure. The development of these adverse events is heavily influenced by the type of anastomosis during surgery. The low specificity of clinical and biologic findings makes the diagnosis challenging. Moreover, direct cholangiographic procedures such as endoscopic retrograde cholangiopancreatography and percutaneous transhepatic cholangiography present an inadmissible rate of adverse events to be utilized in clinically low suspected patients. Magnetic resonance (MR) maging with MR cholangiopancreatography is crucial in assessing abnormalities in the biliary system after liver surgery, including liver transplant. MR cholangiopancreatography is a safe, rapid, non-invasive, and effective diagnostic procedure for the evaluation of biliary adverse events after liver transplantation, since it plays an increasingly important role in the diagnosis and management of these events. On the basis of a recent systematic review of the literature the summary estimates of sensitivity and specificity of MR cholangiopancreatography for diagnosis of biliary adverse events following OLT were 0.95 and 0.92, respectively. It can provide a non-invasive method of imaging surgical reconstruction of the biliary anastomoses as well as adverse events including anastomotic and non-anastomotic strictures, biliary lithiasis and sphincter of Oddi dysfunction in liver transplant recipients. Nevertheless, conventional T2-weighted MR cholangiography can be implemented with T1-weighted contrast-enhanced MR cholangiography using hepatobiliary contrast agents (in particular using Gd-EOB-DTPA) in order to improve the diagnostic accuracy in the adverse events' detection such as bile leakage and strictures, especially in selected patients with biliary-enteric anastomosis.

Threefold increased bile duct injury rate is associated with less surgeon experience in an insurance claims database: more rigorous training in biliary surgery may be needed.

INTRODUCTION: Bile duct injury (BDI) remains the dreaded complication of laparoscopic cholecystectomy (LC) over the last two decades. Although the Fundamentals of Laparoscopic Surgery (FLS) certification is now required for new applicants by the American Board of Surgery, the impact of FLS on procedure-specific outcomes is unknown. Moreover, the FLS content centers on fundamental education and not procedure-specific complication reduction such as BDI, magnifying the importance of understanding the educational impact of FLS on specific case types. This study reviewed the impact of FLS certification and other factors on the incidence of bile duct injury in a large insurance claims database. METHODS: In total, 53,632 LCs were reviewed from July 2009 to December 2010 from a large private payer claims database. Surgeon National Provider Identifier (NPI), FLS certification status, International Classification of Diseases, Ninth Revision (ICD-9) and Current Procedural Terminology (CPT) were available for each event. Each record was analyzed for evidence of any bile duct injury based on associated CPT or ICD-9 data in the claim record. Characteristics of the FLS+ and FLS- surgeon groups were analyzed by a separate reviewer blinded to clinical outcome on a large scale. RESULTS: A total of 53,632 LCs were reviewed; 1748 LC were performed by 441 FLS+ surgeons; and 58,870 LCs by 10,851 FLS- surgeons. (Some procedures involved more than one surgeon). Eighty-two BDIs were identified: 8 in the FLS+ and 74 in the FLS- group. The FLS+ group had a higher rate of BDI than the FLS- group (0.47 vs. 0.14 %, p = 0.0013); however, the FLS+ group was also younger (mean age 38.2 FLS+ vs. 50.4 years) and had significantly fewer years in practice (FLS+ = 6.1 vs. FLS- = 20.7, p = 0.0012). No other complications showed differences between the groups. CONCLUSION: NPI can be used as a linking intermediary between skills certification and outcomes on claims databases. FLS certification was not associated with a reduction in bile duct injury in this analysis, but FLS+ surgeons were also younger and less experienced overall. Since FLS lacks content specific to BDI, large-scale validated training and assessment programs targeted at BDI prevention are needed to impact the rate of this complication during cholecystectomy.