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December 21, 2023 at 1:45 pm #2520
Anonymous
InactiveGallbladder removal with or without bile duct imaging.
August 28, 2013, Vol 310, No. 8 >
Association Between Cholecystectomy With vs Without Intraoperative Cholangiography and Risk of Common Duct Injury .
Kristin M. Sheffield , PhD1; Taylor S. Riall, MD, PhD1; Yimei Han, MS1; Yong-Fang Kuo, PhD2; Courtney M. Townsend Jr, MD1; James S. Goodwin, MD2
[+] Author Affiliations
JAMA. 2013;310(8):812-820.A retrospective cohort study of US data raises caution about interpreting the benefits of using bile duct imaging during gallbladder removal.
Results
Of 92?932 patients undergoing cholecystectomy, 37?533 (40.4%) underwent concurrent intraoperative cholangiography and 280 (0.30%) had a common duct injury. The common duct injury rate was 0.21% among patients with intraoperative cholangiography and 0.36% among patients without it.
In a logistic regression model controlling for patient, surgeon, and hospital characteristics, the
odds of common duct injury for cholecystectomies performed without intraoperative cholangiography were increased compared with those performed with it (OR,?1.79 [95% CI, 1.35-2.36]; P?.001). When confounding was controlled with instrumental variable analysis, the association between cholecystectomy performed without intraoperative cholangiography and duct injury was no longer significant (OR,?1.26 [95% CI, 0.81-1.96]; P?=?.31). Commentary: "Ideally, a large randomised study would be done to prove that cholangiography decreases bile duct injury in cholecystectomy. But to show a 0.2% to 0.4% reduction in injury would need 15,700 participants for 90% power, meaning it is possible, but unlikely, that such a study will be done. "Our next best evidence comes from the analysis of large population datasets. Most, but not all, studies of this type show a 30–50% reduction in bile duct injury with cholangiography. This current study also shows this magnitude of reduction, but on using instrumental variable analyses the association was attenuated to the point of not being statistically significant. The accompanying editorial (Bilimoria et al. 2013) points out that the use of hospital and surgeon cholangiography rates in these analyses assumes those rates are independent of the outcome, and this is debatable. Sheffield et al. (2013) stated that this type of analysis evaluates the effect of cholangiography at the hospital level rather than the patient level. While this is correct, separating these factors in clinical practice is problematic. "Conclusions about whether or not to advocate for an increase in cholangiography rates, or how to apply these study results to an individual patient, remain unclear. On balance, continuing with cholangiography seems the prudent course, but caution needs to be exercised in overstating the evidence for its utility."Mr Michael Rodgers, Chief of Surgery and Hepatobiliary Surgeon, Department of Surgery, North Shore Hospital New Zealand, University of Auckland Dr G Mohan.
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