Injury to bile duct during cholecystectomy nearly triples risk of death

BMJ 2003; 327 doi: (Published 23 October 2003) Cite this as: BMJ 2003;327:946
  1. Scott Gottlieb
  1. New York

    Patients who have their common bile duct injured during removal of their gall bladder have nearly three times the risk of death in the next few years as patients who do not incur the injury (JAMA 2003;290: 2168-73).

    Cholecystectomy is the most common elective abdominal surgical procedure in the United States, with 750 000 procedures performed each year. Injury to the common bile duct occurs in 1 in 200 of these operations. Repair of the duct is considered a technically challenging procedure and sometimes requires the intervention of specialised surgeons.

    Dr David Flum of the University of Washington, Seattle, and colleagues examined the impact of such injury among Medicare beneficiaries who had had a cholecystectomy.

    The researchers used data from the Medicare national claims history part B (1 January 1992 to 31 December 1999) linked to death records and to the American Medical Association's physician masterfile.

    The researchers reviewed records with a procedure code for cholecystectomy and defined as having a common bile duct injury those that were recorded with an additional procedure code for repair of such an injury within 365 days.

    Embedded Image

    A surgeon removes a patient's gall bladder using a laparoscope


    Of the 1 570 361 patients identified as having had a cholecystectomy, 7911 (0.5%) patients had common bile duct injury. Of all the patients who had a cholecystectomy, 33% died within the 9.2 year follow up period, with 55% of patients without the duct injury alive compared with 19.5% of those who had the duct injury. The adjusted hazard ratio for death during the follow up period was significantly higher (2.79; 95% confidence interval 2.71 to 2.88) for patients with common bile duct injury than for those without. The risk of death increased with increasing age of the patient.

    “We also found that improved survival was more likely when a different, more experienced surgeon performed the common bile duct repair, but that 75% of repair procedures were in fact performed by the same surgeon associated with the injury,” Dr Flum said. According to the study, patients had an 11% increased risk of death if the repairing surgeon was the same as the injuring surgeon (1.11; 1.02 to 1.20).

    The higher the level of experience of the surgeon performing the repair, was also correlated with better survival.

    On the basis of the results, the authors recommend that patients with common bile duct injury should be referred to a surgeon and to an institution with greater experience in handling the specialised repair.

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