Intraoperative assessment of biliary anatomy for prevention of bile duct injury: a review of current and future patient safety interventions

Background Bile duct injury (BDI) is a dreaded complication of cholecystectomy, often caused by misinterpretation of biliary anatomy. To prevent BDI, techniques have been developed for intraoperative assessment of bile duct anatomy. This article reviews the evidence for the different techniques and discusses their strengths and weaknesses in terms of efficacy, ease, and cost-effectiveness. Method PubMed was searched from January 1980 through December 2009 for articles concerning bile duct visualization techniques for prevention of BDI during laparoscopic cholecystectomy. Results Nine techniques were identified. The critical-view-of-safety approach, indirectly establishing biliary anatomy, is accepted by most guidelines and commentaries as the surgical technique of choice to minimize BDI risk. Intraoperative cholangiography is associated with lower BDI risk (OR 0.67, CI 0.61-0.75). However, it incurs extra costs, prolongs the operative procedure, and may be experienced as cumbersome. An established reliable alternative is laparoscopic ultrasound, but its longer learning curve limits widespread implementation. Easier to perform are cholecystocholangiography and dye cholangiography, but these yield poor-quality images. Light cholangiography, requiring retrograde insertion of an optical fiber into the common bile duct, is too unwieldy for routine use. Experimental techniques are passive infrared cholangiography, hyperspectral cholangiography, and near-infrared fluorescence cholangiography. The latter two are performed noninvasively and provide real-time images. Quantitative data in patients are necessary to further evaluate these techniques. Conclusions The critical-view-of-safety approach should be used during laparoscopic cholecystectomy. Intraoperative cholangiography or laparoscopic ultrasound is recommended to be performed routinely. Hyperspectral cholangiography and near-infrared fluorescence cholangiography are promising novel techniques to prevent BDI and thus increase patient safety

Constipation and Nonspecific Abdominal Pain in Teenage Girls Referred for Emergency Surgical Consultation

Objective: The aim of this study was to describe the discharge diagnoses of children receiving surgical consultation for acute abdominal pain according to age and sex. Methods: Retrospective chart review. Results: Nine hundred forty-one children were included. Appendicitis was confirmed in 31% of young boys (<12 years), 42% of teenage boys (>= 12 years), 38% of young girls, and only 18% of teenage girls. A large number of teenage girls were diagnosed as having constipation and nonspecific abdominal pain. Gynecological diagnoses were relatively rare (9% of teenage girls). Teenage girls often required multiple visits to the emergency department. In addition, they frequently received consultation from other medical specialists: 30% versus 20% of young girls and 12% of boys. Teenage girls had the highest rate of (retrospectively) unnecessary surgery: 36% versus 10% of young girls (P <0.01) and 11% of boys (P <0.01). Conclusions: Most children receiving surgical consultation for acute abdominal pain do not have diseases requiring surgery. In teenage girls, especially, the proportion with appendicitis is low. Constipation and nonspecific abdominal pain are the main discharge diagnoses in this group. Physicians should have a high index of suspicion of constipation when examining teenage girls with acute abdominal pain

Lower Rate of Major Bile Duct Injury and Increased Intraoperative Management of Common Bile Duct Stones after Implementation of Routine Intraoperative Cholangiography

BACKGROUND: Our university medical center is the only center in The Netherlands that has adopted a policy of routine intraoperative cholangiography (IOC) during cholecystectomy. This study aimed to describe the rate of bile duct injury (BDI) and management of common bile duct (CBD) stones before and after implementation of a routine IOC policy. STUDY DESIGN: Medical records were reviewed of all patients undergoing cholecystectomy in the 3 years before implementation of routine IOC and 3 years after. Dissection with the goal to achieve the critical view of safety was the standard operative technique during the entire study period. RESULTS: Four hundred and twenty-one patients underwent cholecystectomy with selective IOC and 435 patients with routine IOC. Groups were similar in age, sex, comorbidity, indication for surgery, and surgical approach. IOC was attempted in 5.9% in the selective IOC group and 59.8% in the routine IOC group (p <0.001). The rate of major BDI was 1.9% in the selective IOC group and 0% in the routine IOC group (p = 0.004). The injuries consisted of 5 type B and 3 type D injuries, according to the Amsterdam classification. The rate of minor BDI did not differ substantially among the groups. More CBD stones were detected in the routine IOC group (4.8% versus 1.0%; p = 0.001) and they were managed intraoperatively more frequently (2.8% versus 0.7%; p = 0.023). There was a trend toward fewer preoperative and postoperative ERCPs and other interventions for CBD stones (19.1% versus 24.2%; p = 0.067). CONCLUSIONS: Implementation of routine IOC policy was followed by fewer major BDIs and higher rates of intraoperative CBD stone management. (J Am Coll Surg 2011;213:267-274. (C) 2011 by the American College of Surgeons

Large neonatal thoracoabdominal aneurysm:case report and review of the literature

We present a neonate with a large saccular aneurysm of the thoracoabdominal aorta, extending from the intrathoracic aorta to the left common iliac artery. No underlying cause could be identified. Despite an early diagnosis, the aneurysm was deemed inoperable because of the lengthy involvement and the frail aspect of all visceral arteries. A review of the literature on congenital abdominal aortic aneurysm in infants was conducted. Eleven cases of live-born infants with a congenital abdominal aortic aneurysm have previously been published. None of them involved as large a part of the thoracic and abdominal aorta as the case presented here. (C) 2008 Published by Elsevier Inc

Location in the Right Hemi-Colon Is an Independent Risk Factor for Delayed Post-Polypectomy Hemorrhage:A Multi-Center Case-Control Study

OBJECTIVES: Delayed hemorrhage is an infrequent, but serious complication of colonoscopic polypectomy. Large size is the only polyp-related factor that has been unequivocally proven to increase the risk of delayed bleeding. It has been suggested that location in the right hemi-colon is also a risk factor. The objective of this study was to determine whether polyp location is an independent risk factor for delayed post-polypectomy hemorrhage. METHODS: A retrospective case-control study was conducted in two university hospitals and two community hospitals. RESULTS: Thirty-nine cases and 117 controls were identified. In multivariate analysis, size and location were found to be independent polyp-related risk factors for delayed type hemorrhage. The risk increased by 13% for every 1 mm increase in polyp diameter (odds ratio (OR) 1.13, 95% confidence interval (CI) 1.05-1.20, P <0.001). Polyps located in the right hemi-colon had an OR of 4.67 (1.88-11.61, P = 0.001) for delayed hemorrhage. Polyps in the cecum seemed to be especially at high risk in univariate analysis (OR 13.82, 95% CI 2.66-71.73), but this could not be assessed in multivariate analysis as the number of cases was too small. Polyp type (sessile or pedunculated) was not a risk factor. CONCLUSIONS: Polyp location in the right hemi-colon seems to be an independent and substantial risk factor for delayed post-polypectomy hemorrhage. A low threshold for preventive hemostatic measures is advised when removing polyps from this region

Kumar versus Olsen cannulation technique for intraoperative cholangiography:a randomized trial

<p>There is resistance to routine intraoperative cholangiography (IOC) during cholecystectomy because it prolongs surgery and may be experienced as cumbersome. An alternative instrument may help to reduce these drawbacks and lower the threshold for IOC. This trial compared the Kumar cannulation technique to the more commonly used Olsen clamp for IOC (KOALA trial; Dutch Trial Register NTR2582).</p><p>Patients undergoing elective laparoscopic cholecystectomy were randomized between IOC using the Kumar clamp and the Olsen clamp. Primary end points were the time that the IOC procedure took and its perceived ease as measured on a visual analog scale from 0 (impossible) to 10 (effortless). To detect a difference of 33 % in IOC time, a total sample size of 40 patients was required.</p><p>Fifty-nine patients were randomized. Nine were excluded because of conversion to open cholecystectomy before the IOC procedure. Twenty-eight patients underwent IOC with the Kumar clamp and 22 with the Olsen clamp. The success rate was 23 (82.1 %) of 28 for the Kumar clamp and 19 (86.4 %) of 22 for the Olsen clamp (p > 0.999). The mean IOC time was 10 min 27 s +/- A 6 min 17 s using the Kumar clamp and 11 min 34 s +/- A 7 min 27 s using the Olsen clamp (p = 0.537). Surgeons graded the ease of the Kumar clamp as 6.8 +/- 2.7 and the Olsen clamp as 6.8 +/- A 2.1 (p = 0.977).</p><p>IOC using the Kumar clamp was neither faster nor easier than using the Olsen clamp. Both clamps facilitated IOC in just over 10 min. Individual surgeon preference should dictate which clamp is used.</p>