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Cholecystectomy with intraoperative cholagniography and risk of common duct injury

This week's issue of the Journal of the American Medical Association investigates the association between cholecystectomy with and without intraoperative cholangiography and risk of common duct injury.

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Significant controversy exists regarding routine intraoperative cholangiography in preventing common duct injury during cholecystectomy.

Dr Kristin Sheffield and colleagues from Texas, USA investigated the association between intraoperative cholangiography use during cholecystectomy and common duct injury.

Retrospective cohort study of all Texas Medicare claims data from 2000 through 2009.

The researchers identified Medicare beneficiaries 66 years or older who underwent inpatient or outpatient cholecystectomy for biliary colic or biliary dyskinesia, acute cholecystitis, or chronic cholecystitis.

The team compared results from multilevel logistic regression models to the instrumental variable analyses.

40% underwent concurrent intraoperative cholangiography
Journal of the American Medical Assocation

Intraoperative cholangiography use during cholecystectomy was determined at the level of the patients, hospitals, and surgeons.

Percentage of use at the hospital and percentage of use by surgeon were the instrumental variables.

The research team's main outcomes included patients with claims for common duct repair operations within 1 year of cholecystectomy who were considered as having major common duct injury.

Of 92,932 patients undergoing cholecystectomy, 40% underwent concurrent intraoperative cholangiography, and less than 1% had a common duct injury.

The common duct injury rate was 0.2% among patients with intraoperative cholangiography, and 0.4% 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.

When confounding was controlled with instrumental variable analysis, the association between cholecystectomy performed without intraoperative cholangiography and duct injury was no longer significant.

Dr Sheffield's team concludes, "When confounders were controlled with instrumental variable analysis, there was no statistically significant association between intraoperative cholangiography and common duct injury."

"Intraoperative cholangiography is not effective as a preventive strategy against common duct injury during cholecystectomy."

JAMA 2013;310(8): 812-820
29 August 2013

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