Prevention and Treatment of Major Complications After Cholecystectomy

Abstract

Annually, over 19.000 patients undergo a cholecystectomy in the Netherlands, of which approximately 16.500 are performed laparoscopically. The complication rate after laparoscopic cholecystectomy (LC) is 2–12 % and the mortality rate about 0.2 %. General complications include wound infection, intra-abdominal abscess formation, and postoperative bleeding from the cystic artery which occurs in about 0.05 % and usually presents within a few hours after surgery. Laparoscopy-induced “access injuries” are visceral and vascular injuries that are mostly related to the puncture technique. Although the incidence of these complications is low, ranging from 0 to 0.05 % for the open technique versus 0.044 to 0.07 % for the closed technique, the overall mortality rate is high, ranging from 13 to 21 %. The most specific and devastating complication after cholecystectomy is bile duct injury (BDI). This complication is, especially in combination with vascular injury, accompanied by substantial morbidity, mortality, and a decrease in the life expectancy and long-term quality of life. The incidence reported in literature is dependent on its definition, study design, and study population and ranges from 0.16 to 1.5 % after LC versus 0.0 to 0.9 % after open cholecystectomy (OC). After the introduction of LC, initially there seemed to be an increase in the number of BDI. Go et al. evaluated the incidence of BDI after the introduction of LC in the Netherlands in 1990 until 1992 by using a written questionnaire which was sent to all 138 Dutch surgical institutions and reported an incidence of BDI of 0.86 %. Gouma et al. studied the incidence of BDI in 1991 using a questionnaire to all Dutch surgical departments to analyze the number of surgical reconstructions for BDI and therefore the true incidence of severe BDI and reported an incidence of 1.09 % after LC and 0.51 % BDI after OC. The higher incidence of BDI after LC in those days was mostly related to technical difficulties, unfamiliarity with the procedure, and the “learning curve” effect. A Cochrane systematic review from Keus et al. in 2006 suggests that the incidence of BDI has been stabilized since they found no difference in complications after LC or OC, with BDI occurring in 0.2 % in both groups. Nevertheless, annually 40–45 patients are still referred to the Academic Medical Center, without any sign of decrease in recent years. This suggests a higher incidence of BDI in the Netherlands than reported in the literature. As stated before, initially inexperience probably contributed to the high incidence of BDI, but other factors such as anatomical variation and techniques without using the critical view of safety (CVS) of Strasberg as the standard of care seem to be responsible for the current incidence of BDI. Furthermore, there appears to be a lack of knowledge of escape techniques in difficult cholecystectomies to prevent BDI. Buddingh et al. recently conducted a nationwide survey in which 97.6 % of Dutch surgeons reported to use the technique of CVS. Hereby the incidence of BDI in the Netherlands might decline in the future.