2023 General Surgery Presentations

Joseph Gutierrez, MD; Daniel Chen, MD, MPH; Andrea Lombardi, DO; Christopher Yheulon, MD, FACS; Christopher Mangieri, MD, FSSO; Tripler Army Medical Center

Objective: The most feared complication during laparoscopic cholecystectomy remains a bile duct injury (BDI).  Accurately risk-stratifying patients for a BDI remains difficult and imprecise.  The majority of the current literature simply demonstrates that acute cholecystitis is the only significant risk factor for a BDI.  The aim of this study was to evaluate if "the lethal triad" of acute cholecystitis, obesity, and steatohepatitis is a more specific and prognostic measure to identify patients at an increased risk for a BDI.

Methods: A retrospective review of the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) registry was performed.  All laparoscopic cholecystectomy cases within the main NSQIP database for 2012-2019 were extracted via CPT coding (47562, 47563).  Identification of a BDI was performed by querying the NSQIP registry for ICD-9 and ICD-10 codes associated with a BDI for each individual case.  Two study cohorts were constructed.  One with "the lethal triad" defined as the patient having acute cholecystitis, BMI >35, and steatohepatitis.  While the other cohort did not have that triad present.  Multivariate analysis was performed via logistic regression modeling with calculation of odds ratios (OR) to identify significant factors associated with a BDI.

Results: There was a total of 387,501 laparoscopic cholecystectomy cases extracted from the NSQIP registry.  36,346 cases contained "the lethal triad" while the remaining 350,295 cases did not have the triad present at surgery.  For the entire study population 860 BDIs were identified (overall BDI incidence rate 0.22%).  When comparing the study cohorts there were 541 BDIs within "the lethal triad" and only 319 BDIs in the other cohort.  On multivariate analysis that resulted in a significantly increased risk of a BDI by over 15-fold (OR 16.35, 95%CI 14.28-18.78, P<0.0001) when "the lethal triad" was present.  The individual components of "the lethal triad" were also independent risk factors for a BDI on multivariate analysis with ORs of 1.22 (P=0.002), 2.31 (P<0.001), and 1.04 (P=0.041) for acute cholecystitis, obesity, and steatohepatitis respectively.

Conclusions: This study demonstrates "the lethal triad" of acute cholecystitis, obesity, and steatohepatitis significantly increases the risk of a BDI during performance of a laparoscopic cholecystectomy.  While limited by the retrospective nature of the analysis the study findings are important to better identify patients who are prone to BDI to provide enhanced patient counseling and potentially alter the operative approach.