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Procedure Cuts Gall Bladder Surgery Complication

Debate continues over whether every patient should get it before operation

TUESDAY, April 1, 2003 (HealthDayNews) -- It may seem an esoteric discussion about an obscure subject, but a paper about a procedure called cholangiography should be of interest to hundreds of thousands of Americans.

The question is whether people who have cholecystecomy, surgery to remove the gall bladder, should first have cholangiography, which is the injection of radiographic contrast material into the cystic duct to reduce the chance of injury to the bile duct.

Why should you care? Because more than 750,000 Americans have surgery to remove a gall bladder every year, and an injury to the bile duct during that operation is "the most dreaded complication," says study author Dr. David R. Flum. His report appears in the April 2 issue of the Journal of the American Medical Association, and it says routine cholangiography can cut the risk of that complication by about half.

Gall bladder removal is done when gallstones grow large enough to block a duct that carries bile, a digestive liquid secreted by the liver, to the gall bladder and then to the intestines during digestion. The stone can be in the common bile duct, which runs from the liver to the intestine, or more commonly in the cystic duct, which branches off the bile duct and runs to the bladder, where bile is stored. That blockage can cause excruciating pain. It is being seen in younger and younger Americans because high-fat diets promote the formation of stones.

The gall bladder isn't really needed, and it is easily removed in an operation that often does not even require an overnight hospital stay. The surgeon clips off the cystic duct, and the gall bladder with it. However, sometimes the surgeon makes a mistake and cuts into the bile duct.

"When that occurs, it almost always requires a second operation to fix the bile duct," says Flum, a professor of surgery at the University of Washington in Seattle. "Sometimes two or three operations are needed. Often you must reconstruct the whole system by hooking the intestines to the liver."

Flum's study was massive, looking at data on more than 1.5 million Medicare patients who had gall bladder operations from 1992 to 1999. It found 7,911 bile duct injuries, about one in every 200 operations. The injury rate was 0.39 percent for those who had cholangiography, 0.58 percent for those who didn't.

"Even after controlling for important patient-level and surgeon-level factors, we found that the adjusted relative risk of common bile duct injuries was 71 percent higher when cholangiography was not used," the report says.

There has been a running controversy for decades about whether all gall bladder patients should have cholangiography, says an accompanying editorial by Dr. Mark A. Talamini, director of minimally invasive surgery at Johns Hopkins School of Medicine.

Flum contends the issue has been settled, by his and other large-scale analyses of surgical data. "This is the third population-based study, looking at over a million patients, showing that the relationship is not just a statistical fluke," he says. "There is a real relationship."

Talamini isn't convinced. "There is enough doubt about the way their data was collected and processed to prove the point," he says.

For example, it's possible the surgeons who do routine cholangiography are those who do more operations and therefore are more skilled at avoiding mistakes, Talamini says. Or maybe many bile duct injuries were recognized and repaired during the removal operation, so they don't show up in Flum's data.

While the study is "an important addition" to the debate, only a controlled trial can settle the issue, Talamini says. "There never has been a large-scale, randomized trial," he says. Talamini and his colleagues reserve cholangiography for selected patients.

More information

You can learn about the gall bladder and its problems from the American Gastrointestinal Society or the National Institute of Diabetes and Digestive and Kidney Diseases.

SOURCES: David R. Flum, M.D., M.P.H., professor, surgery, University of Washington, Seattle; Mark A. Talamini, M.D., director, minimally invasive surgery, Johns Hopkins School of Medicine, Baltimore; April 2, 2003, Journal of the American Medical Association
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