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Acute cholecystitis, obesity, and steatohepatitis constitute the lethal triad for bile duct injury (BDI) during laparoscopic cholecystectomy

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A Correction to this article was published on 15 March 2024

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Abstract

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. This study evaluated if the lethal triad of acute cholecystitis, obesity, and steatohepatitis is a prognostic measure for BDI.

Methods

A retrospective review of the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) registry was performed. All laparoscopic cholecystectomy cases within the main NSQIP database for 2012–2019 were queried. Two study cohorts were constructed. One with the lethal triad of acute cholecystitis, BMI ≥ 30, and steatohepatitis. The other cohort did not have the full triad present. Multivariate analysis was performed via logistic regression modeling with calculation of odds ratios (OR) to identify independent factors for BDI. An uncontrolled and controlled propensity score match analysis was performed.

Results

A total of 387,501 cases were analyzed. 36,887 cases contained the lethal triad, the remaining 350,614 cases did not have the full triad. 860 BDIs were identified resulting in an overall incidence rate 0.22%. There were 541 BDIs within the lethal triad group with 319 BDIs in the other cohort and an incidence rate of 1.49% vs 0.09% (P < 0.001). Multivariate analysis identified the lethal triad as an independent risk factor for a BDI by over 15-fold (OR 16.35, 95%CI 14.28–18.78, P < 0.0001) on the uncontrolled analysis. For the controlled propensity score match there were 29,803 equivalent pairs identified between the cohorts. The BDI incidence rate remained significantly higher with lethal triad cases at 1.65% vs 0.04% (P < 0.001). The lethal triad was an even more significant independent risk factor for BDI on the controlled analysis (OR 40.13, 95%CI 7.05–356.59, P < 0.0001).

Conclusions

The lethal triad of acute cholecystitis, obesity, and steatohepatitis significantly increases the risk of a BDI. This prognostic measure can help better counsel patients and potentially alter management.

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Authors and Affiliations

  1. Division of Surgery, General Surgery, Department of Surgery, Tripler Army Medical Center, 1 Jarrett White Road, Honolulu, HI, 96859, USA

    Joseph V. Gutierrez, Daniel G. Chen, Christopher G. Yheulon & Christopher W. Mangieri

  2. Department of General Surgery, Emory University School of Medicine, 201 Dowman Drive, Atlanta, GA, 30322, USA

    Christopher G. Yheulon

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  1. Joseph V. Gutierrez
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  2. Daniel G. Chen
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  3. Christopher G. Yheulon
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  4. Christopher W. Mangieri
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Correspondence to Joseph V. Gutierrez.

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The views and opinions expressed in this article are those solely of the authors and in no way reflect the opinions of the United States Government. Drs. Joseph Gutierrez, Daniel Chen, Christopher Yheulon, and Christopher Mangieri have no conflicts of interest or financial ties to disclose.

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The below research was accepted for a podium presentation at the 2023 SAGES annual meeting in Montreal, QC.

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Gutierrez, J.V., Chen, D.G., Yheulon, C.G. et al. Acute cholecystitis, obesity, and steatohepatitis constitute the lethal triad for bile duct injury (BDI) during laparoscopic cholecystectomy. Surg Endosc (2024). https://doi.org/10.1007/s00464-024-10727-9

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