Avoiding Dangers of Gall Bladder Surgery

The advent of laparoscopic surgery, which uses small instruments guided by a television camera, has made many types of surgery safer and less invasive.

In the case of gall bladder surgery, though, it has led to some unintended consequences. Surgeons could previously navigate the area around the gall bladder by feeling structures with their hands. But now, guided by a television image, surgeons can mistakenly damage the bile duct, the tube attached to the gall bladder.

"We've lost the ability to feel the structures in the abdomen," said Dr. David Flum, assistant professor of surgery at the UW. "Because of that, the risk of an injury to the bile duct is very real. It doesn't happen often, but when it does happen, it's devastating."

Gall bladder surgery, also known as cholecystectomy, is a common abdominal surgery, with about 750,000 patients in the United States having the procedure each year. Bile duct injury, one of the most common complications in that surgery, occurs in one out of every 200 procedures.

A series of studies led by Flum, a gastrointestinal surgeon and surgical outcomes researcher, indicate that bile duct injuries are difficult to fix , that the injuries can often be prevented by a simple pre-surgical imaging procedure, and that the imaging procedure is more cost-effective than treating a bile duct injury. The results were published in the Journal of the American Medical Association on April 2 and Oct. 22, 2003, and the Journal of the American College of Surgeons in March 2003.

Flum and his colleagues set out to illustrate the impact of bile duct injuries. They studied the records of more than 1.5 million Medicare patients who underwent gall bladder surgery, including the nearly 8,000 patients who suffered bile duct injuries. Nearly one-third of patients suffering a bile duct injury died within a year after the surgery. Researchers also found that repairing the injury requires a great deal of skill.

Flum's team then examined ways that bile duct injuries could be prevented. They reviewed the usefulness of a cholangiogram, an X-ray of the gall bladder and the surrounding area.

"It's like a road map," explained Flum. "A surgeon can see whether what he or she thought was the right tube was actually the right one, or if the assumption is wrong."
The researchers learned that the risk of bile duct injury dropped by half when patients had a cholangiogram before the surgery. A cholangiogram is performed only about 40 percent of the time.

The researchers noted that a cholangiogram adds about $100 to the cost of gall bladder surgery, compared to more than $87,000 for the cost of a bile duct injury and $390,000 per life saved.

"We found it's a bargain to do a cholangiogram, given the cost of repairing a bile duct injury, and the number of patients who die from the injury," Flum said.

Flum is working on a program to track the use of cholangiograms, in an effort to help doctors across the state increase the use of that and other safety interventions. As a surgical outcomes researcher, he plans to continue to look for ways to improve the quality of care in all types of common surgery.

Dr. David Flum