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Annals of Surgery Journal Club
Interactive resource for surgery residents and surgeons to discuss and critically evaluate articles published in Annals of Surgery selected by a monthly guest expert who will review an article each month, offer questions and respond to reader's comments.
Tuesday, July 10, 2012
July Journal Club

Single Incision Laparoscopic Cholecystectomy Is Associated With a Higher Bile Duct Injury Rate: A Review and a Word of Caution.

Joseph M, Phillips MR, Farrell TM, Rupp CC.

Ann Surg. 2012 Jun 1. [Epub ahead of print]


Article Summary:

Joseph et al. perform a systematic review of studies evaluating the safety of single incision laparoscopic cholecystectomy. Of 76 candidate studies, 45 met their inclusion criteria (n= 2,625 patients). A minority of patients (~9%) underwent cholecystectomy for acute cholecystitis. Across all studies there were 19 (0.72%) bile duct injuries. Based on comparison to historical rates of bile duct injury (~0.4% to 0.5%), the authors conclude that the single incision approach may be associated with a higher rate of bile duct injury. The authors go on to suggest controlled trials to more rigorously evaluate the safety of this new technique.

Question 1: Single incision laparoscopic surgery is a new innovation in surgery. What factors influence the uptake and diffusion of new surgical innovations? Based on these factors, is the single incision approach likely to be adopted as widely as standard laparoscopy?

Question 2: This systematic review combines several smaller case series, which are limited by publication bias, i.e., surgeons with the best outcomes are more likely to submit their results for publication. How would this bias impact this study? Is it valid to compare the results of this review to historical controls? What are the limitations of this approach?

Question 3: A randomized clinical trial would be the ideal method to evaluate the safety of this new approach to cholecystectomy. Given the low event rate for bile duct injury, approximately how many patients would be needed to adequately power such a study? Is such a trial feasible?

Please feel free to comment on any or all of the questions above. We look forward to hearing from you, the Annals readers.

About the Author

Dr. David T Efron
Dr. Efron is an Associate Professor of Surgery, Anesthesiology & Critical Care Medicine and Emergency Medicine at the Johns Hopkins School of Medicine. He is the Director of Trauma and Chief of the Division of Acute Care Surgery (encompassing Trauma, Emergency Surgery and Surgical Critical Care) in The Johns Hopkins Hospital Department of Surgery. He is currently the Vice-Chair of the Maryland State Committee on Trauma. Dr. Efron’s current research interests are within the realm of regulation of inflammatory mediators of septic and post-injury states, particularly focusing on the role that statins play in this milieu. Dr. Efron carries additional interest in traumatic injury from interpersonal violence, measures of violence intensity, and trauma recidivism with an eye to prevention strategies.

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