title: Prevention of iatrogenic bile duct injuries in difficult laparoscopic cholecystectomies: is the naso-biliary drain the answer?
abstract: BACKGROUND
  Prevention of iatrogenic injuries is of paramount importance in difficult laparoscopic cholecystectomies (LC). The objective of this study was to analyze the effectiveness of cholangiography using a pre-inserted endoscopic naso-biliary drain (ENBD) for navigation during difficult cholecystectomies.
  
  
  METHODS
  The study design was a retrospective case analysis. In 508 patients who underwent LC in a tertiary referral university hospital from 1996 through 2007, difficult cholecystectomy was anticipated in 26 patients due to possibly aberrant biliary anatomy (four patients), unclear cystic duct anatomy during magnetic resonance cholangiopancreatography (MRCP) and/or endoscopic retrograde cholangiopancreatography (ERCP) (three patients), and acute cholecystitis (19 patients). An ENBD was inserted during ERCP prior to LC for cholangiography (ENBDC) to facilitate safe dissection during LC. Prevalence of biliary complications was assessed as the main outcome measurement.
  
  
  RESULTS
  The majority (68%) of the patients who underwent ENBDC had complicated cholecystitis. Advanced technical expertise was not required for insertion of an ENBD. In retrospect, ENBDC was useful in prevention of a possible catastrophe in 69% of cases. Open conversion was necessary in five patients and biliary complications occurred in five patients only in the non-ENBD group. There were no procedure-related complications. One limitation of the study was that it was not randomized and there was no comparison with patients without ENBDC.
  
  
  CONCLUSIONS
  ENBDC is a useful and safe tool in the prevention of iatrogenic bile duct injuries in LC.
authors.affiliation: Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, 812-8582, Japan.
authors.forename: Chandika A H
authors.initials: CA
authors.lastname: Liyanage
authors.forename: Yoshihiko
authors.initials: Y
authors.lastname: Sadakari
authors.forename: Hidehisa
authors.initials: H
authors.lastname: Kitada
authors.forename: Jun
authors.initials: J
authors.lastname: Ienaga
authors.forename: Reiko
authors.initials: R
authors.lastname: Tanabe
authors.forename: Shunichi
authors.initials: S
authors.lastname: Takahata
authors.forename: Toshinaga
authors.initials: T
authors.lastname: Nabae
authors.forename: Masao
authors.initials: M
authors.lastname: Tanaka
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001652:Bile Ducts / Q000293:injuries*; D002760:Cholangiopancreatography, Endoscopic Retrograde; D049448:Cholangiopancreatography, Magnetic Resonance; D017081:Cholecystectomy, Laparoscopic; D002764:Cholecystitis / Q000601:surgery; D003549:Cystic Duct / Q000000981:diagnostic imaging; D004322:Drainage / Q000379:methods*; D005260:Female; D006801:Humans; D007431:Intraoperative Complications / Q000517:prevention & control*; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D055815:Young Adult