title: Late two-stage laparoscopic cholecystectomy is associated with an increased risk of major bile duct injury.
abstract: BACKGROUND
  Late laparoscopic cholecystectomy (LC) after endoscopic retrograde cholangiopancreatography (ERCP) and sphincterotomy (ES) for common bile duct (CBD) stone clearance, two-stage LC (TSLC), is associated with difficult surgical dissection and an increased rate of conversion to open procedure. The purpose of the study was to evaluate whether the interval between ERCP/ES and LC is associated with major bile duct injury (BDI) and determine an optimal period for TSLC.
  
  
  METHODS
  This was a retrospective cohort study of adult patients who underwent LC. The exclusion criteria were absence of CBD stones on imaging or ERCP, surgical treatment of choledocholithiasis, post-operative endoscopic CBD stone clearance and open cholecystectomy.
  
  
  RESULTS
  The eligibility criteria were met by 183 patients. There were six major BDIs (3%). Comparisons of the early and late TSLC showed statistically significant difference in major BDI at 16-week cut-offs. Binomial regression analysis demonstrated that late (≥16 weeks) TSLC was associated with 10-fold increase in major BDI (95% confidence interval: 1.1-95.7, P = 0.043). Survival analysis comparing early (<16 weeks) with late (≥16 weeks) TSLC demonstrated that both groups had similar survival time (log-rank test: 0.317).
  
  
  CONCLUSIONS
  General surgeons should be aware of the increasing risk of major BDI with delaying TSLC and perform interval LC before week 16.
authors.affiliation: Department of Surgery, Auckland City Hospital, Auckland, New Zealand.
authors.forename: Andrei M
authors.initials: AM
authors.lastname: Beliaev
authors.affiliation: Department of General Surgery, North Shore Hospital, Auckland, New Zealand.
authors.forename: Michael
authors.initials: M
authors.lastname: Booth
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001652:Bile Ducts / Q000293:injuries*; D002760:Cholangiopancreatography, Endoscopic Retrograde / Q000009:adverse effects / Q000379:methods; D017081:Cholecystectomy, Laparoscopic / Q000009:adverse effects* / Q000379:methods; D015331:Cohort Studies; D005260:Female; D042882:Gallstones / Q000000981:diagnostic imaging / Q000601:surgery; D006801:Humans; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D055815:Young Adult
keywords: bile duct injury; endoscopic retrograde cholangiopancreatography; laparoscopic cholecystectomy