This is being suggested as a way to decrease the incidence of bile duct injuries – as this is one of the largest reasons for malpractice lawsuits within general surgery. I wonder if any of the surgeons who read this blog can comment:
Cholangiograms have a lot of potential, but “they have not been adopted as a routine part of most surgeons’ practices,” says Lawrence Way, a surgeon at the University of California San Francisco who is an expert in repairing bile-duct injuries. He says one reason for the lack of enthusiasm is that hundreds of cholangiograms would have to be performed to avoid one bile-duct injury. Some studies have suggested the cost of routine cholangiograms — about $122 by one estimate — doesn’t justify the expected benefit.The issue highlights a bigger debate in the medical community over the cost-effectiveness of added safety measures. Even as doctors are pressured to reduce medical errors, there is counter-pressure to cut back on unnecessary procedures and justify each expense.
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{ 3 comments }
As with any test, if it’s performed regardless of the indications it not only makes no sense but it totally removes the thought processes from medicine.
I’m sure most surgeons have their own indications for cholangiograms. Mine are as follows.
1. Can’t see shit. (Anatomy not clearly defined.)
2. Bump in LFTs indicative of possible CBD stone.
3. Something bad may have happened and it’s better to find out now than later.
It used to be recommended for routine cholangiography in training programs and perhaps that’s the perspective of Dr. Way. But cholangiogram certainly wasn’t routine in open cholecystectomy so I’m not sure why it should be routine in laparoscopic cholecystectomy.
Larry Way, along with several other academicians, has been promulgating this mindset for years. Unfortunately, the data have never supported the idea of routine cholangiography during laparoscopic cholecystectomy — the best that can be pointed to is a decrease in the severity of the bile duct injury when cholangiography is used (and interpreted correctly). The overwhelming majority of general surgeons utilize cholangiography selectively; that is certainly the standard of care in my community.
I have been pondering this article. The debate on routine intraop cholangiography has been going on since the early 90’s with the rise of lap choles. This is but the latest resurrection of the debate.
I do claims defense for a medmal insurer. I can certainly tell you that there is no shortage of respected surgeons (sometimes academic, sometimes commmunity) who are willing to testify for the plaintiff that always doing a cholangiogram is the standard of care. It can be difficult to successfully rebut that testimony. It is generally spun as thus: a simple test, taking only 15 minutes to do, and costing less than $ 150, would likely have prevented this outcome. If only the surgeon had done the test, the patient would not have become septic, needed emergency surgery to repair the damage, had five days postop in the ICU and lost two months of work, not to mention the pain and suffering. If the jury buys this, they can award some respectable verdicts against the surgeon.
I have used Dr. Way as a defense expert many times over the years and find his comments interesting. I wonder if always doing this study will become the defacto standard of care. Although there is a certain amount of CBD damage that can occur during the study.
The plaintiff attorneys will likely cite the WSJ and AJS articles as further evidence that intraop cholangiography is, or should be, the standard of care.
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