Context Common bile duct (CBD) injury during cholecystectomy is a significant
source of patient morbidity, but its impact on survival is unclear.
Objective To demonstrate the relation between CBD injury and survival and to identify
the factors associated with improved survival among Medicare beneficiaries.
Design, Setting, and Patients Retrospective study using Medicare National Claims History Part B data
(January 1, 1992, through December 31, 1999) linked to death records and to
the American Medical Association's (AMA's) Physician Masterfile. Records with
a procedure code for cholecystectomy were reviewed and those with an additional
procedure code for repair of the CBD within 365 days were defined as having
a CBD injury.
Main Outcome Measure Survival after cholecystectomy, controlling for patient (sex, age, comorbidity
index, disease severity) and surgeon (procedure year, case order, surgeon
Results Of the 1 570 361 patients identified as having had a cholecystectomy
(62.9% women), 7911 patients (0.5%) had CBD injuries. The entire population
had a mean (SD) age of 71.4 (10.2) years. Thirty-three percent of all patients
died within the 9.2-year follow-up period (median survival, 5.6 years; interquartile
range, 3.2-7.4 years), with 55.2% of patients without and 19.5% with a CBD
injury remained alive. The adjusted hazard ratio (HR) for death during the
follow-up period was significantly higher (2.79; 95% confidence interval [CI];
2.71-2.88) for patients with a CBD injury than those without CBD injury. The
hazard significantly increased with advancing age and comorbidities and decreased
with the experience of the repairing surgeon. The adjusted hazard of death
during the follow-up period was 11% greater (HR, 1.11; 95% CI, 1.02-1.20)
if the repairing surgeon was the same as the injuring surgeon.
Conclusions The association between CBD injury during cholecystectomy and survival
among Medicare beneficiaries is stronger than suggested by previous reports.
Referring patients with CBD injuries to surgeons or institutions with greater
experience in CBD repair may represent a system-level opportunity to improve