LETTERS TO THE EDITOR
Intraoperative cholangiography: A century-old practice
and still debated
Dear Editor,
It was with great interest that we read the longitudinal study
published by Mui et al. 1 on the use of intraoperative cholangi-
ography (IOC) in Australia. We congratulate the authors on this
important work. They presented an accurate picture of the
Australian surgeons’ daily practice. They found that, despite
the guidelines, the incidence of IOC remained high and
unchanged in the last 20 years. In parallel, the incidence of bile
duct injuries (BDIs) did not decrease. This paper raises an
important question about the actual protective effect of IOC. In
our opinion, IOC has two distinct roles according to its timing.
When performed early in the procedure before any dis-
section and dividing of the bile ducts, IOC can prevent severe
BDIs by showing the biliary anatomy. But the IOC can also be
performed later, to confirm or detect a BDI and allow its repair
during the same procedure. In this case, IOC does not prevent
the BDI but enables the surgeon to detect it intraoperatively.
Unfortunately, in this paper, the data were collected from an
administrative database that does not give this information
(early or late IOC). Hence, the question of the protective effect
of IOC remains unanswered. A possible shift from routine early
IOC to IOC performed to manage a BDI might explain why the
incidence of BDI remained unchanged while the use of IOC
increased.
In conclusion, besides the bias related to the lack of precise
timing of IOC in this study, the available data from the literature do
not answer this question with a high level of evidence, because
BDIs are rare events and thousands of patients would need to be
included in a randomized trial.2
Conflict of interest
Karem Slim declares conflict of interest with Sanofi, Merck and
B-Braun. Jean-Marc Regimbeau declares no conflict of interest.
Author contributions
Karem Slim discussed the subject and wrote the letter. Jean-Marc
Regimbeau discussed the subject and corrected the text.
References
1. Mui J, Mayne DJ, Davis KJ, Cuenca J, Craig SJ. Increasing use of
intraoperative cholangiogram in Australia: is it evidence-based? ANZ J
Surg. 2021; https://doi.org/10.1111/ans.16912.
2. Ford JA, Soop M, Du J, Loveday BPT, Rodgers M. Systematic review of
intraoperative cholangiography in cholecystectomy. Br J Surg. 2012;99:160–7.
© 2021 Royal Australasian College of Surgeons.
Karem Slim,* MD
Jean-Marc Regimbeau,†‡ MD, PhD
*Department of Digestive Surgery, University Hospital, CHU
Clermont-Ferrand, Clermont-Ferrand, France, †Department of
Digestive Surgery, Amiens University Hospital,
Amiens, France and ‡SSPC (Simplification of Surgical Patients
Care) Clinical Research Unit, University of Picardie Jules Verne,
Amiens, France
doi: 10.1111/ans.16994
And then, there is the anaesthesiologist
Dear Editor,
The recent introduction to emotional intelligence for surgeons, pub-
lished in ANZ Journal of Surgery,1 is of tremendous importance.
Today’s surgeons and anaesthesiologists are under increasing pres-
sure to perform high, that is handle more procedures in less time
and at lower costs.
New ‘recommendations’ should be incorporated in daily practice.
Students and trainees rotating through medical departments for ever
shorter periods need to be taught ‘everything’ in an tempered yet
stimulating way. And then, there is the anaesthesiologist, talking
about comorbidities, American Society of Anesthesiology physical
status, roll-in-roll-out changeover times and the implications of dis-
ease severity on operating room (OR) decision management.2
Stop
Breathe gently and slowly, in and out, and look around. Despite the
increasing complexity of surgical routine, the surgeon has some
potential sources of support.
Established routine can save you time, and routine involving
team players used to working together may save your neck. Diffi-
cult surgery, frail patients, and identification errors are challenges
but not necessarily road blocks. A friendly word from your anaes-
thesiologist, a joke or a laugh, might just make your day. Non-
technical skills such as nonviolent communication and situation
awareness are likely more important for outcome than currently val-
ued in most healthcare teams. Optimal set-up of perioperative teams
can increase team coherence, enhance efficiency in the OR, out-
come and improve management and decision-making skills.3
ANZ J Surg 91 (2021) 1633–1634