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There and Never Back Again: Completing Difficult Biliary Procedures

Gustafsson, Arvid LU orcid (2026) In Lund University, Faculty of Medicine Doctoral Dissertation Series
Abstract
Background:
Laparoscopic cholecystectomy (LC) and endoscopic retrograde cholangiopancreatography (ERCP) are among the most performed procedures in healthcare. Despite their frequent use, both procedures share a characteristic feature: a sudden and unexpected increase in technical difficulty. A difficult procedure poses a substantial challenge to the surgeon or endoscopist. Consequently, a wide array of management strategies has evolved to counter difficult biliary interventions. This thesis aims to identify factors that influence outcomes across the continuum of biliary procedures, including operative technique, surgeon training, and endoscopic cannulation strategies.

Methods:
This thesis comprises five population-based... (More)
Background:
Laparoscopic cholecystectomy (LC) and endoscopic retrograde cholangiopancreatography (ERCP) are among the most performed procedures in healthcare. Despite their frequent use, both procedures share a characteristic feature: a sudden and unexpected increase in technical difficulty. A difficult procedure poses a substantial challenge to the surgeon or endoscopist. Consequently, a wide array of management strategies has evolved to counter difficult biliary interventions. This thesis aims to identify factors that influence outcomes across the continuum of biliary procedures, including operative technique, surgeon training, and endoscopic cannulation strategies.

Methods:
This thesis comprises five population-based studies that utilize prospectively collected, nationwide registry data from the Swedish Registry for Gallstone Surgery and ERCP (GallRiks). Paper III also included data collected from medical records. Paper I examined bile leakage rates associated with the use of two versus three clips on the cystic duct during laparoscopic cholecystectomy (LC) in 124,818 patients from 2006 to 2019. Paper II (46,700 patients, 2020–2023) evaluated how surgeon subspecialty—including resident surgeons (RS), attending surgeons (AS), upper gastrointestinal/hepatopancreatobiliary surgeons (UGIS), acute care surgeons (ACS), and alternate subspecialty surgeons (ASS)—influences operative outcomes. Paper III analyzed 58 subtotal cholecystectomies, comparing fenestrating versus reconstituting techniques with a one-year follow-up period. Paper IV assessed the impact of periampullary diverticulum (PAD) subtypes (Boix type 1 versus types 2–3) on cannulation success and adverse events during ERCP in 66,974 patients from 2006 to 2021. Paper V examined difficult cannulation scenarios, comparing transpancreatic sphincterotomy (TPS) and precut sphincterotomy (PCS) for biliary access.

Results:
Using three clips on the cystic duct is as safe as using two. In complicated gallstone disease, however, three clips are associated with higher rates of bile leakage (1.4% vs. 1.0%), which is likely due to procedural difficulty rather than the clips themselves. The surgeon's subspecialty influences outcomes, with UGIS demonstrating shorter operative times and fewer adverse events. Supervised resident surgeons achieve comparable safety and lower bile duct injury rates in elective cases of LC. The two subtotal cholecystectomy techniques show similar morbidity. The fenestrating approach shows a tendency toward more early bile leaks, whereas the reconstituting technique shows a tendency toward more recurrent events. A type 1 PAD reduces cannulation success (80.1% vs. 88.7%), whereas a Type 2-3 PAD paradoxically improves success (91.7%) compared to regular anatomy. In difficult ERCP cannulation, TPS achieves cannulation more often than PCS (86.5% vs. 69.7%), but this comes at the cost of increased adverse events such as pancreatitis (10.5% vs. 6.4%) and perforation (1.6% vs. 0.8%).

Conclusions:
Outcomes in surgical and endoscopic biliary procedures are influenced by procedural difficulty, technical and anatomical factors, surgeon subspecialty, and the management strategies that follow. Despite this complexity, residents can safely perform laparoscopic cholecystectomy under appropriate supervision, supporting the continued role of the procedure in surgical training. In ERCP, anatomical challenges and difficult cannulation scenarios are associated with worse outcomes and may add further morbidity to an already difficult cholecystectomy. These findings support treatment strategies aimed at minimizing the need for repeated biliary interventions. (Less)
Please use this url to cite or link to this publication:
author
supervisor
opponent
  • docent Dalenbäck, Jan, Sahlgrenska akademin, Göteborg
organization
publishing date
type
Thesis
publication status
published
subject
keywords
laparoscopic cholecystectomy, endoscopic retrograde cholangiopancreatography, ERCP, bile leakage, surgeon subspecialty, subtotal cholecystectomy, cannulation, adverse events, surgical training
in
Lund University, Faculty of Medicine Doctoral Dissertation Series
issue
2026:137
pages
192 pages
publisher
Lund University, Faculty of Medicine
defense location
Föreläsningssal 2, Centralblocket, Entrégatan 7, Skånes Universitetssjukhus i Lund. Join by Zoom: https://lu-se.zoom.us/j/68787519995
defense date
2026-10-23 09:00:00
ISSN
1652-8220
ISBN
978-91-8021-936-5
language
English
LU publication?
yes
id
ddb41dfc-d05f-4a98-946d-3edb51009a08
date added to LUP
2026-05-18 22:52:48
date last changed
2026-10-02 13:58:05
@phdthesis{ddb41dfc-d05f-4a98-946d-3edb51009a08,
  abstract     = {{Background:<br/>Laparoscopic cholecystectomy (LC) and endoscopic retrograde cholangiopancreatography (ERCP) are among the most performed procedures in healthcare. Despite their frequent use, both procedures share a characteristic feature: a sudden and unexpected increase in technical difficulty. A difficult procedure poses a substantial challenge to the surgeon or endoscopist. Consequently, a wide array of management strategies has evolved to counter difficult biliary interventions. This thesis aims to identify factors that influence outcomes across the continuum of biliary procedures, including operative technique, surgeon training, and endoscopic cannulation strategies.<br/><br/>Methods:<br/>This thesis comprises five population-based studies that utilize prospectively collected, nationwide registry data from the Swedish Registry for Gallstone Surgery and ERCP (GallRiks). Paper III also included data collected from medical records. Paper I examined bile leakage rates associated with the use of two versus three clips on the cystic duct during laparoscopic cholecystectomy (LC) in 124,818 patients from 2006 to 2019. Paper II (46,700 patients, 2020–2023) evaluated how surgeon subspecialty—including resident surgeons (RS), attending surgeons (AS), upper gastrointestinal/hepatopancreatobiliary surgeons (UGIS), acute care surgeons (ACS), and alternate subspecialty surgeons (ASS)—influences operative outcomes. Paper III analyzed 58 subtotal cholecystectomies, comparing fenestrating versus reconstituting techniques with a one-year follow-up period. Paper IV assessed the impact of periampullary diverticulum (PAD) subtypes (Boix type 1 versus types 2–3) on cannulation success and adverse events during ERCP in 66,974 patients from 2006 to 2021. Paper V examined difficult cannulation scenarios, comparing transpancreatic sphincterotomy (TPS) and precut sphincterotomy (PCS) for biliary access.<br/><br/>Results:<br/>Using three clips on the cystic duct is as safe as using two. In complicated gallstone disease, however, three clips are associated with higher rates of bile leakage (1.4% vs. 1.0%), which is likely due to procedural difficulty rather than the clips themselves. The surgeon's subspecialty influences outcomes, with UGIS demonstrating shorter operative times and fewer adverse events. Supervised resident surgeons achieve comparable safety and lower bile duct injury rates in elective cases of LC. The two subtotal cholecystectomy techniques show similar morbidity. The fenestrating approach shows a tendency toward more early bile leaks, whereas the reconstituting technique shows a tendency toward more recurrent events. A type 1 PAD reduces cannulation success (80.1% vs. 88.7%), whereas a Type 2-3 PAD paradoxically improves success (91.7%) compared to regular anatomy. In difficult ERCP cannulation, TPS achieves cannulation more often than PCS (86.5% vs. 69.7%), but this comes at the cost of increased adverse events such as pancreatitis (10.5% vs. 6.4%) and perforation (1.6% vs. 0.8%).<br/><br/>Conclusions:<br/>Outcomes in surgical and endoscopic biliary procedures are influenced by procedural difficulty, technical and anatomical factors, surgeon subspecialty, and the management strategies that follow. Despite this complexity, residents can safely perform laparoscopic cholecystectomy under appropriate supervision, supporting the continued role of the procedure in surgical training. In ERCP, anatomical challenges and difficult cannulation scenarios are associated with worse outcomes and may add further morbidity to an already difficult cholecystectomy. These findings support treatment strategies aimed at minimizing the need for repeated biliary interventions.}},
  author       = {{Gustafsson, Arvid}},
  isbn         = {{978-91-8021-936-5}},
  issn         = {{1652-8220}},
  keywords     = {{laparoscopic cholecystectomy; endoscopic retrograde cholangiopancreatography; ERCP; bile leakage; surgeon subspecialty; subtotal cholecystectomy; cannulation; adverse events; surgical training}},
  language     = {{eng}},
  number       = {{2026:137}},
  publisher    = {{Lund University, Faculty of Medicine}},
  school       = {{Lund University}},
  series       = {{Lund University, Faculty of Medicine Doctoral Dissertation Series}},
  title        = {{There and Never Back Again: Completing Difficult Biliary Procedures}},
  url          = {{https://lup.lub.lu.se/search/files/261978076/Completing_Difficult_A_Gustafsson_without_p3_note.pdf}},
  year         = {{2026}},
}