Fluorescence during cholecystectomy tracks with a 38% lower bile duct injury rate across 1.27 million operations

The edition in brief

Two large analyses converge on the same operation this morning. In 1,266,024 laparoscopic cholecystectomies from the Epic Cosmos dataset, indocyanine green fluorescence cholangiography was used in 13% of cases and, after inverse probability of treatment weighting, was associated with common bile duct injury in 0.25% versus 0.40% — a relative risk of 0.62. Conversion to open surgery was roughly halved, and subsequent biliary intervention and 30-day non-biliary complications were both lower. This is observational: surgeons who reach for fluorescence may differ from those who do not in ways weighting cannot capture. A separate health-system study of 1,828 minimally invasive cholecystectomies stratified difficulty by the Nassar score and found that operative approach interacts with difficulty and body mass index rather than dominating them. In high-risk gallbladders at a body mass index of 30, laparoscopic surgery carried an odds ratio of 3.69 for conversion or a Clavien-Dindo grade 3 or worse complication. In low and intermediate-risk patients with a low body mass index the two approaches were comparable. Robotic surgery cost about $2,200 more per case in every stratum. After open pancreatoduodenectomy, a randomised non-inferiority trial in 92 patients found a single 0.2 mg intrathecal morphine injection non-inferior to bilateral preperitoneal continuous wound infiltration on mean coughing pain across 72 hours, with better early analgesia and less patient-controlled fentanyl, at the cost of more respiratory depression and pruritus in the first 24 hours. Both arms had coughing pain scores near 6, which is worth noticing.