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S Connor, O J Garden, Authors' reply: Bile duct injury in the era of laparoscopic cholecystectomy (Br J Surg 2006; 93: 158–168), British Journal of Surgery, Volume 93, Issue 5, May 2006, Pages 640–641, https://doi.org/10.1002/bjs.5461
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Sir
We disagree that we have presented a biased view in favour of intra-operative cholangiography (IOC). It is stated clearly in the opening paragraph that IOC is controversial and that randomized data are not available, and are unlikely to exist in the future. However, large population based studies are more likely to contribute to the available evidence because of the low incidence of bile duct injury. We acknowledge that others disagree with this view1,2 and note that Mr Manson accords himself with these. Nonetheless, we stand by our interpretation of Flum's data which is based on 1·57 million patients who underwent cholecystectomy, of whom 7911 suffered a bile duct injury3. In those patients who did not undergo IOC (n = 956 655), 5531 (0·58 per cent) suffered a bile duct injury as compared with 2380 (0·39 per cent) of 613 706 patients who did (adjusted relative risk for patient and surgeon factors 1·71 (95 per cent c.i., 1·61–1·81)). The reasons for failure to perform cholangiography were not determined. Manson states that the data for surgeons who perform IOC infrequently (n = 741 742) were not presented by Flum et al., but this is incorrect.
