The following letters from Guy Voeller, MD, and Michael Brunt, MD, et al, respectively, conclude an ongoing debate about bile duct injury prevention that began with the Great Debates column in the December 2020 issue. The debate between Dr. Voeller and Dr. Brunt centers on the issue of guidelines, their role and their value, and how they are disseminated to the surgical community.

To the Editor:

After reading the response of Dr. Michael Brunt et al [General Surgery News, June 2021, page 1], I will borrow the line from ”Hamlet,” spoken by Queen Gertrude, and say, “the gentlemen and ladies doth protest too much, methinks.”

The guideline madness will continue since many of the people who do these things believe they are smarter and better than the practicing surgeon. It reminds me of our politicians who think they know better than their constituents. Below, I incorporate some of the responses that I received from practicing surgeons.

Dr. Brunt freely admits that it took the committee 2.5 years to review the literature and the best they could muster is a set of recommendations that carry little to no evidence to support any of the claims. They even conclude their article by admitting the poor quality of evidence and the high risk for bias for many key questions (Ann Surg 2020;272[1]:3-23; co-publication Surg Endosc 2020;34[7]:2827-2855). Despite the overall lack of evidence, they have plowed forward with very rigid recommendations that limit and handcuff the practicing surgeon.

To say that “guidelines” are not mandated or in any way enforced is completely disingenuous. In fact, the committee says they want them disseminated everywhere. Every plaintiff attorney sees “guidelines” as the standard of care, I can promise you. I just finished testifying in a bile duct injury trial for which the committee’s guidelines were front and center as the standard of care.

If one reads the original paper by Strasberg and Soper (J Am Coll Surg 1995;180[1]:101-125), there are acceptable variations from the critical view. In this paper, the dome-down approach, which is disparaged by the committee, is considered an acceptable alternative to achieving the critical view. In addition, clipping and cutting the cystic artery prior to completing the dissection of the cystic duct is also acceptable. These alternatives are not mentioned. They are things that practicing surgeons do all the time in performing safe and successful cholecystectomy.

Performing a subtotal gallbladder removal might be the lesser of two evils for some surgeons. It is certainly not true for most experienced practicing surgeons. Leaving the patient with a diseased gallbladder or biliary fistula is not best for the patient when an open cholecystectomy or a well-done lap chole can remove many of these gallbladders that the committee says should not be removed. We are failing young surgeons by not teaching them how to properly do an open cholecystectomy or a proper difficult lap chole, and that is failing our patients by condemning them to a biliary fistula and continued gallbladder problems due to a suboptimal operation. Shame on us.

Brunt et al end their response by saying, like it or not, we live in an era of evidence-based medicine. I don’t know what that has to do with the guidelines since even they admit the evidence is terrible at level IV for most all of their “guidelines.” They also conclude that out in the real world, surgeons need guidelines, not dictums and mandates. They, for some reason, fail to see that what they are doing with “guidelines” are dictums and mandates when viewed by nonsurgeons. I cannot believe they are this naive.

For me, as I said in the original column regarding bile duct injury guidelines, I applaud all the hard work done by the committee. There are some wonderful educational points for the practicing surgeon. I do not applaud the rigidity and arrogance and the effort to disseminate these “guidelines” as they say, “to hospitals, health care systems, healthcare plans, malpractice insurance, and patient safety organizations.”

Lastly, I want to end by saying that every point we have made is for the patient, so that they have the best result possible. The most important person for the patient in that equation is the surgeon, and we should help the surgeon do the best possible operation to cure the patient of their disease. In those few rare instances when a gallbladder cannot be safely removed, the alternatives may be considered.

—Guy Voeller, MD,
Professor of Surgery at the University of Tennessee
Health Science Center, Memphis.

Dr. Brunt et al Response To Dr. Voeller

We thank General Surgery News for the opportunity to reply regarding the bile duct injury guidelines follow-up commentary. We previously replied in detail to Dr. Voeller’s comments and criticism of the consensus conference guideline and will not rehash those here, since there is nothing substantively new in his most recent commentary. Undoubtedly, we wish the same goals, that is the best outcome for our patients and application of sound surgical judgment and technique.

The guidelines provide a rigorous and high-level review of the best available evidence for enhancing safety around cholecystectomy, heightened awareness of the risks, possible pitfalls one may encounter, strategies to help achieve the best possible approach under difficult circumstances, and some approaches to get out of trouble when encountering challenging or unsafe situations or pathology. The fact that the committee took 2.5 years, on a volunteer basis, only serves to demonstrate the dedication of these surgeons to patient safety. Raising the level of awareness of this topic is a start, and some of us have already witnessed the result of independent surgeons reaching out for advice intraoperatively or perioperatively, because of awareness of the guidelines.

The public trusts us to set and keep high standards of care, even when they are not “popular.” The goal of these, and any, guidelines is not to defend the surgeon at all costs (although they can), but to put forth standards that are reasonable and should, indeed, be weighed in the context of sound surgical judgment and decision making.

We must collaborate and all be on the same team, regardless of practice environment, helping each other along, encouraging others to ask for advice/coaching/help, and keep moving the needle forward with these types of discussions to advance the healing art of surgery in a safe, expert and sound manner. If we are not willing to be open to change and adapt, then the problem of bile duct injury will not diminish to the detriment of our patients and the surgical community alike.

Respectfully submitted,

—L. Michael Brunt, MD, Professor of Surgery,
Washington University School of Medicine, St. Louis.

Marian McDonald, MD
Dana Telem, MD, MPH
Dan Deziel, MD
Taylor Riall, MD, PhD
Steven Strasberg, MD
Dimitrios Stefanidis, MD, PhD