Plus ça change…

2. Seiden SC, Barach P. Wrong-side/wrong-site, wrong-procedure,and wrong-patient adverse events: are they preventable? ArchSurg 2006;141:931–939.

3. JCAHO Universal Protocol for Preventing Wrong Site, Wrong Per-son Surgery, 2003. Available at: http://www.jointcommission.org.Accessed: June 26, 2007.

4. NewYork State Surgical and Invasive Protocol Procedure (NYSSIPP)for Hospitals, Diagnostic and Treatment Centers, AmbulatoryCenters, and Individual Practitioners, 2007. Available at: www.health.state.ny.us/professionals/protocols_and_guidelines/index.htm. Accessed: June 26, 2007.

Plus ça change���

Thomas M Egan, MD, MSC, FACS

Chapel Hill, NC

Robin McLeod, MD, FACS

Toronto, Ontario, Canada

It is intriguing to see that there remains interest in defininga role for bupivacaine, a long-acting local anesthetic, in themanagement of patients undergoing abdominal surgery.1

In a study published almost 20 years ago, we randomized415 patients having elective laparotomy to receive intrafas-cial infiltration of 0.25% bupivacaine or not, to determineif this therapy could reduce atelectasis and analgesic re-quirement.2 Our study was sufficiently powered to refutean earlier study in 40 patients extolling the virtue of bupiv-acaine infiltration after open cholecystectomy.3 Sadly, therewas no impact of bupivacaine on atelectasis (assessed bychest radiograph and measurement of expiratory reservevolume), or total narcotic anesthetic used in our study ofpatients having open laparotomy for a variety of indica-tions, consistent with Symons’ findings of no difference inclinically relevant outcomes if patients received IP bupiva-caine after laparoscopic gastric bypass. Plus ça change, plusc’est la même chose!

REFERENCES

1. Symons JL, Kemmeter PR, Davis AT, et al. A double-blinded,prospective randomized controlled trial of intraperitoneal bupiv-acaine in laparoscopic Roux-en-Y gastric bypass. J Am Coll Surg2007;204:392–398.

2. Egan TM, Herman SJ, Doucette EJ, et al. A randomized, con-trolled trial to determine the effectiveness of fascial infiltration ofbupivacaine in preventing respiratory complications after electiveabdominal surgery. Surgery 1988;104:734–740.

3. Patel JM, Lanzafame RJ, Williams JS, et al. The effect of inci-sional infiltration of bupivacaine hydrochloride upon pulmonaryfunctions, atelectasis and narcotic need following elective chole-cystectomy. Surg Gynecol Obstet 1983;157(4):338–40.

Role of IntraoperativeCholangiography in Avoiding BileDuct Injury

Gennaro Nuzzo, MD, Felice Giuliante, MD,Ivo Giovannini, MD, Francesco Ardito, MD,Fabrizio D’Acapito, MD, Maria Vellone, MD, PhD,Marino Murazio, MD, Giovanni Capelli, MD

Rome, Italy

We have read with great attention the extremely interestingarticle by Massarweh and Flum,1 which is the most up-to-date and accurate analysis on this controversial topic. Wewould like to further discuss the issue addressed in theirarticle, with particular regard to the different rate of bileduct injury (BDI) associated with routine or selective use oflaparoscopic cholangiography, quoted from our previoussurvey, “Bile duct injury during laparoscopic cholecystec-tomy: results of an Italian national survey on 56,591cholecystectomies.”2

In our survey we reported no significant difference in therate of BDI in surgical units in which intraoperativecholangiography (IOC) was routinely or selectively used(0.32% versus 0.43%). Massarweh and Flum1 state that 7BDIs were improperly included in the former group, be-cause these were suspected before performing IOC. There-fore, according their interpretation, IOC was not per-formed to prevent the injury, but only to confirm it. Thisalternative evaluation of the data is important, because ex-clusion of these 7 cases from the comparison would movecloser to significance the difference in rate of BDI in thetwo groups of surgical units (0.23% versus 0.43%).

We disagree with their reinterpretation of our rigorouslyanalyzed data. In the questionnaire used for the survey,each surgeon was clearly asked whether IOC was routinelyor selectively used in current practice in his or her unit. Ofthe surgeons questioned, 10.3% answered that IOC wasroutinely used. This group of surgeons reported 25 BDIs,14 of which were recognized during the procedure. In 7 ofthese 14 cases, the BDI was suspected before performingthe IOC. In our opinion two remarks support the consis-tency of our analysis: in the units which routinely usedIOC, IOC would have been performed independently ofany suspicion of a BDI, therefore it was not performed justto confirm a BDI; and precisely because 7 BDIs occurredbefore IOC in units which were routinely using IOC, IOCdid not prevent in itself the occurrence of a BDI.

Opinions on the advantages of routine versus selectiveuse of IOC are still diverging and, as reported by Massar-weh and Flum,1 a conclusive study on this issue is difficult

e5Vol. 205, No. 4, October 2007 Letters