A meta-analysis of the use of intraoperative cholangiography; time to revisit our approach to cholecystectomy?

Abstract

Background Despite some evidence of improved survival with intraoperative cholangiography during cholecystectomy, debate has raged about its benefit, in part because of its questionable benefit, time, and resources required to complete. Methods An International Prospective Register of Systematic Reviews–registered (ID CRD42018102154) meta-analysis following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines using PubMed, Scopus, Web of Science, and Cochrane library from 2003 to 2018 was undertaken including search strategy “intraoperative AND cholangiogra* AND cholecystectomy.” Articles scoring ≥ 16 for comparative and ≥ 10 for noncomparative using the Methodological Index for Non-Randomized Studies criteria were included. A dichotomous random effects meta-analysis using the Mantel-Haenszel method performed on Review Manager Version 5.3 was carried out. Results Of 2,059 articles reviewed, 62 met criteria for final analysis. The mean rate of intraoperative cholangiography was 38.8% (range 1.6%–96.4%).There was greater detection of bile duct stones during cholecystectomy with routine intraoperative cholangiography compared with selective intraoperative cholangiography (odds ratio = 3.28, confidence interval = 2.80–3.86, P value < .001). While bile duct injury during cholecystectomy was less with intraoperative cholangiography (0.39%) than without intraoperative cholangiography (0.43%), it was not statistically significant (odds ratio = 0.88, confidence interval = 0.65–1.19, P value = .41). Readmission following cholecystectomy with intraoperative cholangiography was 3.0% compared to 3.5% without intraoperative cholangiography (odds ratio = 0.91, confidence interval = 0.78–1.06, P value = .23). Conclusion The use of intraoperative cholangiography still has its place in cholecystectomy based on the detection of choledocholithiasis and the potential reduction of unfavorable outcomes associated with common bile duct stones. This meta-analysis, the first to review intraoperative cholangiography use, identified a marked variation in cholangiography use. Retrospective studies limit the ability to critically define association between intraoperative cholangiography use and bile duct injury.

Increasing use of intraoperative cholangiogram in Australia: is it evidence‐based?

“…When adjusted for population changes, the decrease in actual service rates of IOC is slightly smaller than for cholecystectomy claims (5.5 and 32.6 per 100 000 persons, respectively), demonstrating an increased frequency of IOC usage. In total, between 1 January 2001 and 31 December 2019 approximately 79% of cholecystectomies in Australia will have had an IOC, contrasting greatly with international rates (6.9–33%) 5,7,8,22–24 . The service rate of BDI repairs has remained relatively unchanged; however, although the magnitude of the confidence interval is greater than the change itself.…”

“…The reason for this is not clear, although local surgical training culture and surgeon preference is likely influential factor, demonstrating the need for greater standardization across the country. Previous studies have reported variations in IOC use being attributable to factors such as hospital preference or policy, surgeon preference, and clinical indication 7,27 . Higher rates of IOC in small, rural, non‐teaching hospitals 5,27 may be due to difficulties in access to endoscopic retrograde cholangiopancreatography and/or technical expertise.…”

“…The authors therefore recommended selective, rather than routine, use of IOC. Furthermore, a recent meta‐analysis identified IOC rates anywhere between 1.6% and 96.4%, with no significant effect of IOC on BDI rate, 7 while another study identified correlations between routine IOC and increased overall complication rates, post‐surgical procedures and an average cost of USD 15000 per annum (p.a.) each surgeon using IOC routinely 5 …”

“…Two reasons are commonly given to support routine IOC; delineation of anatomy to prevent BDI, and the detection of occult common bile duct stones (CBDS). However, BDI in present day LC is extremely rare, with rates between 0.2% and 0.3%, and only 0.1% representing major injury or complication 4,7,10 . Of course, BDI can be a significant complication when it does occur; BDI‐associated mortality has been estimated to be approximately 3.5%, although historical reports were at 9.4% 1,3,11,12 …”

Subvesical duct and hepaticocholecystic duct in one patient

“…Also, the judicious use of intra-operative cholangiogram to defi ne the anatomy was recommended though there is no evidence to show this reduces the rate of bile duct injury [7].…”