Feasibility, benefit and risk of systematic intraoperative cholangiogram in patients undergoing emergency cholecystectomy

Abstract

BackgroundThe role of intraoperative cholangiogram (IOC) during cholecystectomy is debated. The aim of the present study was to evaluate the feasibility, benefit and risk of performing systematic IOC in patients undergoing cholecystectomy for acute gallstone-related disease.MethodsBetween July 2013 and January 2015, all patients admitted for an acute gallstone-related condition and undergoing same-hospital-stay cholecystectomy were prospectively followed. IOC was systematically attempted and predictors of IOC failure were analyzed.ResultsAmong the 581 enrolled patients, IOC was deliberately not performed in 3 cases. IOC was successful in 509/578 patients (88.1%). The main predictors of IOC failure were age, body mass index, male gender and associated acute cholecystitis. Thirty-two patients with suspected common bile duct stone on IOC underwent 38 unnecessary negative postoperative common bile duct investigations (32/509, 6.3%). There was one IOC-related adverse outcome (mild pancreatitis, 1/578, 0.2%).ConclusionsIOC can be successfully and safely performed in the majority of patients undergoing cholecystectomy for acute gallstone-related disease. Although its positive predictive value is suboptimal and results in a number of unnecessary postoperative common bile duct investigations, IOC accurately rules out common bile duct stones in patients with acute gallstone-related conditions.

When Should We Perform Intraoperative Cholangiography? A Prospective Assessment of 1000 Consecutive Laparoscopic Cholecystectomies

“…Similarly, another study determined that the predictive value of IOC was around 50% resulting in several unnecessary postoperative procedures. 25 Our rate of false-positive IOC was 3.4% (2 of 58 filling defects on IOC). Two patients underwent unnecessary interventions because of false IOC images suggesting CBD stones.…”

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

“…A selective policy of IOC use was adopted in 14 studies with a mean IOC use of 16.7% (2.8%–36.9%) in 12,064 patients [ 18 , 19 , 34 , [37] , [38] , [39] , [40] , [41] , [42] , [43] , [44] , [45] , [46] , [47] ]. Additionally, 14 studies adopted a policy of routine IOC with a mean average use of 88.3% (63.5%–99.2%) in 25,072 patients [ 17 , 19 , 34 , 37 , 42 , [48] , [49] , [50] , [51] , [52] , [53] , [54] , [55] , [56] ].…”

“…Eleven studies ( n = 10,466) reported the incidence of CBD stones on routine IOC with a mean of 11.8%, ranging from 2.8% to 18.9% [ 19 , 34 , 37 , 38 , [50] , [51] , [52] , [53] , [54] , [55] , [56] ]. Eight studies ( n = 4,556) reported the incidence of CBD stones on selective IOC with a mean of 3.9%, range 0.7% to 12.8% [ 18 , 19 , 34 , [37] , [38] , [39] , 44 , 45 ].…”

“…In 25 studies ( n = 71,191 patients) who reported successful IOC completion, the mean success rate was 95% (range 66%–99%) [ 5 , 6 , [16] , [17] , [18] , [19] , 34 , [37] , [38] , [39] , [40] , [41] , [42] , [43] , [44] , [48] , [49] , [50] , [51] , [52] , [53] , 55 , 56 , 59 , 60 ]. Successful completion of IOC was significantly greater with a routine IOC policy (95.2%) compared to a selective policy (90.6%) (OR = 2.09, CI = 1.73–2.51, P value < .001).…”

Unanticipated Admission Following Outpatient Laparoscopic Cholecystectomy: Identifying Opportunities for Improvement

“…2,4,[8][9][10] Previously, it has been shown that IOC identifies a common bile duct stone (CBD) in 22.4% of cases when performed in all patients undergoing cholecystectomy for gallstone-related disease and that in 29% of these patients with a CBD stone, IOC was the first imaging modality to identify a stone. 17 Further analysis with a broader access to variables such as patient symptoms and laboratory values at presentation may aid in identifying which patients are most likely to benefit from increased IOC use so that resources can be most effectively allocated. Although previous studies have reported increased risk of complications and unplanned admission with IOC, 8 this was not supported by our cohort.…”