Five‐year Prospective Audit of Routine Intravenous Cholangiography and Selective Endoscopic Retrograde Cholangiography with or without Intraoperative Cholangiography in Patients Undergoing Laparoscopic Cholecystectomy

Abstract

Consensus has never been reached regarding the need or the imaging technique for evaluating the common bile duct (CBD) in patients considered for cholecystectomy. With the advent of laparoscopic cholecystectomy there has been a resurgence of interest in the role of preoperative intravenous cholangiography (IVC) as an alternative for evaluating the CBD. The purpose of this audit was to assess whether a diagnostic workup based on IVC, which permits selective use of intraoperative cholangiography (IOC) and endoscopic treatment of CBD stones before surgery, could be useful in patients undergoing laparoscopic cholecystectomy (LC). In patients without jaundice, gallstone pancreatitis, a prior diagnosis of CBD stones, a prior history of contrast allergy, or a risk of contrast-associated acute renal failure, IVC was performed routinely. Patients suspected to have CBD stones based on IVC results or with inconclusive IVC and patients with a strong clinical suspicion of CBD stones were referred for endoscopic retrograde cholangiography (ERC). IOC was carried out in patients who had a history of contrast allergy or risk of contrast-associated acute renal failure and whenever the surgeon was in doubt as to the biliary anatomy or CBD clearance. IVC was carried out in 1155 patients, ERC in 225, and IOC in 54. IVC was conclusive in 1132 patients, with a diagnostic accuracy of 99%. Our workup permitted the sequential endoscopic-laparoscopic treatment of cholecystocholedocholithiasis in 162 cases. During the follow-up period residual CBD stones were detected in four patients. Our diagnostic workup showed that routine IVC exposes the population to a large radiation burden, and the cost is high for the small number of patients who benefit. Moreover, it does not seem helpful in reducing the incidence of CBD injuries during LC.

Scoring system to predict asymptomatic choledocholithiasis before laparoscopic cholecystectomy

“…During the 1980s, the introduction of new contrast media and improved radiological techniques favored a reintroduction of this test method [8]. In our recent experience, sensitivity and specificity of IVC used in 1,155 consecutive patients were 91.6 and 99.7%, respectively [32]. No patients in our series had allergic reactions [40].…”

“…The 408 patients in the control group were 162 men and 246 women with a mean age of 55.3 years (range, [18][19][20][21][22][23][24][25][26][27][28][29][30][31][32][33]. Indications for cholecystectomy were biliary colic (340 patients), resolved acute cholecystitis (51 patients), and resolved jaundice (17 patients).…”

For patients with predicted low risk for choledocholithiasis undergoing laparoscopic cholecystectomy, selective intraoperative cholangiography and postoperative endoscopic retrograde cholangiopancreatography is an effective strategy to limit unnecessary procedures

“…There is ongoing debate about whether intraoperative cholangiography (IOC) should be performed routinely [1][2][3][4] or selectively [5][6][7] during laparoscopic cholecystectomy (LC), and regarding the timing of preoperative or postoperative endoscopic retrograde cholangiopancreatography (ERCP) [8][9][10][11][12][13][14] in patients who are suspected of having choledocholithiasis. Laparoscopic common bile duct (CBD) exploration has emerged recently as a treatment option for ductal stones; however, ERCP before or after LC is still the most common approach [15][16][17].…”

Current Status of Laparoscopic Therapy of Cholecystolithiasis and Common Bile Duct Stones

“…Routine IOC is further applied if laparoscopic CBD clearance is favored. Secondly, IOC can be used only selectively [41][42][43][44] .…”