Incidence and management of choledocholithiasis on routine intraoperative cholangiogram: a 5‐year tertiary centre experience

Abstract

Background The incidence of choledocholithiasis on routine intraoperative cholangiogram (IOC) during cholecystectomy is approximately 12%. Cholecystectomy without IOC may lead to undiagnosed choledocholithiasis placing patients at risk of complications such as pancreatitis or cholangitis. This study aims to determine the incidence of choledocholithiasis intraoperatively as well as the associated risk factors and the methods of management. Methods A retrospective observational analysis of all laparoscopic cholecystectomies with IOC at the Gold Coast Hospital and Health Service from 1 January 2016 to 2 December 2021 was carried out. Patient demographics, operative data and cholangiogram findings were collected from electronic medical systems. Results A total of 3904 cholecystectomies were carried out over the study period. 3520 (90.1%) had an IOC, and 474 (13.4%) had positive IOC findings. 158 (33.3%) of the cases were managed intraoperatively with hyoscine butylbromide with or without intravenous glucagon followed by biliary tree flushing alone, 183 (38.6%) received transcystic bile duct exploration (TCBDE) with a success rate of 83% and 167 (35.2%) received endoscopic retrograde cholangiopancreatography (ERCP). Choledocholithiasis was incidental in 44 (9.28%) patients. Conclusion Incidental choledocholithiasis during routine IOC is not uncommon. Management predominantly includes intraoperative TCBDE or postoperatively via an ERCP. This study has not found reliable preoperative factors to predict choledocholithiasis based on preoperative clinical, radiological and biochemical factors. A small proportion of patients received preoperative endoscopic intervention, and the decision‐making process requires further investigation.

Using neural networks to autonomously assess adequacy in intraoperative cholangiograms

“…The failure to consistently recognise the presence of filling defects likely stems from several factors. Stones are detected in a small minority of cholangiograms with reported rates ranging from 5 to 20% [ 22 – 25 ]. In our dataset, there were 227 frames containing fillings defects and a total of 363 instances representing just over a quarter of total frames.…”

Choledocholithiasis: A Review of Management and Outcomes in a Regional Setting

“…Incidental choledocholithiasis poses a significant and difficult management decision for surgeons, with incidences reported around 10% [ 2 ]. The ASGE guidelines also suggest that "pre- or post-operative ERCP or laparoscopic treatment be performed for patients at high risk of choledocholithiasis or positive IOC, depending on local surgical and endoscopic expertise".…”

“…Initial investigations for suspected choledocholithiasis typically follow a presentation of clinical jaundice or symptomatic cholelithiasis and include a comprehensive clinical examination, liver function tests (LFTs), and imaging. However, predicting choledocholithiasis is often difficult, and the diagnosis frequently presents as an incidental finding [ 2 ] on an intraoperative cholangiogram (IOC). The 2019 European Society of Gastrointestinal Endoscopy (ESGE) guidelines [ 3 ] outline several approaches to the management of choledocholithiasis, including multi-stage decompression of the common bile duct via an endoscopic retrograde cholangiopancreatography (ERCP) either before or after laparoscopic cholecystectomy (LC), or a single-stage LC with common bile duct exploration (CBDE).…”