Role of Selective Intra‐operative Cholangiography During Cholecystectomy

Singh, Gurmeet; Gupta, Pooja; Sridar, G.; Katariya, RN

doi:10.1046/j.1440-1622.2000.01765.x

Cited by 17 publications

(11 citation statements)

References 16 publications

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“…To prevent such complications, some authors recommend routine intra-operative cholangiogram to exclude unsuspected CBD stones, while undertaking laparoscopic cholecystectomy. [1][2][3] Proponents of routine IOC also argue that the use of the procedure is associated Table 2 Positive predictive value of indicators for positive cholangiogram with a lower incidence and earlier recognition of bile duct injury, which is associated with an improved outcome. 4 However, intra-operative cholangiography itself has a number of disadvantages.…”

Section: Discussionmentioning

confidence: 99%

Prospective evaluation of a selective approach to cholangiography for suspected common bile duct stones

Horwood

Akbar

Davis

et al. 2010

annals

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Ann R Coll Surg Engl 2010; 92: 206-210 206Common bile duct (CBD) stones remain a considerable source of morbidity and mortality, and their presence should be considered in all patients presenting with symptomatic calculi. Intra-operative cholangiography (IOC) has been shown to be a sensitive and specific method of demonstrating bile duct stones; 1 however, it is time consuming, has resource implications and may result in unnecessary bile duct explorations due to false-positive examinations.Other methods for pre-operative assessment of the CBD have previously been evaluated. Magnetic resonance cholangiopancreatography (MRCP) is a sensitive, non-invasive method of imaging the biliary tree.2,3 However, it lacks the immediate therapeutic options available during IOC or endoscopic retrograde cholangiopancreatography (ERCP) and consumes the valuable MRI resource. ERCP, however, is an invasive procedure with morbidity and mortality rates Common bile duct (CBD) stones can cause serious morbidity or mortality, and evidence for them should be sought in all patients with symptomatic gallstones undergoing cholecystectomy. Routine intra-operative cholangiography (IOC) involves a large commitment of time and resources, so a policy of selective cholangiography was adopted. This study prospectively evaluated the policy of selective cholangiography for patients suspected of having choledocholithiasis, and aimed to identify the factors most likely to predict the presence of CBD stones positively. PATIENTS AND METHODS Data from 501 consecutive patients undergoing laparoscopic cholecystectomy (LC) for symptomatic gallstones, of whom 166 underwent IOC for suspected CBD stones, were prospectively collected. Suspicion of choledocholithiasis was based upon: (i) deranged liver function tests (past or present); (ii) history of jaundice (past or present) or acute pancreatitis; (iii) a dilated CBD or demonstration of CBD stones on imaging; or (iv) a combination of these factors. Patient demographics, intra-operative findings, complications and clinical outcomes were recorded. RESULTS Sixty-four cholangiograms were positive (39%). All indications for cholangiogram yielded positive results. Current jaundice yielded the highest positive predictive value (PPV; 86%). A dilated CBD on pre-operative imaging gave a PPV of 45% for CBD calculi; a history of pancreatitis produced a 26% PPV for CBD calculi. Patients with the presence of several factors suggestive of CBD stones yielded higher numbers of positive cholangiograms. Of the 64 patients having a laparoscopic common bile duct exploration (LCBDE), four (6%) required endoscopic retrograde cholangiopancreatography (ERCP) for retained stones (94% successful surgical clearance of the common bile duct) and one (2%) for a bile leak. Of the 335 patients undergoing LC alone, three (0.9%) re-presented with a retained stone, requiring intervention. There were 12 (7%) requiring conversion to open operation. CONCLUSIONS A selective policy for intra-operative cholangiography yields acceptably high positive ...

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Section: Discussionmentioning

confidence: 99%

Prospective evaluation of a selective approach to cholangiography for suspected common bile duct stones

Horwood

Akbar

Davis

et al. 2010

annals

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“…In addition, there is evidence to suggest that routine IOC during LC is a cost-effective means of preventing the costs of delayed recognition of bile duct injuries [27]. However, other studies have shown that IOC could be selectively performed and had few postoperative CBD stone complications [5,7,[28][29][30]. One group proposed that it is LFTs Liver function tests, CBD common bile duct 23:1933-1937 1935 unreasonable to perform routine IOC during laparoscopic cholecystectomy because it is negative in [90% of cases [31].…”

Section: Discussionmentioning

confidence: 99%

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

et al. 2008

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For patients who underwent LC, we performed selective IOC with postoperative ERCP for positive studies. Review of our experience using this algorithm showed it to be a powerful tool in limiting unnecessary ERCPs. Our data suggest that routine preoperative ERCP cannot be justified. Selective IOC during LC misses relatively few cases of biliary stones; these can be managed quickly by experienced endoscopists.

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“…Early treatment of any inadvertent bile duct injury is associated with a better prognosis. The arguments for selective IOC are that most asymptomatic CBD stones either remain asymptomatic or pass spontaneously; that the need for IOC can be accurately predicted from preoperative history, liver function test (LFT) and abdominal ultrasound; that experienced operators do not need an IOC to confirm biliary anatomy and that operative time is reduced by not carrying out routine IOC 3,4 …”

Section: Introductionmentioning

confidence: 99%

Prospective Audit of Laparoscopic Cholecystectomy Experience at a Secondary Referral Centre in South Australia

Tan

Suyapto

Neo

et al. 2006

ANZ Journal of Surgery

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Selective IOC would miss a proportion of patients with choledocholithiasis. Early laparoscopic cholecystectomy for acute cholecystitis is associated with a higher conversion rate than elective laparoscopic cholecystectomy. Overall complication rate is low, with 95% of patients having no complications. Laparoscopic CBD exploration is feasible with a reasonable success rate. This can all be achieved at a secondary referral centre staffed by general surgeons.

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Role of Selective Intra‐operative Cholangiography During Cholecystectomy

Abstract: Routine IOC during cholecystectomy is not essential for the prevention of retained stones. A combination of the various indicators of choledocholithiasis can be used to select patients for cholangiography.

Cited by 17 publications

References 16 publications

Prospective evaluation of a selective approach to cholangiography for suspected common bile duct stones

Prospective evaluation of a selective approach to cholangiography for suspected common bile duct stones

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

Prospective Audit of Laparoscopic Cholecystectomy Experience at a Secondary Referral Centre in South Australia

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