Unsuspected choledocholithiasis found by routine intra‐operative cholangiography during laparoscopic cholecystectomy

Abstract

Background: The true incidence of unsuspected choledocholithiasis found during laparoscopic cholecystectomy (LC) is unknown. Untreated 'silent' stones may be associated with significant long-term risks. The aim of this study was to establish the incidence of unsuspected common bile duct stones (CBDS) and to determine the management and associated risk factors for unsuspected CBDS. Methods: Retrospective review of a large consecutive series of patients from Australia who underwent LC in a tertiary referral setting. Percentages of unsuspected CBDS, management and complications were reported. Pre-operative and intra-operative factors associated with unsuspected CBDS were determined using multivariable logistic regression analysis. Results: From a total of 1998 patients who underwent LC, 747 (37.4%) patients with no pre-operative suspicious factors were the subject of this study. CBDS were detected in 24 (3.2%) patients and all were managed either laparoscopically or endoscopically. Risk factors independently associated with unsuspected CBDS included patients >55 years of age (odds ratio 2.93, P = 0.038) and a large cystic duct size (odds ratio = 3.13, P < 0.001) on multivariable analysis. Conclusion: The incidence of patients with unsuspected CBDS on intra-operative cholangiography is low. Complete clearance of these stones can be achieved using a combination of laparoscopic and endoscopic methods.

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

“…Early awareness of dislodged stones can help triage patients in the way of urgency for a procedure but also aids in the planning of necessary personnel for the operating theatre or prompt ERCP. This can reduce poor outcomes associated with complications such as cholangitis or gallstone pancreatitis from persistent stones for those who practice selective IOC as well as aid in the reduction of incidental choledocholithiasis for those who practice routine IOC 10,20 . Other reasons for preoperative ERCP apart from cholangitis, included the identification of stones on imaging via US or CT imaging during workup for abdominal pain.…”

“…This can reduce poor outcomes associated with complications such as cholangitis or gallstone pancreatitis from persistent stones for those who practice selective IOC as well as aid in the reduction of incidental choledocholithiasis for those who practice routine IOC. 10,20 Other reasons for preoperative ERCP apart from cholangitis, included the identification of stones on imaging via US or CT imaging during workup for abdominal pain. There were 15 (51.7%) patients who received pre-operative endoscopic intervention after more biliary-specific imaging in the form of MRCP.…”

“…Nonetheless, the probability of a common bile duct (CBD) stone is higher in the presence of multiple abnormal indicators. The most commonly cited indicators used include deranged liver function tests (LFTs), a previous preoperative diagnosis of pancreatitis, cholangitis or clinical jaundice, and the presence of CBD dilation or suspected choledocholithiasis on imaging either by US, Computed Tomography (CT) or MRCP 10,11 …”

“…The most commonly cited indicators used include deranged liver function tests (LFTs), a previous preoperative diagnosis of pancreatitis, cholangitis or clinical jaundice, and the presence of CBD dilation or suspected choledocholithiasis on imaging either by US, Computed Tomography (CT) or MRCP. 10,11 The primary aim of this study is to determine the incidence of choledocholithiasis on routine IOC during a cholecystectomy. Secondary aims include identifying the associated risk factors and patient demographics, predictors of choledocholithiasis and the methods of management.…”

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

“…Recently, a single‐centre, retrospective cohort study appeared examined the incidence of unsuspected CBDS with routine IOC at a tertiary Australian referral hospital 13 . Only 3.2% of patients were discovered to have unsuspected CBDS.…”