Operative cholangiography.

Abstract

touring the years 1950 to 1955 inclusive, 180 operative cholangiograms were obtained by the surgical staff and interpreted by the radiological staff of the Mary Hitchcock Memorial Hospital. It is hoped that a careful review of our experience may lead to a better understanding of the value of this procedure. Operative cholangiography was first described in 1932 by Mirizzi (6) of Argentina, who reported his personal experience with 91 patients. Largely because of the low-power portable x-ray equipment used and the relatively poor quality of the films, this method received little attention for ten to fifteen years. Recently there have been many reports on the value of routine cholangiography during cholecystectomy (1, 3, 5). The great majority of these have appeared in surgical journals. There has been a complete lack of papers on this subject in the American radiological literature in the past five years (5). The question as to the selection of patients for operative cholangiography has met with varying answers. Some feel that it should be a routine procedure in all gallbladder surgery (2). Others believe that it should be reserved for cases in which indications for common duct exploration are borderline, or for the poor-risk patient. Some use it in every case of biliary surgery in which the common duct is explored, for a pre-exploration “map” and a post-exploration check (1). Johnston, Waugh, and Good (4) believe that operative cholangiography must become more accurate than it is today before it can replace common duct exploration by experienced surgeons or become a routine procedure in biliary surgery. They report an incidence of 8 per cent residual common duct stones demonstrated by postoperative cholangiography, a figure which compares favorably with the findings of those who advocate operative cholangiography. These same authors emphasize that small stones embedded in crypts or ulcerations close to the ampulla of Vater and in the hepatic ducts are most easily overlooked. Norman (8) reported an incidence of hepatic duct stones of 24 per cent in 195 choledochostomies. The left duct was implicated slightly more often than the two right ducts combined. There were, however, 13 cases in his series in which stones were demonstrated in the relatively inaccessible right dorsocaudal duct. Stones in the hepatic radicles manifest themselves less frequently as negative shadows than as absence of filling when the other hepatic ducts are well visualized. Many surgeons believe that stones of the type which descend from the hepatic radicles a few days postoperatively make up a good percentage of retained stones. There is therefore a need for visualization of the entire biliary tree if the incidence of retained stones is to be lowered by operative cholangiography.