Abstract
Background and objectiveLaparoscopic cholecystectomy is used for the treatment of symptomatic gallstones. Intraoperative cholangiogram (IOC) is used to diagnose common bile duct (CBD) stones. There is controversy surrounding routine vs selective use of IOC based on clinical, biochemical and ultrasound criteria. The aim of this study was to evaluate the outcomes from routine IOC and its utility in laparoscopic cholecystectomy.Materials and methodsThis was a UK-based single-centre retrospective study evaluating the outcomes from IOC for all laparoscopic cholecystectomies performed between May 2014 and February 2020. All adult patients undergoing elective, semi-elective or emergency operations were included. Demographics, biochemistry as well as radiological and endoscopic investigations were analysed. IOC was performed using a standardised technique and was interpreted by a single surgeon.ResultsA total of 744 out of 804 patients underwent IOC. The median age of the cohort was 51 years (SD: ±17.5); there were 468 females (62.9%) and 276 males (37.1%). Filling defects were identified in 43/744 (5.8%) patients, with 23/43 having stone extraction via endoscopic retrograde cholangiopancreatography (ERCP). Logistic regression analysis identified alkaline phosphatase (ALP) as a predictor of filling defects in IOC (OR: 1.003; 95% CI: 1.001-1.005, p=0.015).ConclusionBased on our findings, the routine use of IOC during laparoscopic cholecystectomy is safe and effective. Preoperative clinical, radiological and biochemical parameters apart from ALP have a limited role in predicting the diagnostic yield of IOC.
Highlights
The incidence of gallstones is estimated to be 6-15% with a further 10-15% of these patients presenting with common bile duct (CBD) stones [1]
Logistic regression analysis identified alkaline phosphatase (ALP) as a predictor of filling defects in Intraoperative cholangiogram (IOC) (OR: 1.003; 95% CI: 1.001-1.005, p=0.015)
The initial diagnosis of CBD stones is performed through a combination of assessment of liver function tests (LFTs) [gamma-glutamyltransferase, alkaline phosphatase (ALP), alanine aminotransferase (ALT), aspartate aminotransferase (AST) and bilirubin] and trans-abdominal ultrasound (US) scan [1,2,3]
Summary
The incidence of gallstones is estimated to be 6-15% with a further 10-15% of these patients presenting with common bile duct (CBD) stones [1]. The negative predictive value for CBD stones for combined LFTs is 97% and 95% for a ductal diameter of 3-6 mm on US scan [2,3] These techniques have low sensitivity and specificity, meaning further investigations including magnetic resonance cholangiopancreatography (MRCP), endoscopic ultrasound (EUS), endoscopic retrograde cholangiopancreatography (ERCP) or intraoperative cholangiogram (IOC) are often required. Selective IOC is based upon specified clinical, biochemical and/or US findings as well as intraoperative anatomical distortion [6] This may lead to CBD stones being missed with delayed presentation of patients in the acute setting. The aim of this study was to evaluate the outcomes from routine IOC and its utility in laparoscopic cholecystectomy
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