Sa1486 Are There Predictive Factors That Assist in Need for Intervention After a Positive Intraoperative Cholangiogram?

Abstract

Intra-operative cholangiogram (IOC) is commonly used to evaluate the biliary anatomy during laparoscopic cholecystectomy. However its utility in detecting retained biliary stones has been associated with high rates of false positivity and may lead to unnecessary post-operative endoscopic retrograde cholangiopancreatography (ERCP). Aims: To determine if findings on abdominal sonogram (US) or transaminase levels can aid in predicting which patients with a positive IOC should undergo ERCP. Hypothesis: ERCP should be performed only on patients with positive IOC with either 1) dilated bile duct 2) elevated transaminases on initial presentation or 3) transaminases not decreased by >50% during the hospitalization as that may indicate a past stone. This is a retrospective study of 369 consecutive patients undergoing cholecystectomy with IOC in a two year period at a county hospital. Data on 1) dilated bile duct (greater than 6mm) 2) elevated transaminases (AST/ALT >35) on initial presentation 3) transaminases not decreased by >50% during the hospitalization were compared in patients using Chi Square test. Three-hundred-sixty-nine patients underwent IOC resulting in 80 (22%) positive filling defects. Sonogram detected CBD dilation in 50/80 patients (63%). ERCP was performed in 44/50 patients with 27 (61%) having CBD stones. Of the 30 patients with normal CBD, 24 patients underwent ERCP with 12 patients (50%) having stones. Probability of positive ERCP in patients with dilated CBD compared to normal CBD was not statistically significant (p=0.18). Of all patients with a positive IOC, 63 of 80 (79%) had elevated transaminases. ERCP was performed in 54 patients with 32 (59%) positive for stones. In those with normal transaminases, 14/17 underwent ERCP with 8 patients (57%) having confirmed stones. Probability of positive ERCP in patients with elevated transaminases compared to normal transaminases was not statistically significant (p=0.44). Of all patients with positive IOC, 21 (26%) had a transaminase decrease of 50% during the post-operative course. Of this group, 17 had ERCP with 10 (59%) patients having retained stones (p=0.47). Even with positive IOC, 78% did not have confirmatory stones on ERCP. The variables of dilated common bile ducts, elevated transaminases, and 50% decrease in transaminases were unable to predict which patients with positive IOC needed ERCP. Therefore, EUS prior to ERCP to confirm retained stones may obviate the need for unnecessary ERCP.