Intraoperative Cholangiogram Research Articles

Choledochal Semi Volvulus with Normal LFTs: A Complication of Paraesophageal Hernia, with Literature Review

86 year old lady presented with sudden onset of sub-sternal and epigastric pain, with radiation to the neck and the back, associated with nausea, palpitation, diaphoresis, and vomiting dark material. PMH: Long standing hiatal hernia with bloating, belching, and chest discomfort. BP 220/110. All labs normal except troponin slightly elevated 0.06. Initial diagnosis: Acute Coronary Syndrome. Urgent Cardiac catherization was normal. CT of the abdomen revealed a large paraesophageal hernia with all of the stomach located intra-throacically, with possible incarceration, along with a hugely distended gallbladder, with dilation of CBD to 13 mm with no gallstones. Patient was taken to OR for reduction and fixation of hernia. An abdominal approach was taken, upon opening of the abdomen a large hemorrhagic, gangrenous gallbladder was seen along with hiatus hernia with pulled cholodocal ductal system along with the tenting of duodenum. Intraoperative cholangiogram showed no filling defect or gall stones. Patient underwent cholecystectomy along with reduction and fixation of hiatus hernia. Literature Review: 4 similar cases have been reported. Miller and Thompson (1977): Intermittent dislocation of Liver; A syndrome associated with volvulus of stomach, transverse colon and obstructive jaundice. Llaneza PP et al. (1986): Extrahepatic obstruction of CBD at the diaphragmatic hiatus in association with intrathoracic volvulus. Lamouliatte et al. (1992): Biliary obstruction complicating diaphragmatic hiatus hernia with jaundice due to choledochal dislodgement and torsion. Caldiero et al. (2001): Choledochal semi volvulus with jaundice due to hiatal hernia. All the 4 cases presented with cholestatic syndrome secondary to either obstruction or stretching of CBD in the diaphragmatic hiatus and hiatus hernia was diagnosed retrospectively. By contrast, our patient presented with chest/ epigastric pain with normal LFTs and was subsequently found to have gangrenous acalculous cholecystitis in association with incarcerated hiatus hernia. This observation emphasizes the possibility of direct relationship of gangrenous cholecystitis and hiatus hernia even with normal LFT, could be due to intermittent stretching or tension of CBD. If time permits HIDA scan is recommended to confirm the diagnosis. But, if the clinical suspicion is high, an abdominal approach is recommended to repair the volvulus and at the same time explore the gallbladder to reduce the added mortality of these coexisting clinical entities.

Foregut atresias and bile duct anomalies: rare, infrequent or common?!

The association of foregut atresias and bile duct anomalies is reportedly rare. We encountered five referrals within 2 years where the secondary diagnosis was missed at operation. Four patients initially presented on antenatal scans as a foregut atresia whereas the fifth presented at nine years with abdominal pain due to a choledochal cyst. The biliary anomalies (cholecysto-hepatic duct, liver cyst and choledochal cysts) in the first four presented as postoperative jaundice during infancy whereas the fifth patient developed subacute intestinal obstruction due to congenital duodenal stenosis at fifteen years. In the patients with duodenal atresia neither did the preoperative X ray reveal any distal bowel gas nor did the subsequent intraoperative cholangiograms reveal bifid common bile duct or pancreato-biliary malunion. Atresias were corrected by primary repair (duodenoduodenostomy for congenital duodenal obstruction in four patients and disconnection/ligation of tracheo-oesophageal fistula with oesophageal anastomosis in one patient). The biliary anomalies were corrected by excision of the abnormal bile ducts (choledochal cyst/liver cyst/cholecystectomy) with Roux en Y hepaticojejunostomy. All patients are asymptomatic and liver function and biliary dilatation has normalised. The association of foregut atresias and bile duct anomalies is not as rare as previously reported. Antenatal ultrasound suggesting either a foregut or a biliary anomaly should alert one to the association. Full radiological and/or imaging investigation may be indicated prior to corrective surgery of the primary anomaly.

Who should perform laparoscopic cholecystectomy? A 10-year audit

Laparoscopic cholecystectomy is one of the most common operations in general surgery. It is performed by surgeons with a specialist interest in biliary disease as well as by surgeons with other specialist interests. This retrospective audit of all cholecystectomies was conducted in a single hospital over a 10-year period from 1996 to 2005. Data were extracted from two independent electronic databases and supplemented by a full note review of cases with extended postoperative stay or unplanned readmission. The outcomes for cases under the care of specialist upper gastrointestinal (GI) consultants were compared with outcomes for cases of general surgery consultants from other firms. Data from 4,139 cholecystectomies were obtained. More cholecystectomies performed by upper GI firms were completed laparoscopically (96.2% vs 80.1%) with a higher rate of intraoperative cholangiograms (83.4% vs 16.9%). The mean operating time was shorter for upper GI cases (69 vs 84 min), as was the postoperative hospital stay (2 vs 3.6 days). There also was a significantly lower incidence of bile duct injury in upper GI cases (0.1% vs 0.9%). In their institution, the authors found evidence of improved outcomes when laparoscopic cholecystectomy was performed under the care of surgeons with a specialist interest in upper GI or hepatopancreaticobiliary surgery.

Prospective Study of Operator-Controlled Guidewire Cannulation of the Bile Duct

Bile duct (BD) access during ERCP is usually achieved by contrast injection (CI) and/or assistant-directed guidewire cannulation (GWC). Short wire biliary catheters now allow the operator to control guidewire manipulations during ERCP. The aim of this prospective study was to evaluate the efficiency and safety of operator-controlled GWC when only BD cannulation is intended. Methods: BD cannulation was attempted in all cases using a hydrophilic tipped guidewire controlled by the endoscopist. Contrast was injected after GWC of the BD or when needed to help achieve BD cannulation. Access sphincterotomy (precut) was usually performed if repeated unintentional PD cannulations occurred. Data collected included ERCP indication, BD GWC success and need for CI, unintentional pancreatic duct (PD) GWC or CI, cannulation difficulty, and complications. Cannulation difficulty was graded as: easy (1-4 attempts & < 5 min), moderate (5-10 attempts & < 10 min), difficult, or precut. Results: From 996 ERCPs performed between 5/2004 and 11/2006, 398 patients without prior endotherapy underwent attempted operator-controlled GWC. GWC of only the BD was intended in 223 patients. Indications for ERCP were: abnormal liver tests (n = 135), abnormal intraoperative cholangiogram (n = 43), pain (n = 23), biliary pancreatitis (n = 12), or other (n = 10). Successful BD cannulation was achieved in 220 (99%) cases. GWC of the BD was achieved before any CI in 114 (51%). CI was needed in 48 and precut was performed in 58. Unintentional PD cannulation occurred in 110 (49%) cases with only GWC of the PD in 28 and PD GWC + PD CI in 82. BD cannulation difficulty and post-procedure complication data according to whether the PD was cannulated are found in Tables 1 & 2. One case of mild post-ERCP pancreatitis occurred after operator-controlled unintentional PD GWC without CI. Conclusions: 1) Operator-controlled GWC of the BD is most often easily obtained but unintentional PD cannulation still occurs about half the time. 2) Attempted GWC of the BD is associated with an acceptable risk for post-ERCP complications but is most safe when PD cannulation is completely avoided. Table 1Operator-controlled biliary GWC difficulty according to PD cannulation Cannulation difficulty Easy Moderate Difficult Precut Failed No PD cannulation (n = 113) 85 17 3 7 1 Unintentional PD (n = 110) 19 27 11 51 2 Total (n = 223) 104 44 14 58 3 Open table in a new tab Table 2Post-procedure complications Pancreatitis Perforation Other complications No PD cannulation (n = 113) 0 0 1 (pain) Unintentional PD (n = 110) 5 (4.5%) 1 (0.9%) 1 (bleed) Total ERCP (n = 996) 20 (2%) 7 (0.7%) 21 Open table in a new tab

The role of intraoperative cholangiogram in the management of patients recovering from acute biliary pancreatitis

Use of the standard management for gallstone-associated acute pancreatitis calls for cholecystectomy with cholangiography performed during the same hospitalization after acute symptoms has decreased. No previous studies, however, have objectively addressed the usefulness of intraoperative cholangiography (IOC) for the management of this condition. This study aimed to determine the incidence of common bile duct (CBD) stones after an acute episode of gallstone pancreatitis. The medical records of all patients who underwent a cholecystectomy and IOC after an episode of gallstone pancreatitis during the same admission between 1999 and 2004 at the University of Alberta and Royal Alexandra hospitals were examined to determine the incidence of CBD stones after resolution of gallstone pancreatitis. After a chart review for a series of 86 patients, 63 met the inclusion criteria. All except for one patient had undergone successful IOC (98%). Among the patients who had no evidence of CBD obstruction on preoperative imaging or lab work, three were found to have a filling defect on IOC and stones on their postoperative endoscopic retrograde cholangiopancreatography (ERCP) (3/63, 5%). This is not significantly different from the 4.6% incidence of CBD stones among patients with cholelithiasis who had normal preoperative imaging and blood work. In the setting of normal preoperative imaging and lab work, the incidence of CBD stones among patients recovering from acute mild to moderate gallstone pancreatitis is not significantly higher than among patients with no history of pancreatitis. Therefore, an IOC for post-gallstone pancreatitis does not alter management.

Early Management of Acute Gallstone Pancreatitis

Early Management of Acute Gallstone Pancreatitis

Optimizing Choledocholithiasis Management

Endoscopic retrograde cholangiopancreatography (ERCP) is more cost-effective for managing incidental choledocholithiasis (CDL) after laparoscopic cholecystectomy and intraoperative cholangiogram (LC/IOC) than laparoscopic common bile duct exploration (LCBDE). A cost-effectiveness analysis was performed to compare ERCP with LCBDE. Sensitivity analyses were performed to determine the key contributors to cost-effectiveness between the 2 treatment options. Costs were approached from the institutional perspective considering a typical patient undergoing LC/IOC at a large referral center. The base case patient evaluated was a woman 18 years of age or older with symptomatic cholelithiasis and incidental CDL discovered at the time of LC/IOC. Endoscopic retrograde cholangiopancreatography with drainage procedure performed after LC/IOC or LCBDE during LC/IOC. Costs, quality-adjusted life years gained, mean cost-effectiveness ratios, and incremental cost-effectiveness ratios. In the base case analysis, ERCP was the optimal treatment choice with a cost of $24 300 for 0.9 quality-adjusted life years gained compared with $28 400 and 0.88 quality-adjusted life years for LCBDE. Endoscopic retrograde cholangiopancreatography remained the optimal strategy for CDL in multiway probabilistic sensitivity analysis. If LCBDE were performed and the cost of a potential operative case lost was $3100 or less and the cost of ERCP hospitalization was $18 000 or more, then LCBDE became the preferred treatment for CDL. Endoscopic retrograde cholangiopancreatography was both less costly and more effective than LCBDE. Factors important to choosing the best strategy for CDL management included the cost of a potential case lost due to LCBDE performance and the cost of ERCP hospitalization.

Is ERCP necessary in all patients with an abnormal intraoperative cholangiogram?

Is ERCP necessary in all patients with an abnormal intraoperative cholangiogram?

The long-term follow-up of patients with positive intraoperative cholangiograms during laparoscopic cholecystectomy

The long-term follow-up of patients with positive intraoperative cholangiograms during laparoscopic cholecystectomy

MIRIZZI SYNDROME

Mirizzi Syndrome is an unusual presentation of obstructive jaundice. In this rare entity gallstone impaction in Hartmann's pouch or in the cystic duct causes external compression of the common hepatic duct, resulting in biliary obstruction. First described by Mirizzi in 1948. This syndrome has been reported in 0.7-1.4% of all adult patients undergoing cholecystectomy. Rare in children, never been reported in infants. 2 months old male infant presented with gradual increasing direct hyperbilirubinemia. He was born at full term with gastrochisis, corrected by surgery shortly after birth. There was no resection of intestine during surgery. Received TPN for 3 weeks after birth. He was sent home at 1 month of age. Direct bilirubin at discharge was 3.2, normal alkaline phosphatase (AP), mildly elevated AST and ALT. At presentation direct bili was 5.2, AST 186, ALT 216, AP 421. Unremarkable CBC, BMP, and CRP. Blood cultute, urine culture, TORCH study, and viral hepatitis screening was negative. Hepatobiliary ultrasonography (US) showed mild hepatomegaly, contracted gall bladder, mild dilatation of common bile duct. Given the negative infectious workup, the US findings raise the suspicion of biliary atresia. Liver biopsy was done, which revealed obstructive cholestasis. Liver biopsy findings supported the diagnosis of biliary atresia. Pediatric Surgery was consulted for Kasai procedure. Intraoperative cholangiogram before Kasai revealed a small stone at the junction of the cystic and common hepatic duct that was causing extrinsic compression on the common hepatic duct. Exploration of CBD revealed no stones or other cuases of obstruction. The diagnosis of the Mirizzi syndrome was made. Cholecystectomy was done and a T tube was placement. T tube cholangiogram showed good flow. Direct hyperbilirubin level back to normal over the next few weeks. Though rare, Mirizzi syndrome can occur in infant and should be considered in the differential diagnosis of cholestatic jaundice.

Aberrant Right Hepatic Sectoral Duct Injury Following Laparoscopic Cholecystectomy: Evaluation and Treatment of a Diagnostic Dilemma

Bile duct injury (BDI) and postoperative biliary leaks are common complications following laparoscopic cholecytectomy. Biliary damage and leaks can often be easily diagnosed by an intraoperative cholangiogram, postoperative endoscopic retrograde cholangiopancreatography (ERCP), or percutaneous transhepatic cholangiogram (PTC). We present a case of a persistent biliary leak with biloma associated with unrevealing intraoperative cholangiograms, ERCPs, and PTCs. The final diagnosis of an aberrant right hepatic sectoral duct injury with a posterior sector bile leak was suspected and ultimately confirmed during a repeat operation that was required to repair the persistent biliary leak.

Anatomic landmarks: their usefulness in safe laparoscopic cholecystectomy

The incidence of bile duct injury in laparoscopic cholecystectomy is 0.3% to 1.0%. This is higher than the incidence reported for open cholecystectomy (i.e., 0.1-0.2%), and the surgeons all over the world are relentlessly trying to find the ways and means to lower this incidence. Various operating strategies, techniques, and instrumentations such as the 0 degrees telescope, intraoperative cholangiogram, hydrodissection, and peanut gauze dissection have been claimed by various authors to minimize the risk of bile duct injury during cholecystectomy. However, the surgical fraternity agrees that there has been no substitute for meticulous dissection and display of various vital structures near the common bile duct. The authors describe seven anatomic landmarks encountered during laparoscopic cholecystectomy that assist in safe dissection to prevent bile duct and vascular injury. On the basis of their experience, they believe that if surgeons adhere to these landmarks, excellent results can be achieved.

Novel Use of Rifaximin for Treatment of Secretory Diarrhea in a Pediatric Patient with Biliary Diversion

Patients with ostomies are at high risk of bacterial overgrowth. We report a case of a patient with PFIC-1 who had partial biliary diversion and secretory diarrhea. HISTORY: 3yo male with PFIC-1 diagnosed by biopsy and genetic testing. Biliary diversion done at age 18mo. Last winter after an acute “viral” illness he developed worsening jaundice and severe diarrhea. Treatment consisted of IV antibiotics for presumed cholangitis without significant improvement of his jaundice. Loss of large quantities of fluid and solid food from the stoma required IV normal saline supplementation of 1L/d. Attempt at endoscopic stomal cholangiogram was complicated by perforation. Exploratory laparotomy and intraoperative cholangiogram did not identify any obtruction. He was treated empirically with IV antibiotics, probiotics, and oral ciprofloxacin without improvement in the stool output (800 to >1000cc/day). Jaundice gradually resolved. Due to persistent foul smelling excessive drainage, pt was treated with rifaximin 200 mg TID for 2 weeks. Ostomy drainage decreased from averaging more than 1000cc/night to 400cc/night. His drainage became greener with no further visible food particles. Impression: this patient demonstrates secretory diarrhea likely due to bacterial overgrowth. Previous antibiotic therapy with ciprofloxacin was not broad enough to cover possible anerobic contamination. Rifaximin is an oral, non-systemic, gut-selective antibiotic with minimal absorption by the GI tract. Its in vitro activity is against both gram-positive, gram-negative, aerobic and anaerobic isolates. Its use in pediatrics has been limited to infectious diarrhea but it has been approved for use in the treatment of traveler's diarrhea in adults but not approved for use in children. It has been shown to be useful in gut decontamination for treatment of hepatic encephalopathy, and anecdotally in IBD and bacterial overgrowth in adults. Due to the disruption of his quality of life secondary to daily normal saline infusions, use of this non-approved agent was tried. Ciprofloxacin, which is not approved for use in children, was already tried without success. Metronidazole was not attempted due to its poor palatability as a suspension and also due to side effect profile. Rifaximin was well tolerated in our patient and had no side effects. Treatment was short term with long term results significantly improving our patient's quality of life.

*Endoscopic Ultrasound is Safe, Accurate, and Cost Effective in the Evaluation of Abnormal Intraoperative Cholangiograms.

*Endoscopic Ultrasound is Safe, Accurate, and Cost Effective in the Evaluation of Abnormal Intraoperative Cholangiograms.

PROSPECTIVE AUDIT OF LAPAROSCOPIC CHOLECYSTECTOMY EXPERIENCE AT A SECONDARY REFERRAL CENTRE IN SOUTH AUSTRALIA

Laparoscopic cholecystectomy is now the gold standard procedure for symptomatic gallstone disease. Nevertheless, there are still several controversies such as the need for routine intraoperative cholangiogram (IOC), the indications for and results of early laparoscopic cholecystectomy in the setting of acute cholecystitis and the use of endoscopic retrograde cholangiopancreatography versus laparoscopic common bile duct (CBD) exploration for intraoperatively detected choledocholithiasis. The aim of this study was to investigate some of these controversies. All laparoscopic cholecystectomies carried out at our institution, a secondary referral centre in Adelaide, South Australia, over a 9-month period were prospectively audited. Data were collected regarding indications for surgery, rate of conversion to open operation, use of IOC, rate of choledocholithiasis and complication rate. There were 202 patients, of whom 152 were women and 50 men. Age range was 15-83 years. Sixty-one per cent of emergency operations were for acute cholecystitis. The conversion rate for emergency operations was 20.6% and for elective procedures was 4.2% (P = 0.003). One hundred and eighty-four patients had an IOC performed. Twelve of these patients had choledocholithiasis. Six of these 12 patients had both normal preoperative ultrasound and liver function tests. Four of the patients went on to postoperative endoscopic retrograde cholangiopancreatography, four had successful laparoscopic CBD exploration, two had open CBD exploration and two had their distal CBD filling defects flushed away with normal saline. There was no morbidity associated with performance of the IOC. There were three patients with postoperative bile leak and one with a bile duct injury. 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.

Yield At ERCP of Patients Referred for “Positive Intraoperative Cholangiogram”

Background: There are few studies addressing the true incidence of common bile duct (CBD) stones or other abnormalities after a “positive” intraoperative cholangiogram (IOC). The true incidence of abnormalities in this patient population is not well documented. Methods: We prospectively entered information into a database on 1451 patients undergoing ERCP by a single operator at a tertiary referral center over 5 years. Indications for ERCP were prospectively entered including abnormal IOC. Patients referred for abnormal IOC were then retrospectively selected for analysis. Results: 88 patients were referred for abnormal IOC, 85 for suspected common bile duct stones and 3 for stricture(s). There were 60 females and 28 males. Of these 88 patients, 86 had successful ERCP (97.7%); 2 referred for suspected stones failed because of prior surgical gastric bypass and are thus excluded from data analysis. All patients referred for suspected stones, who had a successful cannulation, had biliary sphincterotomy and balloon sweep of the duct (N = 83). Only 46 of 83 patients referred for suspected stones actually had them on ERCP (55%). Three of 3 patients referred for apparent CBD strictures actually had them (1 gallbladder cancer, 1 pancreatic cancer, 1 primary sclerosing cholangitis). Increasing CBD diameter appears to increase the likelihood of a true-positive IOC (15% true-positive for CBD <=5 mm, 70% for CBD > 10 mm). Age, gender, and preoperative liver function tests were not predictive of a true-positive IOC. There were no ERCP-related complications among any of these patients. Conclusions: The true incidence of CBD stones after abnormal IOC is lower than expected. Increasing CBD diameter is a predictor of the presence of stones on postoperative ERCP. Although the numbers are small, intraoperative cholangiography appears to be accurate for the identification of biliary strictures. More research is needed to determine if there are other predictive factors besides duct diameter that might be useful for excluding patients with “positive” IOCs who are at lower risk for CBD stones, and in whom postoperative ERCP might not be indicated.

Utility of Endoscopic Ultrasound Is Safe and Accurate in the Evaluation of Abnormal Intraoperative Cholangiograms

Background: There is no consensus on the imaging modality for evaluating abnormal post-cholecystectomy intraoperative cholangiograms (IOC). IOC usage in laparoscopic cholecystectomy is increasing in order to evaluate retained common bile duct stones. Common bile duct stones are detected in 17% of post-cholecystectomy cases. The gold standard in evaluating the biliary system, and for choledocholithiasis, has been endoscopic retrograde cholangiopancreatography (ERCP), however this procedure is associated with increased morbidity and mortality when compared to endoscopic ultrasound (EUS). EUS has been shown in previous studies to have a sensitivity 88-97% and specificity of 96-100% in the evaluation of patients with suspected choledocholithiasis. There has not been a study published to date in which EUS performance was evaluated in the setting of an abnormal IOC. Methods: A retrospective study to evaluate the utility of EUS imaging of the extrahepatic biliary system for abnormal IOC. All medical records for EUS performed in the setting of an abnormal IOC since 1997 at Scott & White Hospital were reviewed. Positive EUS results for choledocholithiasis were confirmed by direct visualization of stones in the duodenum after ERCP extraction or ERCP which showed cholangiogram with filling defects that resolved after extraction. Negative EUS results were considered if the patient had a negative EUS for choledocolithiasis and remained symptom free (no abdominal pain, cholangitis or LFT abnormalities) on follow up of at least 6 months. Results: A total of 62 patients met inclusion criteria. Age ranged from 14 to 89 years of age, mean age 54 years of age, with 37% male and 63% female. There were 34 cases with a negative EUS result, 13 were excluded for inadequate follow up of six months. For all cases there was no evidence of a missed stone (no abdominal pain, cholangitis or LFT abnormalities) at 6 months follow up. There were 28 cases with positive EUS results all of which had conformation of common bile duct stones at ERCP. In 26 cases there was direct visualization of the stone in the duodenum after extraction and 2 cases with filling defects on cholangiogram that resolved after extraction. EUS evaluation of an abnormal IOC has a sensitivity of 85-100% and specificity of 81-100% with 95% confidence interval. There were no complications from any EUS. Conclusion: The results of this study confirm EUS is highly reliable method of evaluating abnormal intraoperative cholangiograms. The increased use of endoscopic ultrasound should reduce morbidity and mortality associated with unnecessary ERCP and reduce overall costs and length of hospital stay.

Painless Choledocholithiasis in African American and Hispanic Patients

Background: Typical symptoms of choledocholithiasis include colicky right upper quadrant abdominal pain, nausea, vomiting, fever and jaundice. However elderly patients with choledocholithiasis may present with atypical manifestations and without biliary colic. Objective: To determine the frequency of painless presentation of choledocholithiasis by age, sex and race/ethnicity. Methods: Retrospective review of medical records of 527 patients aged 23 to 97 years over 10-year period with a definitive diagnosis of choledocholithiasis. The diagnosis was suspected by abnormal liver chemistry, abdominal ultrasound (US) and/or computerized tomographic (CT) scan of abdomen, and was confirmed by one or more of the following: endoscopic retrograde cholangiopancreatography, surgery, intraoperative cholangiogram. Presence or absence of pain at the time of admission and findings of US and CT were recorded. The patients were stratified according to age into three groups: 23-65 years (Group I): 216 patients, 66-75 years (Group II): 199 patients, 76-97 years (Group III): 112 patients. Data were analyzed by age, sex and race/ethnicity. Results: Of 527 patients 124 had painless presentation (24%). Number of patients presenting without abdominal pain differed significantly by age (Group I = 16%, Group II = 26% and Group III = 33%, p = 0.001). The odds of having painless presentation for subjects in age group III was 2.5 times that of those in age group I (Odds Ratio = 2.5, 95% Confidence Interval = 1.4-4.5). Painless presentation did not differ by sex (male = 23%, female = 24%, p = 0.8), or race/ethnicity (African American = 24%, Hispanics = 23%, p = 0.8). Conclusions: A significant number of patients may present with painless choledocholithiasis. The presentation of painless choledocholithiasis increases with aging. Clinicians should have a high index of suspicion for choledocholithiasis, and low threshold for diagnostic testing in the patients presenting with abnormal liver tests even in absence of abdominal pain.

Intraoperative cholangiography: past, present, and future

The extrahepatic biliary tree was first visualized in 1918 when Reich injected bismuth and petrolatum and defined a biliary fistula, thus opening the field for further studies of the biliary tree. Mirizzi recorded the first series of intraoperative cholangiography in 1932 using static films. Later, the mobile C-arm image intensifier using a TV monitor was reported in a series by Berci and colleagues in 1978. They emphasized the importance of using routine cholangiography in all laparoscopic cholecystectomies. This procedure can be performed through the cystic duct or through the gallbladder with excellent visualization of the anatomy of the extrahepatic biliary tree, including the potential of finding bile duct stones, stricture, and tumor, as well as defining the function and anatomy of Oddi's sphincter. Numerous benefits of this technique can be observed, including early definition of a bile duct leak or injury. X-ray resolution will continue to improve as well as three-dimensional imaging, and intraoperative magnetic imaging cholangiopancreatography may be developed as the future intraoperative cholangiogram.

Do all patients with abnormal intraoperative cholangiogram merit endoscopic retrograde cholangiopancreatography?

Endoscopic retrograde cholangiopancreatography (ERCP) is commonly used for postoperative evaluation of an abnormal intraoperative cholangiogram (IOC). Although a normal IOC is very suggestive of a disease-free common bile duct (CBD), abnormal studies are associated with high false-positive rates. This study aimed to identify a subset of patients with abnormal IOC who would benefit from a postoperative ERCP. This prospective study investigated 51 patients with abnormal IOC at laparoscopic cholecystectomy who underwent postoperative ERCP at two tertiary referral centers over a 3-year period. Univariate and multivariate logistic regression analyses were performed to determine predictors of CBD stones at postoperative ERCP. For all 51 patients, ERCP was successful. The ERCP showed CBD stones in 33 cases (64.7%), and normal results in 18 cases (35.2%). On univariate analysis, abnormal liver function tests (p < 0.0001) as well as IOC findings of a large CBD stone (p = 0.03), multiple stones (p = 0.01), and a dilated CBD (p = 0.07) predicted the presence of retained stones at postoperative ERCP. However, on multivariable analysis, only abnormal liver function tests correlated with the presence of CBD stones (p < 0.0001). One-third of patients with an abnormal IOC have a normal postoperative ERCP. Elevated liver function tests can help to identify patients who merit further evaluation by ERCP. The use of less invasive methods such as endoscopic ultrasound or magnetic resonance cholangiopancreatography should be considered for patients with normal liver function tests to minimize unnecessary ERCPs.