Operative Cholangiogram Research Articles

757 Biliary obstruction impairs red cell oxidative capacity

At 19 weeks' gestation, two cystic structures were first identified in the abdomen of a fetus. A repeat ultrasonography at 34 weeks confirmed a definite cyst communicating with the liver. The baby was born at 39 weeks, and serum direct bilirubin started to rise to 4.1 mg/dL. An operative cholangiogram at 23 days of life showed a cystically dilated choledochus with distal atresia and a relatively smooth yet hypoplastic intrahepatic biliary tree. Complete obliteration of the cystic duct was also noted. After excision of the cystic common bile duct, hepatico-jejunal anastomosis was performed, and the patient did well for 8 months postoperatively. Liver biopsy showed proliferation of the bile ductules, but no interlobular bile ducts were observed in any portal triad. A diagnosis of biliary atresia was established. Including the present case, five cases of antenatally diagnosed biliary atresia have been reported. All of them had type I cyst, and antenatal diagnosis was made at 19 to 32 weeks' gestation. Differential diagnosis between biliary atresia of type I cyst and choledochal cyst with complete distal obstruction has been a matter of discussion, and recognition of the entity of antenatally diagnosed biliary atresia is of significant importance from an etiological point of view.

Biliary tract anomalies in thoraco-omphalopagus conjoined twins

Thoraco-omphalopagus conjoined twins were separated urgently on the ninth day of life because of bowel obstruction and impending intestinal perforation. Preoperative studies clarified the cardiac, intestinal, and hepatic parenchymal anomalies, but the precise biliary anatomy remained obscure. Operative cholangiogram through the single gallbladder visualized only the extrahepatic biliary anatomy in twin A. At reoperation for abdominal patch removal, exploration in twin A found biliary atresia. Because of the unusual duodenal anatomy and extreme short bowel, the authors elected to treat the biliary atresia in twin A with an appendix portoenterostomy. Twin B had no gallbladder and a profoundly hypoplastic biliary tree. Both twins have normal bilirubin and liver function at 18 months of age. The anatomic details of 8 additional cases of complex biliary tract anomalies in thoraco-omphalopagus conjoined twins are reviewed. In all cases, the complex biliary anatomy has been associated with conjoined duodenum. In most cases the preoperative technetium 99m HIDA scan has been inconclusive or misleading. J Pediatr Surg 37:1716-1719. Copyright 2002, Elsevier Science (USA). All rights reserved.

Laparoscopic transcystic bile duct stenting in the management of common bile duct stones

The management of patients with common bile duct stones associated with stones in the gall bladder remains controversial. Over the three-year period from 1996 to 1999, patients with cholelithiasis and known choledocholithiasis, or choledocholithiasis found at laparoscopic cholecystectomy, were initially treated by placing a stent across the sphincter of Oddi. The stent was pushed along a guide wire through the cystic duct and then down the common bile duct, before the cystic duct was closed. Subsequently, the stent was used to facilitate performance of a needle knife endoscopic sphincterotomy. The stent was then removed, a cholangiography was performed and the common bile duct was cleared. Patients with persistent jaundice usually had a preoperative endoscopic retrograde cholangio-pancreatography. Transcystic stenting was the 'intention-to-treat' basis of therapy for 56 of the patients. The placement of the stent only failed once when the stent became trapped in the cystic duct. Complications of the operation included: pain and jaundice (n = 2), cholangitis (n = 1), and pulmonary embolus (n = 1). The median postoperative hospitalization was 2 days (range: 1-15). Five further patients had common bile duct stones removed via a choledochotomy; a stent was placed through the choledochotomy before its closure. The selective common bile duct cannulation rate at the first endoscopic retrograde cholangio-pancreatography, was 98%. A second endoscopic retrograde cholangio-pancreatography was required in 15% of patients. The only complication of all the endoscopic procedures was a single case of mild cholangitis; there were no cases of pancreatitis. A treatment option open to all surgeons for non-jaundiced patients with known choledocholithiasis or choledocholithiasis found at operative cholangiogram, is the transcystic stenting of the sphincter of Oddi at the time of laparoscopic cholecystectomy. At a subsequent sitting, the common bile duct can be safely cleared endoscopically using a sphincterotomy facilitated by the stent.

Retained gallbladder/cystic duct remnant calculi as a cause of postcholecystectomy pain.

Pain following cholecystectomy can pose a diagnostic and therapeutic dilemma. We reviewed our experience with calculi retained in gallbladder and cystic duct remnants that present with recurrent biliary symptoms. Over the last 6 years, seven patients were referred to us for the evaluation of recurrent biliary colic or jaundice. There were four men and three women ranging in age from 35 to 70 years. All seven had biliary pain similar to the symptoms that precede cholecystectomy; two of them also had also associated jaundice and one had pancreatitis. The time from cholecystectomy to onset of symptoms ranged from 14 months to 20 years (median, 8.5 Years). Four had undergone laparoscopic cholecystectomy and three had had an open cholecystectomy; none had an operative cholangiogram. Five of seven underwent diagnostic endoscopic retrograde cholangiography (ERC), which revealed obvious filling defects in the cystic duct or gallbladder remnant. The final patient was diagnosed by laparoscopic ultrasound after eight negative radiographic studies. Four patients underwent laparotomy and resection of a retained gallbladder and/or cystic duct. Two patients were treated with extracorporeal shock-wave lithotripsy (ESWL); one of them also required endoscopic biliary holmium laser lithotripsy. One patient underwent successful repeat laparoscopic cholecystectomy. There were no treatment-related complications. At a median follow-up of 11.5 months, all have achieved complete stone clearance and are asymptomatic. Retained gallbladder and cystic duct calculi can be a source of recurrent biliary pain, and a heightened suspicion may be required to make the diagnosis. This entity can be prevented by accurate identification of the gallbladder-cystic duct junction at cholecystectomy and by routine use of cholangiography. A variety of therapeutic options can be employed to obtain a successful outcome.

Selective operative cholangiography and Perioperative endoscopic retrograde cholangiopancreatography (ERCP) during laparoscopic cholecystectomy: a viable option for choledocholithiasis.

Most common bile duct (CBD) stones can now be removed by minimally invasive methods using pre- or postoperative endoscopic sphincterotomy. A few centers explore the bile duct laparoscopically, but not every hospital has access to the equipment for magnetic resonance (MR) cholangiopancreatography to diagnose ductal stones. This study shows the results of an alternative management option. We did a retrospective review of perioperative endoscopic retrograde cholangiopancreatographies (ERCPs) and sphincterotomies that were performed on patients in whom choledocholithiasis had been revealed on operative cholangiogram. Thirteen patients underwent perioperative ERCP. Nine had successful duct clearance, three had failure to cannulate, and one was converted to an open procedure due to an anatomical problem. The combined median operating time for both procedures was 75 min and hospital stay was 2.5 days. No pancreatitis was reported. Selective operative cholangiography and perioperative ERCP during laparoscopic cholecystectomy is a viable option for the simultaneous management of CBD and gallbladder stones. Moreover, it helps to avoid unnecessary normal ERCP.

Laparoscopic surgery and the common bile duct.

Many biliary tract surgeons have now reached a level of sophistication with laparoscopic cholecystectomy that they are now able to deal with the common bile duct at the same time. Preoperative endoscopic cholangiography can be reserved for cases where choledocholithiasis has a high degree of probability. This has served to decrease the number of negative studies. The surgeon has five choices regarding stones confirmed by operative cholangiography during laparoscopic cholecystectomy: (1) do nothing, hoping the stones will pass spontaneously or that a postoperative sphincterotomy with stone extraction will be successful; (2) perform a transcystic laparoscopic common bile duct exploration (best for stones less than 1 cm and distal to the cystic duct); (3) perform a laparoscopic common bile duct exploration by choledochotomy (best for large stones in patients with common bile ducts greater than 1 cm. It is also the preferred approach with stones proximal to the insertion of the cystic duct.); (4) perform an intraoperative sphincterotomy with stone extraction, either retrograde or antegrade (this approach has some proponents but has not gained popularity among the majority of surgeons); and (5) place a double lumen catheter through the cystic duct with a proximal lumen in the common bile duct and the distal lumen in the duodenum. This can be used for serial postoperative cholangiography to confirm spontaneous stone passage or falsely positive operative cholangiograms. It is useful in situations when laparoscopic common bile duct exploration equipment or surgeon expertise is not available. If stones persist, a guidewire can be introduced through the distal lumen of the catheter for a guidewire-assisted sphincterotomy. Other CBD interventions that have been reported include laparoscopic biliary bypass and resection of choledochal cysts. Malignant lesions should not be approached by a laparoscopic method except in unusual circumstances.

Hepatic technetium-99m-mebrofenin iminodiacetate scans and serum gamma-glutamyl transpeptidase levels interpreted in series to differentiate between extrahepatic biliary atresia and neonatal hepatitis.

Hepatic technetium-99m-mebrofenin iminodiacetate (99mTc-mebrofenin IDA) scans and serum gamma-glutamyl transpeptidase (GGTP) have high sensitivity for extrahepatic biliary atresia (EHBA). This study was based on the hypothesis that the interpretation of results of 99mTc-mebrofenin IDA scans and serum GGTP levels in series would result in a reduction of the false positivity observed with these tests individually. The aetiology of neonatal cholestasis in 132 study patients was: 25% (33/132) EHBA, 45.5% (60/132) neonatal hepatitis (NH) with an identifiable cause and 19.7% (26/132) idiopathic NH. Of the various clinical, biochemical and imaging parameters that were significantly different between patient groups, sensitivity for EHBA was: serum GGTP > or = 150 IU l(-1) (100%), 99mTc-mebrofenin IDA scans (100%), pale stools (82.8%) and total serum bilirubin > or = 12 mg dl(-1) (66%). However, specificity ranged from 48.5 to 79%. Of the 63 patients who had non-excreting IDA scans, operative cholangiograms could be avoided on the basis of a specific aetiological diagnosis of NH, made concurrently, in only 9 infants. The rest (54) underwent operative cholangiograms; 21 (39%) of these had patent biliary trees and therefore underwent the procedure unnecessarily. If serum GGTP (< 150 IU l(-1)) had been used as a screen after IDA scanning in these 54 patients, operative cholangiograms could have been avoided in another 12 patients and thereafter only 9/42 (21%) of the operative cholangiograms would have been considered unnecessary. A diagnostic algorithm is proposed wherein serum GGTP level (at a cut-off level that maintains 100% sensitivity for EHBA) is used in series with non-excreting 99mTc-mebrofenin IDA scans (for patients with no specific aetiological label). This strategy reduces the false positivity of individual tests.

Hepatic technetium‐99m‐mebrofenin iminodiacetate scans and serum γ‐glutamyl transpeptidase levels interpreted in series to differentiate between extrahepatic biliary atresia and neonatal hepatitis

Hepatic technetium‐99m‐mebrofenin iminodiacetate (99mTc‐mebrofenin IDA) scans and serum γ‐glutamyl transpeptidase (GGTP) have high sensitivity for extrahepatic biliary atresia (EHBA). This study was based on the hypothesis that the interpretation of results of 99mTc‐mebrofenin IDA scans and serum GGTP levels in series would result in a reduction of the false positivity observed with these tests individually. The aetiology of neonatal cholestasis in 132 study patients was: 25% (33/132) EHBA, 45.5% (60/132) neonatal hepatitis (NH) with an identifiable cause and 19.7% (26/132) idiopathic NH. Of the various clinical, biochemical and imaging parameters that were significantly different between patient groups, sensitivity for EHBA was: serum GGTP ≥ 150 IU 1−1(100%), 99mTc‐mebrofenin IDA scans (100%), pale stools (82.8%) and total serum bilirubin ≥ 12mg d1−1 (66%). However, specificity ranged from 48.5 to 79%. Of the 63 patients who had non‐excreting IDA scans, operative cholangiograms could be avoided on the basis of a specific aetiological diagnosis of NH, made concurrently, in only 9 infants. The rest (54) underwent operative cholangiograms; 21 (39%) of these had patent biliary trees and therefore underwent the procedure unnecessarily. If serum GGTP (&lt;150 IU 1−1) had been used as a screen after IDA scanning in these 54 patients, operative cholangiograms could have been avoided in another 12 patients and thereafter only 9/42 (21%) of the operative cholangiograms would have been considered unnecessary. Conclusion: A diagnostic algorithm is proposed wherein serum GGTP level (at a cut‐off level that maintains 100% sensitivity for EHBA) is used in series with non‐excreting 99mTc‐mebrofenin IDA scans (for patients with no specific aetiological label). This strategy reduces the false positivity of individual tests.

Erratum to: Evaluation of operative cholangiography in 2043 patients undergoing laparoscopic cholecystectomy: a case for the selective operative cholangiogram

BACKGROUND There is still some controversy over whether to use laparoscopic operative cholangiograms routinely (RLOC) or selectively (SLOC). Due to their high cost as well as other issues, in March 1997 we converted from RLOC to SLOC. The purpose of this study was to validate that decision. METHODS The results of 2043 laparoscopic cholecystectomies (LC) were compiled and analyzed. The results of RLOC in 1556 patients undergoing LC from March 1990 through February 1997 were compared to the results of SLOC in 16 patients undergoing LC from March 1989 through February 1990 and 471 patients undergoing LC from March 1997 through December 1998. The literature was reviewed and data were compiled. Reasons that are typically given for operative cholangiograms (OC) were collected and scrutinized. Finally, cost surveys for RLOC and related procedures were obtained. RESULTS Overall, laparoscopic operative cholangiogram (LOC) was attempted in 1661 patients and was successful in 1656 cases (99.7%). Bile duct stones (BDS) were evident in 166 patients. Laparoscopic bile duct exploration (LBDE) was attempted in all cases. None were referred for preoperative endoscopic retrograde cholangiopancreatography (ERCP). In the RLOC group, evidence of BDS was observed in 136 patients (9%). Forty-two were unsuspected (2.8%) and five were false positive (0.3%). In a collection of other RLOC studies, the average rate of unsuspected BDS was 2.9%, while the average rate of false positive cholangiograms was 1.6%. In the SLOC group, LOC was indicated in 139 of 487 patients (28.6%). None of the patients who did not have a LOC developed symptomatic residual BDS in < or = 11 years of follow-up. In a large collection of other SLOC studies, the rate of symptomatic residual BDS was 0.3%. A cost survey in February 1997 revealed that the average minimum global charge (MGC) for an OC was $1283.21; for a transcystic duct LBDE it was $1055.10, and for a transcholedochal LBDE it was $3263.61 [corrected]. The MGC for an ERCP with papillotomy was $4303.00. Thus, to avoid one patient with symptomatic residual BDS, 354 unnecessary procedures (333 RLOC, 18 LBDE, and three postoperative ERCP) costing $473,927.52 would be performed. There were no false negatives, bile duct injuries, or other complications attributable to RLOC or SLOC. CONCLUSIONS The increased morbidity and cost of RLOC to avoid symptomatic residual BDS is not justified. All other reasons given for RLOC are either flawed or indicate that the procedure can be safely employed selectively. SLOC is an effective method of verifying suspected BDS and is safer and less expensive than RLOC.

Cystic dilatation of the common bile duct in adults: report of five cases and review of literature

The authors report five cases of cystic dilatation of the common bile duct Type I (Todani’s classification) in adults patients, in Division of General Surgery of a University Hospital, treated over a- 25-year- period from 1974 to 1999, among 16.057 operations, and not previously published. Diagnosis was obtained by operative cholangiogram (OC) in the first case, percutaneous transhepatic cholangiogram on the second one (PTHC) and by ultrasonography (US), endoscopic retrograde cholangiopancreatography (ERCP), and operative cholangiogram (OC), respectively, on the last three cases. The second patient had an adenocarcinoma arising in the cystic wall associated with peritoneal metastasis. The first two cases were treated by internal drainage and the last three by excision of the cysts and bilioenteric anastomoses. Classification, incidence, etiology, diagnosis, malignization and surgical treatment of biliary cystic disease (BCD) were revised, with the conclusion that resection must be the preferable method of treatment, when possible, especially due to the concern of malignization.

Neonatal jaundice: The role of laparoscopy

Background: When managing neonatal jaundice, despite continual improvement of diagnostic tests and increasing knowledge regarding its pathogenesis, there is no single test or imaging modality that can reliably define biliary atresia. Early diagnosis is essential for a better surgical outcome. In many situations, mini-laparotomy and operative cholangiography may be needed to settle the definitive diagnosis, with the risk of having negative exploration in those high-risk patients with medical etiology. The use of laparoscopy may help in avoiding unnecessary exploration for such group of patients. Methods: Thirty-three patients aged between 1 and 4 months with conjugated hyperbilirubinemia were the subject for this study. All had a HIDA scan result suggestive of biliary atresia. They underwent a diagnostic laparoscopy before surgical exploration. When the gallbladder was not visualized we proceeded to laparotomy. In patients with a good size gallbladder visualized at laparoscopy, a laparoscopic-guided cholangiogram was then performed, and laparoscopic liver biopsy done for those who had patent biliary tree. Results: Two groups of patients were identified: the first group (21 patients) showed small atretic gallbladder; 18 patients had biliary atresia with complete intra- and extrahepatic atresia; these patients underwent a Kasai hepatic-portoenterostomy. Two patients showed a patent gallbladder and common bile duct with atresia of the common hepatic and intrahepatic ducts, and they underwent a portocholecystostomy. The last patient showed left-sided gallbladder arising from the left lobe of the liver that was missed during laparoscopy, and operative cholangiogram showed hypoplastic biliary ducts. The second group included 12 patients with good-sized gallbladder, and laparoscopic-guided percutaneous cholangiogram showed normal communicating patent biliary system, hypoplastic in 2, and they underwent laparoscopic liver biopsy. No mortality related to the laparoscopic procedure was encountered in this series, and one patient with hypoplastic gallbladder had adhesive intestinal obstruction on the fifth day after laparoscopy necessitating exploration. Conclusion: Laparoscopy with laparoscopic-guided cholangiography may be a very useful tool used in accurately diagnosing infants with conjugated hyperbilirubinemia, and in avoiding unnecessary laparotomies performed on these critical babies. J Pediatr Surg 35:1706-1709. Copyright © 2000 by W.B. Saunders Company.

Common bile duct stone characteristics: correlation with treatment choice during laparoscopic cholecystectomy

Determining the most appropriate management approach for patients with unsuspected choledocholithiasis may be difficult because of the subjective nature of this decision in the absence of clinical data. Treatment of incidental choledocholithiasis during laparoscopic cholecystectomy was reviewed during a 25-month period. Operative cholangiograms were analyzed retrospectively to determine if associations exist between common bile duct stone characteristics and the intraoperative treatment selected by the operating surgeon. Cholangiographic data included quantification of common bile duct stones, stone dimension, position, and presence of radiopaque contrast flow into the duodenum. Two hundred thirty-six laparoscopic cholecystectomy patients underwent operative cholangiography; 25 (11%) demonstrated choledocholithiasis. Seven patients were converted to open common bile duct exploration (group I), 16 patients were referred for postoperative endoscopic retrograde cholangiopancreatography (group II), and two patients were observed (group III). Evaluation of the operative cholangiograms revealed multiple common bile duct stones (1) in 86% (6 of 7) in group I, 25% (4 of 16) in group II, and none in group III. All patients in group I had at least one stone larger than 5 ml in greatest diameter, whereas only 33% (6 of 18) in groups II and III combined had stones larger than 5 ml. Group I had significantly ( P = 0.027) more representation of delayed or no contrast flow during operative cholangiography compared to groups II and III. The intraoperative decision to proceed with laparoscopic cholecystectomy and rely on postoperative endoscopic retrograde cholangiopancreatography for stone retrieval rather than open common bile duct exploration was associated with (1) a single common bile duct stone, less than or equal to 5 ml in size on operative cholangiogram and (2) normal contrast flow into the duodenum. Open common bile duct exploration was more frequently associated with the demonstration of multiple or large (5 ml) stones. A periampullary stone did not discriminate among treatment choices.

Mirizzi, his syndrome and the operative cholangiogram

Mirizzi, his syndrome and the operative cholangiogram

Laparoscopic Cholecystectomy in Situs Viscerum Inversus Totalis

A 45-year-old female Saudi with a known diagnosis of situs viscerum inversus and chronic myeloid leukemia, for which she had completed her chemotherapy course, presented to the medical services with recurrent attack of left upper quadrant abdominal pain and vomiting, with no history of jaundice. All her hematological and biochemical profiles were reported to be normal. Her radiological investigations confirmed situs viscerum inversus totalis with thick-walled gallbladder, containing multiple stones and normal caliber common bile duct (CBD). After clearly defining the anatomy of the biliary tract by operative cholangiogram and careful dissection, cholecystectomy was carried out as a mirror image of the usual laparoscopic cholecystectomy done for the right side of the gallbladder (Figure 1). Intraoperative cholangiogram showed filling defects in the distal part of CBD (Figure 2). An endoscopic retrograde cholangiopancreatography (ERCP) performed in the immediate postoperative period showed no stones, but histopathology confirmed the diagnosis of chronic cholecystitis.

Bile Peritonitis Due To Choledochal Cyst Perforation In Infants

저자들은 1983년 1월부터 1998년 1월까지 총담관낭 환아 28례 중 4례(14.2 %)에서 자연적으로 발생한 총담관낭 천공에의한 담즙성 복막염을 경험하였고 이 중 3례에서 일차적인 낭종 절제와 간관공장 문합술을 시행하였으며 이 모든 예에서 합병증 없이 회복되었기에 문헌 고찰과 함께 보고하는 바이다. 총담관낭 천공에의한 답즙성 복막염치료는 일차적 낭종 절제와 간관 공장 문합술이 안전하고 효과적인 방법이라고 생각된다. 【Choledochal cyst is rare in the western countries, but common in oriental countries. Complicatioins include ascending cholangitis, recurrent pancreatities, progressive biliary cirrhosis, portal hypertension, stone formation and later malignant transformation. Bile peritonitis secondary to rupture is one of the rarest complications, with an incidence of 1.8 % to 18 %. The anomalous arrangement of the pancreatobiliary ductal system with a long common channel may cause inflammation leading to perforation of the cyst. The authors found 4 cases (14.2 %) of bile peritonitis among 28 cases of choledochal cyst treated from Jan. 1983 to Jan. 1998. The patients ages ranged from 6 months to 3 years and three were female. The perforation sites were located on the common bile duct at its junction with the cystic duct in 2 cases, the distal cyst wall in 1 case and the left hepatic duct at its junction with cyst in 1 case. The types of choledochal cysts by Todani's classification were Type IVa in 3 cases and type I in 1 case. By the new Komi's classification utilizing operative cholangiogram there were 2 cases of Type Ia, 1 case of type IIb and 1 case of type III. One stage cyst excision and hepaticojejunostomy(Roux-en Y type) was done in 3 cases, and two staged operation in 1 case. All patients had an uneventful course postoperatively. The average day of discharge was 9.8th postoperatively. In conclusion, primary excision of the choledochal cyst and biliary reconstruction is a safe and effective treatment of ruptured choledochal cyst in infants.】

Acquired choledochal cyst from anomalous pancreatobiliary duct union

The high incidence of anomalous pancreatobiliary duct union (APBDU) in children who have a choledochal cyst has been well documented. Additionally, cylindrical dilatation of the bile duct has been reproduced in animal models by anastomosing the pancreatic duct to the bile duct. In recent years, APBDU has been considered a possible etiologic factor in the formation of a choledochal cyst. The authors observed a progressive cylindrical dilatation of the common bile duct in a 6-year-old boy over an 18-month period. An operative cholangiogram showed a type I c choledochal cyst and a type B APBDU (Todani classification). This clinical experience suggests that a normal common bile duct in children can be progressively dilated and become an acquired choledochal cyst arising as a complication of the preexisting APBDU.

Biliary atresia — The current management

Despite extensive research, controversies still exist regarding the etiology, pathology and management of biliary atresia. It is now thought to be a progressive panductal inflammatory obliterative process and not a developmental anomaly. The histologic changes are indistinguishable from neonatal hepatitis but some changes have prognostic significance. The clinical presentation is that of infantile obstructive cholangiopathy-waxing and waning icterus, clay coloured stools and high coloured urine from early neonatal period. The diagnosis is suggested by the absence of intestinal excretion on HIDA scan and confirmed on operative cholangiogram. Of utmost importance towards the final prognosis is early detection, prompt confirmation and surgical treatment before 2 months of age. Even with early treatment the result of bilioenteric drainage procedures have been discouraging in the long term. Portoenterostomy (PE) done in older children has been largely unsuccessful all over the world. The poor results of PE prompted the search for alternative treatment and liver transplantation (LT) has emerged as a viable treatment option both as a primary procedure and after failed PE. Although the technical know-how and infrastructure are available, LT in children has still not been done in India because of various economic and social constraints. It is hoped that all physicians and surgeons dealing with such patients would also consider this treatment modality.

OPERATIVE CHOLANGIOGRAPHY IN THE LAPAROSCOPIC ERA: A RETROSPECTIVE REVIEW OF THE QUALITY AND INTERPRETATION OF THIS INVESTIGATION

Operative cholangiograms during the year of introduction of laparoscopic cholecystectomy were reviewed to examine their quality and interpretation. 149 operative cholangiogram films (34 open and 115 laparoscopic) were reviewed retrospectively by a panel and scored for their ability to demonstrate biliary anatomy and detect bile duct stones. Cholangiography performed by the cystic duct was of similar quality, whether performed laparoscopically or open. Cholangiography via the cystic duct (conventional films) produces superior results for both anatomical delineation and detection of choledocholithiasis (80% adequate) than cholangiography performed by direct gallbladder puncture (29-35% adequate). There is no clear evidence to suggest that an intra-operative specialist radiological review of cholangiograms performed by the cystic duct would improve the detection of bile duct stones.

Operative Cholangiogram at Laparoscopic Cholecystectomy

In the open cholecystectomy era, the established principle for treating biliary calculi was to perform intraoperative cholangiography to diagnose and treat the concomitant common duct stone at the time of cholecystectomy. To reduce unnecessary cholangiograms, a selective cholangiogram policy based on preoperative and operative criteria was sometimes used. Although both time and cost were saved, a 4% to 10% chance of missing unsuspected common duct stones was associated with this policy. The introduction of laparoscopic cholecystectomy in Australia initially led to an abandonment of the principles of biliary surgery. Rates of intraoperative cholangiography declined as stones were either ignored or diagnosed preoperatively by endoscopic retrograde cholangiopancreatography and/or intravenous cholangiography. When stones were identified, they were treated by preoperative endoscopic sphincterotomy. This decline in cholangiography was associated with a twofold to fourfold rise in serious bile duct injury as well as a delay in its diagnosis. Over the past two years, as laparoscopic cholecystectomy has become established in Australia, practice is returning to the standards of the open cholecystectomy era. Intraoperative cholangiography rates have been increasing along with the proportion of patients having their duct stones removed laparoscopically. To succeed, this practice depends on the use of fluoroscopic cholangiography, which should be the standard of care in the laparoscopic era. With laparoscopic cholecystectomy, intraoperative cholangiography is no longer optional, but mandatory. Not only does it reduce the incidence and severity of bile duct injury, but it also trains the surgeon to develop techniques of laparoscopic duct exploration.

Operative Cholangiogram at Laparoscopic Cholecystectomy.

In the open cholecystectomy era, the established principle for treating biliary calculi was to perform intraoperative cholangiography to diagnose and treat the concomitant common duct stone at the time of cholecystectomy. To reduce unnecessary cholangiograms, a selective cholangiogram policy based on preoperative and operative criteria was sometimes used. Although both time and cost were saved, a 4% to 10% chance of missing unsuspected common duct stones was associated with this policy. The introduction of laparoscopic cholecystectomy in Australia initially led to an abandonment of the principles of biliary surgery. Rates of intraoperative cholangiography declined as stones were either ignored or diagnosed preoperatively by endoscopic retrograde cholangiopancreatography and/or intravenous cholangiography. When stones were identified, they were treated by preoperative endoscopic sphincterotomy. This decline in cholangiography was associated with a twofold to fourfold rise in serious bile duct injury as well as a delay in its diagnosis. Over the past two years, as laparoscopic cholecystectomy has become established in Australia, practice is returning to the standards of the open cholecystectomy era. Intraoperative cholangiography rates have been increasing along with the proportion of patients having their duct stones removed laparoscopically. To succeed, this practice depends on the use of fluoroscopic cholangiography, which should be the standard of care in the laparoscopic era. With laparoscopic cholecystectomy, intraoperative cholangiography is no longer optional, but mandatory. Not only does it reduce the incidence and severity of bile duct injury, but it also trains the surgeon to develop techniques of laparoscopic duct exploration.