Routine Intraoperative Cholangiography Research Articles

Radiation exposure during laparoscopic cholecystectomy with routine intraoperative cholangiography

For many years, intraoperative cholangiography during cholecystectomy to aid definition of the biliary anatomy and to detect choledocholithiasis has been advocated. Although radiation exposure in fluoroscopic procedures is a concern, few available data exist regarding the radiation exposure incurred during intraoperative cholangiography. This study aimed to determine the average radiation exposure sustained during this procedure. Radiation dose data were recorded between 5 September 2007 and 21 July 2008 for 108 consecutive patients undergoing laparoscopic cholecystectomy with intraoperative cholangiography. Dose area product values were used to calculate the entrance skin dose, an indicator of potential skin damage, and the effective dose, an indicator of long-term cancer risk, for each patient. The median age of the 108 patients (67% females) included in the data analysis was 51 years (range, 17-87 years). The mean entrance skin dose during intraoperative cholangiography was 0.0069 +/- 0.0066 Gy, and the mean effective dose was 0.18 +/- 0.17 mSv. No results exceeded the threshold of 2 Gy for skin damage, and the lifetime risk for the development of new cancer due to intraoperative cholangiography was less than 0.001%. Radiation doses administered during intraoperative cholangiography are safe and do not represent a contraindication to this procedure.

Routine intra-operative cholangiography for safe laparoscopic cholecystectomy and single stage laparoscopic choledocholithotomy

Background: While laparoscopic cholecystectomy is widely accepted for therapy of cholecystolithiasis, controversy still exists concerning the routine use of intra-operative cholangiography (IOC) during laparoscopic cholecystectomy (LC) and its role in management of common bile duct stones at the same procedure whether it is discovered accidentally or expected as a single stage procedure if respective experience is available. Methods: During laparoscopic cholecystectomy a cholangiography via the cystic duct is routinely performed. If bile duct stones are detected they are retrieved via the cystic duct or via incision of the common bile duct by insertion of a Fogarty catheter or Dormia basket. Exclusion criteria against simultaneous laparoscopic management include suspicious of malignancy, severe pancreatitis or cholangitis. Results: From July 2005 to June 2007, 172 patients primarily underwent laparoscopic cholecystectomy at Landeskrankenhaus Bregenz (170 cases) & at Ain Shams Specialized Hospital (2 cases), IOC was successful in 157 (91.2%). Bile duct stones were found in 26 patients (15.1%), dilated ducts without stones in 6 patients (3.4%), and anatomic variations in 3 patients (1.7%). Retrieval was performed via cystic duct and common bile duct in 15 and 11 cases respectively with complete removal. There were 2 (1.1%) minor injuries of the bile duct, which were identified with IOC and repaired at the time of cholecystectomy without any consequences for the patients, while in 3 patients (1.7%) Cholecystography was done for difficult identification of cystic duct and acute inflamed gall bladder. Conclusion: Routine intra-operative cholangiography is feasible, provides valuable information about the anatomy of the biliary tract and might aid in the prevention of bile duct injuries, thereby improving the safety of laparoscopic cholecystectomy. Also, when correct indications and surgical expertise are available, simultaneous laparoscopic management of common bile duct stones represent a safe and minimally invasive alternative to a two stage procedure approach.

LONG‐TERM OUTCOMES AFTER LAPAROSCOPIC BILE DUCT EXPLORATION: A 5‐YEAR FOLLOW UP OF 150 CONSECUTIVE PATIENTS

The treatment of common bile duct stones discovered at routine intraoperative cholangiography includes postoperative endoscopic retrograde cholangiography or intraoperative laparoscopic common bile duct exploration. Given the equivalence of short-term outcome data for these two techniques, the choice of one over the other may be influenced by long-term follow-up data. We aimed to establish the long-term outcomes following laparoscopic common bile duct exploration and compare this with endoscopic retrograde cholangiography. One hundred and fifty consecutive patients underwent laparoscopic common bile duct exploration between March 1998 and March 2006 carried out by a single surgeon. All were prospectively studied for 1 month followed by a late-term phone questionnaire ascertaining the prevalence of adverse symptoms. Patients presented with a standardized series of questions, with reports of symptoms corroborated by review of medical records. In 150 patients, operations included laparoscopic transcystic exploration (135), choledochotomy (10) and choledochoduodenostomy (2). At long-term follow up (mean 63 months), 116 (77.3%) patients were traceable, with 24 (20.7%) reporting an episode of pain and 18 (15.5%) had more than a single episode of pain. There was no long-term evidence of cholangitis, stricture or pancreatitis identified in any patient. Laparoscopic bile duct exploration appears not to increase the incidence of long-term adverse sequelae beyond the reported prevalence of postcholecystectomy symptoms. There was no incidence of bile duct stricture, cholangitis or pancreatitis. It is a safe procedure, which obviates the need and expense of preoperative or postoperative endoscopic retrograde cholangiography in most instances.

Incidence of residual choledocholithiasis detected by intraoperative cholangiography at the time of laparoscopic cholecystectomy in patients having undergone preoperative ERCP

The purpose of this study is to determine the incidence of residual common bile duct (CBD) stones after preoperative ERCP for choledocholithiasis and to evaluate the utility of routine intraoperative cholangiography (IOC) during laparoscopic cholecystectomy (LC) in this patient population. All patients who underwent preoperative ERCP and interval LC with IOC from 5/96 to 12/05 were reviewed under an Institutional Review Board (IRB)-approved protocol. Data collected included all radiologic imaging, laboratory values, clinical and pathologic diagnoses, and results of preoperative ERCP and LC with IOC. Standard statistical analyses were used with significance set at p < 0.05. A total of 227 patients (male:female 72:155, mean age 51.9 years) underwent preoperative ERCP for suspicion of choledocholithiasis. One hundred and eighteen patients were found to have CBD stones on preoperative ERCP, and of these, 22 had choledocholithiasis diagnosed on IOC during LC. However, two patients had residual stones on completion cholangiogram after ERCP and were considered to have retained stones. Therefore, 20 patients overall were diagnosed with either interval passage of stones into the CBD or a false-negative preoperative ERCP. In the 109 patients without CBD stones on preoperative ERCP, nine patients had CBD stones on IOC during LC, an 8.3% incidence of interval passage of stones or false-negative preoperative ERCP. In both groups, there was no correlation (p > 0.05) between an increased incidence of CBD stones on IOC and a longer time interval between ERCP and LC, performance of sphincterotomy, incidence of cystic duct stones, or pathologic diagnosis of cholelithiasis. The overall incidence of retained or newly passed CBD stones on IOC during LC after a preoperative ERCP is 12.9%. Although the natural history of residual CBD stones after preoperative ERCP is not known, the routine use of IOC should be considered in patients with CBD stones on preoperative ERCP undergoing an interval LC.

Routine Intra-Operative Cholangiography for Safe Laparoscopic Cholecystectomy and Single Stage Laparoscopic Choledocholithotomy

Background: While laparoscopic cholecystectomy is widely accepted for therapy of cholecystolithiasis, controversy still exists concerning the routine use of intra-operative cholangiography (IOC) during laparoscopic cholecystectomy (LC) and its role in management of common bile duct stones at the same procedure whether it is discovered accidentally or expected as a single stage procedure if respective experience is available. Methods: During laparoscopic cholecystectomy a cholangiography via the cystic duct is routinely performed. If bile duct stones are detected they are retrieved via the cystic duct or via incision of the common bile duct by insertion of a Fogarty catheter or Dormia basket. Exclusion criteria against simultaneous laparoscopic management include suspicious of malignancy, severe pancreatitis or cholangitis. Results: From July 2005 to June 2007, 172 patients primarily underwent laparoscopic cholecystectomy at Landeskrankenhaus Bregenz (170 cases) & at Ain Shams Specialized Hospital (2 cases), IOC was successful in 157 (91.2%). Bile duct stones were found in 26 patients (15.1%), dilated ducts without stones in 6 patients (3.4%), and anatomic variations in 3 patients (1.7%). Retrieval was performed via cystic duct and common bile duct in 15 and 11 cases respectively with complete removal. There were 2 (1.1%) minor injuries of the bile duct, which were identified with IOC and repaired at the time of cholecystectomy without any consequences for the patients, while in 3 patients (1.7%) Cholecystography was done for difficult identification of cystic duct and acute inflamed gall bladder. Conclusion: Routine intra-operative cholangiography is feasible, provides valuable information about the anatomy of the biliary tract and might aid in the prevention of bile duct injuries, thereby improving the safety of laparoscopic cholecystectomy. Also, when correct indications and surgical expertise are available, simultaneous laparoscopic management of common bile duct stones represent a safe and minimally invasive alternative to a two stage procedure approach.

Kystes hydatiques du lobe de Spiegel : particularités cliniques et thérapeutiques

Hydatid cysts of the spigelian lobe, that is, segment I of the liver, are rare. We analyzed their clinical and therapeutic particularities. We conducted a retrospective search for the hydatid cysts of the liver treated surgically in our department from January 1, 1994, through December 31, 2005. Cases were identified and confirmed with the following investigatory techniques: routine abdominal ultrasonography, abdominal computed tomography recommended by the ultrasound operator when a cyst was discovered in segment I, routine intraoperative cholangiography, and three separate serological techniques: electrosyneresis, hemaglutination and ELISA (enzyme-linked-immunosorbent assay)(the latter two being quantitative). The cystic cavity was treated with hypertonic serum. Several surgeons performed different combinations of the following techniques: deroofing, sometimes with omentoplasty, simple drainage, and subtotal pericystectomy. We treated 44 hydatid cysts of segment I surgically in 10 men and 34 women, with a mean age of 40.6 years. Ten patients (22.7%) had a history of hydatid cysts. Symptoms or complications were noted at admission in 45% of cases. Only five cases (11.4%) required emergency surgery. Surgical examination confirmed vascular compression in 17 cases (38.6%) and a biliary fistula in 17 cases (38.6%). Surgical treatment consisted of deroofing in 37 cases (84,1%), with omentoplasty in 23 (54%), subtotal pericystectomy in 3 and simple drainage in 4. Large biliary fistulas (> 5 mm) were treated with bipolar drainage in 2 cases and internal transfistulary drainage in 3. Some hemorrhaging occurred during surgery in 5 cases, and one cyst ruptured in the peritoneal cavity. Albendazole was prescribed postoperatively for nine patients. There was one intraoperative death, secondary to hemorrhage resulting from erosion of the inferior vena cava. Morbidity was 25%. After a mean follow-up of 32 months, five patients had recurrences in the liver but outside segment I. Segment I of the liver is a rare site for hydatid disease, and a site where vascular and biliary complications are frequent. Its management requires a good knowledge of the vascular anatomy of the liver and wide experience of hydatid cyst surgery and especially of simple surgical procedures.

Preoperative determinants of common bile duct stones during laparoscopic cholecystectomy

The aim of this study is to determine whether there are any clinical or biochemical predictors of common bile duct (CBD) stones in patients undergoing laparoscopic cholecystectomy. A prospective database of nearly 1000 laparoscopic cholecystectomies performed under the care of a single surgeon with a standardised technique between 1999 and 2006, was analysed. Clinical presentation, ultrasound and immediate preoperative biochemical results as well as the operative cholangiogram findings were reviewed. Routine cholangiography was attempted in most patients and the primary outcome variable was the detection of bile duct stones. The data was analysed using chi-squared test for categorical variables. The significant variables on univariate analysis were further characterised to identify the independent predictors of bile duct stones using a logistic regression model (significance p < 0.05). A total of 757 of 988 patients (77%) underwent cholangiography. Male-to-female ratio was 1 : 3 with a median age of 54 years (range: 17-93). Ten per cent of patients had bile duct stones identified on cholangiography. On univariate analysis, jaundice (p = 0.019), cholangitis (p < 0.001), alanine transaminase > 100 (p = 0.024), alkaline phosphatase (ALP) > 350 (p < 0.001) and CBD > 10 mm (p = 0.01) were significant markers for predicting bile duct stones. Bilirubin > 30 (x2 normal) was found not to be significant (p = 0.145). On a logistic regression model, ALP > 350 and/or cholangitis were found to be independent predictive factors of CBD stones (odds ratio 6.1). If a policy of routine intra-operative cholangiography is not adopted, a history of cholangitis or a raised ALP immediately preoperatively should lead to a high suspicion of CBD stones.

Costs and Utilization of Intraoperative Cholangiography

BackgroundRoutine intraoperative cholangiography (IOC) has been advocated as a viable strategy to reduce common bile duct injury (CDI) during cholecystectomy. This is predicated, in part, on the low cost of IOC, making it a cost-effective preventive strategy. Using billed hospital charges as a proxy for costs, we sought to estimate costs associated with the performance of IOC. MethodsThe 2001 National Inpatient Survey (NIS) database was assessed for IOC utilization and associated charges. Average charges for hospital admission where the primary procedure was laparoscopic cholecystectomy were compared for those associated with and without the performance of IOC. ResultsEighteen percent of cholecystectomies were performed in facilities that never perform IOC. Routine IOC (defined as >75% of cholecystectomies performed in any one hospital having a concomitant IOC) was performed in only 11% of hospitals. In the remaining 71% of hospitals, selective IOC was performed. IOCs were associated with US $706–739 in additional hospital charges when performed in conjunction with laparoscopic cholecystectomy. We project a cost of US $371,356 to prevent a single bile duct injury by using routine cholangiography. ConclusionWe conclude that only a minority of hospitals performs cholecystectomies with routine IOC. Because of the significant amount of hospital charges attributable to IOC, routine IOC is not cost-effective as a preventative measure against bile duct injury during cholecystectomy.

Intraoperative cholangiography facilitates simple transcystic clearance of ductal stones in units without expertise for laparoscopic bile duct surgery

In the absence of facilities and expertise for laparoscopic bile duct exploration (LBDE), most patients with suspected ductal calculi undergo preoperative endoscopic duct clearance. Intraoperative cholangiography (IOC) is not performed at the subsequent laparoscopic cholecystectomy. This study aimed to investigate the rate of successful duct clearance after simple transcystic manipulations. This prospective study investigated 1,408 patients over 13 years in a unit practicing single-session management of biliary calculi. For the great majority, IOC was attempted. Abnormalities were dealt with by flushing of the duct, glucagon injection, Dormia basket trawling, choledochoscopic transcystic exploration, or choledochotomy. Of 1,056 cholangiograms performed (75%), 287 were abnormal (27.2%). Surgical trainees, operating under supervision, successfully performed 24% of all cholangiograms. Of 396 patients admitted with biliary emergencies, 94.1% had abnormal cholangiograms. Of the 287 patients with abnormal IOCs, 9.4% required no intervention, 18% were clear after glucagon and flushing, and 13% were cleared using Dormia basket trawling under fluoroscopy. A total of 95 patients required formal LBDE, and 2 required postoperative endoscopic retrograde cholangiopancreatography (ERCP). No postoperative ERCP for retained stones was required after simple transcystic manipulation. Eight conversions occurred, one during a transcystic exploration. Follow-up evaluation continued for as long as 6 years in some cases. Two patients had recurrent stones after LBDE and a clear postoperative tube cholangiogram. In this series, 10% of the abnormal cholangiograms occurred in patients without preoperative risk factors for bile duct stones. Altogether, 88 IOCs (31%) were cleared after either simple flushing or trawling with a Dormia basket. Formal LBDE was not required for 40% of abnormal cholangiograms. Simple transcystic manipulations to clear the bile ducts justify the use of routine IOC in units without laparoscopic biliary expertise.

Laparoscopic biliary tract injury: what are the limits of prevention?

At the joint meeting of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) and the American Hepato-Pancreatic-Biliary Association in April 2005, the program committee convened a forum on the subject of biliary injuries that occur during laparoscopic cholecystectomy. More than 300 surgeons attended this forum, and the discussion was lively, indicating that this topic still is important to practicing surgeons. The editors of Surgical Endoscopy have agreed to publish the papers from this forum in this issue of the journal [1, 2, 5, 6, 8]. There are two articles on the prevention of biliary injuries during cholecystectomy and there are three papers on methods for diagnosing, evaluating, and treating the problem once it has occurred. The editors are to be commended for agreeing to print these proceedings because, they are written by experts in the field and are very informative to all surgeons who treat patients with biliary tract disease. The questions are (1) How safe can we make laparoscopic cholecystectomy? and (2) How much can we reduce the rate of bile duct injury? The answer to both questions is that laparoscopic cholecystectomy should certainly be as safe as open cholecystectomy, with a comparable or lower incidence of biliary injury. In this commentary, I review the highlights of the presentations at the symposium and present my observations on the issue of biliary injury. Cholecystectomy for gallstone disease is one of the most common procedures performed by general surgeons in North America. The introduction of laparoscopic cholecystectomy in the early 1990s stands out as one of the most significant new developments in the practice of surgery for the past three decades. Not only did it dramatically change the management for one of the most common surgical conditions—cholelithiasis; it also ushered in the new era of minimally invasive or laparoscopic surgery, which has been successfully applied to many other intraabdominal and thoracic disorders. This new procedure was quickly accepted and adopted by patients, referring doctors, and industry. The benefits of the laparoscopic approach were readily apparent and included a shorter hospital stay, a shorter recovery period, decreased postoperative pain, and a quicker return to normal activity. Unfortunately, along the way, it became apparent that an increase in the rate of biliary tract injuries was associated with laparoscopic cholecystectomy. In the 1990s, several groups reported that the incidence of bile duct injuries had risen from 0.1% to 0.3% for open cholecystectomy to 0.4% to 0.6% for the laparoscopic approach, which was a doubling of the incidence [3, 4, 7, 11]. Initially, these data were viewed as a reflection of the learning curve for this procedure. However, over the next two decades, the results did not change. Injuries to the bile duct continue to occur although the current generation of surgeons grew up in the laparoscopic era. Any improvement or reduction in the incidence and frequency of biliary tract injuries during cholecystectomy will come about only as a result of specific instruction and attention to anatomic detail. Continuing education programs for surgeons in practice and good teaching for our residents in training with continued emphasis on proper technique and precautions are key components. The price to pay for the complications of a biliary tract injury is indeed considerable. The morbidity of these complications is reflected in additional procedures and operations, cholangitis, intraabdominal infection, biliary cirrhosis, and, in extreme cases, endstage liver disease and death. Dr. Traverso opened the aforementioned forum with a presentation on the routine use of intraoperative cholangiography (IOC) as a valuable tool for lowering the risk of bile duct injury during cholecystectomy. He emphasized the diverse pattern of the biliary anatomy and the importance of recognizing biliary anomalies and variations. For him, routine IOC is key to identifying Correspondence to: G. M. Larson Editorial

Risk Management Observations From Litigation Involving Laparoscopic Cholecystectomy

Limited information exists on the outcome of laparoscopic cholecystectomy (LC) litigation. A retrospective review of a public malpractice database was compared with previously published reviews of LC litigation by K. A. Kern, MD, and the Physician Insurers Association of America. Private surgery practice. Selection The database was searched for cases containing the terms laparoscopy, bile, or gall between August 1, 1999, and August 31, 2004. Identified cases were further reviewed to select only the unique cases that concerned elective biliary surgery. Surgical technique, injuries, and incidence of conversion to open procedures. In Kern's study, injuries triggering litigation involved the bile duct in 61%, bowel in 16%, vascular system in 9%, and miscellaneous events in 14%; in the present study, injuries involved the bile duct in 78%, bowel in 2%, vascular injury in 7%, and miscellaneous injuries in 13%. Missed injuries occurred in 86% in the present study and 83% of the Physician Insurers Association of America cases. Although 15% of cases in the present study were converted to open procedures, in 53% of these cases conversion was performed to repair an injury. Despite residency training, injuries triggering litigation after LC remain largely unchanged. The nature of the bile duct injuries suggests that routine intraoperative cholangiography is unlikely to make LC safer. To minimize the risk of litigation after LC, it is recommended that the threshold for conversion to open procedures be lowered.

Bile duct injury in the era of laparoscopic cholecystectomy

Laparoscopic cholecystectomy is the standard of care for symptomatic cholelithiasis, but it is associated with a higher incidence of bile duct injury than the open approach. A review was performed of the English language literature on the management of bile duct injury listed on Medline databases. There is consensus that careful dissection and correct interpretation of the anatomy avoids the complication of bile duct injury during cholecystectomy. Routine intraoperative cholangiography is associated with a lower incidence and early recognition of bile duct injury. Early detection and repair is associated with an improved outcome, and the minimum standard of care after the recognition of a bile duct injury is immediate referral to a surgeon experienced in bile duct injury repair. Surgery provides the mainstay of treatment, with proximal hepaticojejunostomy Roux en Y being the operation of choice; a selective role for endoscopic or radiological treatment exists. The outcome after bile duct injury remains poor, especially in relation to the initial expectation of the cholecystectomy. Patients are often committed to a decade of follow-up.

Prospective evaluation in 121 consecutive unselected patients undergoing laparoscopic treatment of choledocholithiasis.

Laparoscopic common bile duct (CBD) exploration was attempted in 115 of 121 consecutive unselected patients with choledocholithiasis (mean age 69 (range 21-92) years) found during routine intraoperative cholangiography. The CBD was successfully cleared of all stones in 100 patients (87 per cent). Ten of 11 patients referred for surgery after failure of endoscopic sphincterotomy had complete laparoscopic choledocholithiasis. Eleven patients (10 per cent) required conversion to open CBD exploration, and laparoscopic exploration was not attempted in six (5 per cent) because of inflammation or fibrosis. Postoperative endoscopic sphincterotomy was required in four patients (4 per cent) for retained stones after laparoscopic exploration. There were no postoperative deaths (39 per cent of patients were aged 75 years or more). Routine intraoperative cholangiography, and when required laparoscopic CBD exploration, should be compared in randomized trials with preoperative endoscopic retrograde cholangiography in patients with suspected choledocholithiasis.

Role of intraoperative cholangiography in laparoscopic cholecystectomy.

The results of a policy of selective cholangiography were assessed in 400 patients undergoing laparoscopic cholecystectomy. Preoperative endoscopic retrograde cholangiopancreatography (ERCP) was performed in 81 patients (20 per cent) of whom 31 (38 per cent) showed definite or possible evidence of stones in the bile duct. Seventeen of the 400 patients underwent intraoperative cholangiography and the majority of these (12) were normal. After a minimum follow-up of 1 year, 17 patients (4 per cent) have had ERCP for suspected residual duct stones. Eight (2 per cent) of these revealed stones and all were successfully treated with sphincterotomy and duct clearance. Preoperative and postoperative ERCP was not associated with mortality or major morbidity. No major duct injury occurred and none was diagnosed within 2 years of operation. Routine intraoperative cholangiography is not a necessary part of laparoscopic cholecystectomy in the presence of an efficient and safe ERCP service.

Intraoperative cholangiography and bile duct injury

We are not in agreement with the opinion that the credit for excellent results after laparoscopic cholecystectomy is to be attributed to the routine performing of intraoperative cholangiography. We performed 2538 laparoscopic cholecystectomies without routine intraoperative cholangiography and we obtained very low rate and severity of common bile duct injuries: there was a total of four common bile duct injuries (0.16%), in no case was the injury a major transaction, and injuries were detected intraoperatively and easily repaired with a T-tube. Cholangiography could prevent bile duct transaction, but that it is not necessary for intraoperative cholangiography to be routinely performed for this purpose. It is sufficient for intraoperative cholangiography to be performed whenever the surgeon is in doubt as to the biliary anatomy or common bile duct clearance, and that when dissection of the cholecystic peduncle proves difficult he does not hesitate to convert to open access.

Selective operative cholangiography in the performance of laparoscopic cholecystectomy

The objective of this prospective study was to evaluate the role of intraoperative cholangiography (IOC) for patients undergoing laparoscopic cholecystectomy (LC) to determine whether it could be safely omitted for all patients who fit standard criteria, namely normal liver function tests, no history of gallstone pancreatitis, common bile duct (CBD) diameter less than 10 mm or previous history of jaundice. Data were collected prospectively from 194 consecutive patients who had LC for symptomatic gall bladder disease. IOC was not performed in any patient. The conversion rate was 6.1% and one CBD injury occurred. Our experience demonstrates that LC performed without routine IOC does not result in an increased incidence of retained stones in selected patients who have no history of pancreatitis, normal liver function tests and CBD less than 10 mm diameter.

Laparoscopic cholecystectomy after the learning curve: what should we expect?

The introduction of laparoscopic cholecystectomy (LC) in the late 1980s was accompanied an increase in common bile duct (CBD) injuries. This retrospective analysis of 2,005 cholecystectomies performed at a single institution investigates the factors that have contributed to a record of zero CBD injuries in 1,674 consecutive LC. The medical records of 1,285 consecutive patients operated on from 7 July 1996 to 6 June 2003 were obtained. We also examined the peer review records of an additional 720 LC performed between 1 January 1990 and 7 July 1996. There were no CBD injuries among 1,674 consecutive LC patients spanning the period since 1990. Of the 954 patients who underwent LC since 1996, six had a cystic duct leak and five had a duct of Luschka leak. Intraoperative cholangiography (IOC) was performed in 20.2% of cases (n = 193/954). Seventy of 157 patients who underwent cholangiography alone demonstrated one or more stones in the CBD (44.6%). In 40 patients (58.0%), endoscopic retrograde cholangio pancreatography (ERCP) was uniformly successful in clearing intraoperatively identified stones. In36.2% of cases, the stones were removed via laparoscopic CBD exploration (CBDE) (n = 25). In 5.8% of positive cases, the stones were removed via open CBDE (n = 4). Among 761 patients who did not undergo IOC, seven patients (0.92%) returned to the hospital for retained stones. Three of these patients had elevated liver function tests (LFT) preoperatively (1.3%) and four had normal LFT (1.1%). Injuries of the CBD can be avoided by performing an extensive dissection of the triangle of Calot and by developing a critical view of the operative field to ensure the patient's safety during LC. If all LFT are normal and IOC is not performed, the occurrence of clinically significant stones postoperatively is minimal; in this group, only four patients had retained stones. Thus, in the face of normal LFT, routine IOC is unnecessary for a low CBD injury rate, and a return to the hospital for retained bile duct stones is rarely required, regardless of the number of times ductal stones are found on routine cholangiography. This implies that the significance of the stones discovered at IOC is questionable in most cases, thereby providing an argument against routine cholangiography. Most discovered CBD stones can be treated by ERCP, thus obviating the need for the T-tube drainage associated with CBDE. The 21st century finds LC to be a mature and safe surgical procedure.

PROSPECTIVE COMPARISON OF ROUTINE AND SELECTIVE OPERATIVE CHOLANGIOGRAPHY

In a rural centre with limited resources and no endoscopic retrograde cholangiopancreatography facilities, a prospective cohort study was established to compare policies of routine and selective intraoperative cholangiography (IOC) in order to develop a local protocol. Patients undergoing laparoscopic cholecystectomy from 1 February 1995 to 30 November 2002 were allocated to undergo routine or selective IOC according to birth date. Those with known common bile duct (CBD) stones were excluded. Selective IOC was performed on the basis of abnormal liver function tests or a dilated CBD on ultrasound. Study end points after 12 months follow-up were retained CBD stones, CBD injury, operating times and the effect of IOC on the management of patients with persistent biliary symptoms postoperatively. Of the 148 patients in the routine group, 94 underwent IOC and CBD stones were shown in 12. Of the 155 in the selective group, IOC was performed in 34 of 45 eligible patients and stones were shown in five. Sixteen patients re-presented with recurrent biliary symptoms or jaundice postoperatively and eight had proven retained CBD stones, of whom only one had undergone (false-negative) IOC. There was no significant difference in mean operating time (56 vs 61 min; t-test P = 0.15). There was one CBD injury in each group, both incurred after successful IOC. There was no difference between policies of routine or selective IOC in relation to operating times, retained CBD stone rates or CBD injury. However, the authors found management of patients with recurrent biliary symptoms easier if an IOC had been performed, and IOC was easier to perform when the staff were expecting it. Thus a policy of routine IOC has been adopted.

Combined endoscopic treatment for cholelithiasis associated with choledocholithiasis

The advent of endoscopic techniques changed surgery in many ways. For the management of cholelithiasis, laparoscopic cholecystectomy (LC) is the treatment of choice. This has created a dilemma in the management of choledocholithiasis. Today a number of option exist, including endoscopic sphinterotomy (ES) before LC in patients with suspected common bile duct (CBD) stones, laparoscopic bile duct exploration, open CBD exploration, and postoperative endoscopic retrograde cholangiopancreatography (ERCP). Also, the alternative technique of peroperative ES is emerging. We report our experience of routine intraoperative cholangiography followed either by peroperative ERCP in one step or by transcystic drain and postoperative ERCP. In our technique, to facilitate Vater papilla cannulation we inserted a 450-cm transcystic guidewire that was caught by a duodenoscope. Papillotome was then inserted over the guidewire to ensure cannulation of the CBD. Twenty-eight patients were treated successfully in one step and 24 in two steps. The mean operative time was 181 +/- 41 min for patients treated in one step and 131 +/- 30 min for patients treated in two steps. The mean hospital stay was 4.8 +/- 3.3 days for patients treated in one step and 9.6 +/- 4.0 days for patients treated in two steps. Five patients (18%) with positive intraoperative cholangiography for stones for whom peroperative ERCP was not available showed a normal postoperative transcystic cholangiogram and therefore ERCP was canceled. Fourteen of 25 patients treated in one step and none of 17 treated in two steps had raised serum amylase, which resolved spontaneously with no symptoms. No patient developed postoperative pancreatitis. Three (10%) ERCP complications were observed, consisting of mild bleeding of the papilla. All cases were managed by endoscopic adrenaline injection. There was no mortality. We believe peroperative ERCP with the technique described should be considered as the treatment of choice for choledocholithiasis associated with cholelithiasis. When single-stage treatment is not possible, a two-step rendezvous technique should be preferred.

Does routine intraoperative cholangiography prevent bile duct transection?

The role of routine intraoperative cholangiography is controversial. The aim of this study was to assess the impact of routine intraoperative cholangiography on the incidence of common bile duct injuries, and to evaluate the operative outcome of laparoscopic cholecystectomy carried out in a major teaching hospital and review the literature. Prospectively collected data on 3,145 laparoscopic cholecystectomies performed mainly by surgical trainees in the period 1990 to 2002 using routine intraoperative cholangiography with fluoroscopy were reviewed. The mean age of the study sample (65.6% male, 34.4% female) was 54 years, and 16.9% of the patients had clinical acute cholecystitis. The conversion rate to open cholecystectomy was 4.3%. Intraoperative cholangiography was attempted for 90.7% of the patients with a 95.9% success rate. Five patients (0.16%) had common bile duct injuries. Four injuries had occurred in the first 5 years. One injury (0.06%) had occurred after 1995. This injury was identified intraoperatively and repaired laparoscopically. Routine intraoperative cholangiography prevented one definite common bile duct transection. In this series using routine intraoperative cholangiography, there was a low rate and severity of common bile duct injuries, with a high intraoperative recognition rate. There was no bile duct transection or major injury requiring common bile duct reconstruction. Although intraoperative cholangiography helped in the immediate identification of injuries and the institution of appropriate therapy, injury was not completely prevented.