Routine Operative Cholangiography Research Articles

Use of HIDA scans and laparoscopic cholecystectomy for acalculous biliary symptoms – A 4 year experience in a district general hospital

Use of HIDA scans and laparoscopic cholecystectomy for acalculous biliary symptoms – A 4 year experience in a district general hospital

Operative common bile duct imaging by operative cholangiography and flexible choledochoscopy.

A consecutive series of 108 common bile duct (CBD) explorations was studied to examine the efficacy of routine operative cholangiography and flexible choledochoscopy in the identification of choledocholithiasis. CBD exploration was performed according to the findings of routine operative cholangiography. Nine negative explorations were performed, only one of which would have been avoided had selective cholangiography been employed. Eight patients had unsuspected choledocholithiasis that would have been missed if selective operative cholangiography had been used. Flexible choledochoscopy identified CBD stones on 97 occasions; no additional retained stones were found on subsequent T tube cholangiography. In two cases stones were seen but could not be removed; immediate identification allowed planning for early removal. Flexible choledochoscopy is the most effective method of CBD exploration and should be used in all patients with suspected choledocholithiasis.

Place of routine operative cholangiography at cholecystectomy.

Place of routine operative cholangiography at cholecystectomy.

Operative cholangiography

Abstract Three hundred consecutive operations for calculous biliary-tract disease are reviewed with particular reference to the influence of routine operative cholangiography. The technique and instruments used in cholangiography have been described and the operative and follow-up statistical data have been analysed. The value of operative cholangiography before and after duct exploration is discussed with particular reference to the problem of the residual stone and the fruitless duct exploration.

Routine operative cholangiography.

Abstract The usual clinical and operative indications for exploration of the common bile-duct in cholecyst-ectomies or the selective use of operative cholangio-graphy in such cases are discussed and compared with 150 unselected cases of cholecystectomy and routine operative cholangiography. As far as calculi in the common duct are concerned, it seems fair to say that routine operative cholangiography demonstrates stones that would otherwise be left in situ and reduces the cases in which exploration of the common duct is needed. In this series, stones were present in the common bile-duct in 16 per cent; in about one-fifth of these their presence was unsuspected clinically and at laparotomy. Routine use of the technique is found to reduce the number of false positives. An important secondary benefit of cholangiography is its demonstration of duct anatomy. Various points of technique are discussed, in particular the use of the cystic duct catheter for post-exploration radiography, drainage, and postoperative radiography. Routine operative cholangiography appears to be a useful adjunct to cholecystectomy.

Is operative cholangiography always necessary?

To determine whether operative cholangiography could be performed on a selective basis, 272 consecutive patients undergoing cholecystectomy and routine operative cholangiography were studied prospectively. Appropriate clinical, biochemical and operative data were recorded and the surgeon was asked to estimate the likelihood of common bile duct stones. These factors were correlated with the subsequent cholangiographic and operative findings. From this information, four criteria were selected as indications for performing an operative cholangiogram: an abnormal common bile duct, a wide cystic duct, or elevated levels of alkaline phosphatase or bilirubin documented in the previous six months. Operative cholangiograms would have been indicated by the presence of one or more of these criteria in only 139 of the 272 patients in the study (51 per cent). Only one unsuspected stone would have been missed. It is concluded that a policy of selective cholangiography could have been safely adopted in this series of patients.

A survey of the current surgical treatment of gallstones in Queensland

To survey the current practice of general surgeons in Queensland in their management of patients with gallstones. A postal survey of 123 surgeons practising in Queensland. There were 114 responses to the questionnaire (92.7%) and seven were excluded from the analysis. Laparoscopic cholecystectomy (LC) was preferred by 97.2% and operative cholangiography was almost always attempted by 82.3%. One-third of surgeons used drains routinely. In cases of acute cholecystitis, 56 surgeons (52.3%) favoured laparoscopic cholecystectomy on the same admission. Operative cholangiography (OC) was almost always attempted by 64.8% of surgeons during acute laparoscopic cholecystectomy. Only 3.8% of surgeons frequently offered day case surgery and 51% never offered it. Laparoscopic cholecystectomy is the treatment of choice of nearly all Queensland surgeons in the elective and acute situations. Routine operative cholangiography is favoured by the majority of surgeons. Day case surgery is presently offered by a minority of surgeons.

Features and management of bile leaks after laparoscopic cholecystectomy

Leakage of bile is one of the troublesome complications after laparoscopic cholecystectomy. The present study reviewed our experience with this complication, in order to analyze its characteristics and proper management. Postoperative bile leaks occurred in 23 of 1365 patients (1.7%) undergoing laparoscopic cholecystectomy from July 1990 to May 2002, with the policy of routine operative cholangiography and routine drainage of the gallbladder bed. These patients could be divided into four types. In type 1 (17 patients), bile leakage stopped spontaneously within 3 days (subclinical group). In type 2 (3 patients), the leak continued for longer than 3 days but was controlled by an endoscopic nasobiliary drainage (ENBD tube; minor-leakage group). In type 3 (2 patients), bile leakage continued for longer than 3 days and required open repair (major-leakage group). In type 4 (1 patient), bile leakage started several days after surgery (delayed-leakage group). It is thought that better understanding of these four types of bile leakage should help in the proper management of this complication.

Laparoscopic cholecystectomy without routine operative cholangiography does not result in significant problems related to retained stones.

This study investigated whether failure to identify common bile duct stones at laparoscopic cholecystectomy results in significant postoperative complications related to retained stones. We performed a retrospective analysis of the case notes of 377 consecutive patients undergoing laparoscopic cholecystectomy without routine operative cholangiography under a single surgeon in a district general hospital between 1995 and 1999. Highly selective preoperative endoscopic retrograde cholangiopancreatography (ERCP) was employed to identify and manage suspected bile duct stones in pancreatitis, jaundice, persistently elevated liver function tests, or a dilated common bile duct. Eighteen (4.8%) of 377 patients presented postoperatively with symptoms/signs suggesting biliary pathology. Two (0.5%) were confirmed to have retained duct stones/debris (ultrasound/ERCP); both recovered with conservative treatment. Only 1 patient of 274 (0.4%) without preoperative ERCP subsequently presented with a symptomatic retained stone, the other having been stented preoperatively. Highly selective preoperative ERCP without routine operative cholangiography is not associated with a significant increase in morbidity/mortality related to retained stones following laparoscopic cholecystectomy.

Cholecystectomy in cardiothoracic organ transplant recipients.

To assess the risks associated with cholelithiasis and cholecystectomy in cardiothoracic organ transplant recipients at this hospital and to identify any differences with potential causal significance between the group with known gallstones and the transplant recipient group as a whole. Medical records survey. Tertiary care university hospital. Six hundred forty-five patients had cardiothoracic organ transplantation at this hospital between February 1, 1984, and May 31, 1996. Gallstones were detected in 37 (5.7%) of these patients and 32 patients underwent cholecystectomy, of which 29 operations were performed primarily for symptomatic gallstone disease. All cholecystectomies were performed after transplantation. Mortality, morbidity, postoperative biliary disease. Patients with gallstones were significantly older than the transplant patient group as a whole (Student t test, P=.001); they were more likely to be female (chi2 test, P=.05); and they had a higher body mass index (t test, P=.001). There were no significant differences in the maximum serum bilirubin level during the transplantation admission, incidence of diabetes mellitus, cholestyramine use, or cyclosporine dosage during the first 12 months after transplantation. Cholecystectomy was performed after a median 5-month symptomatic period, mostly by the minilaparotomy method. Forty-five percent of cholecystectomies were urgent or semi-urgent. One patient died of lung infection on the second postoperative day. The median postoperative stay was 3 days. At a median 33 months' follow-up, 4 patients have had further biliary problems (2 patients with common bile duct stones, 1 patient with intrahepatic stones, and 1 patient with biliary dyskinesia). Four other patients with asymptomatic gallstones who did not receive cholecystectomy have remained asymptomatic for between 15 and 67 months. Cholecystectomy by the minilaparotomy or laparoscopic methods, with routine operative cholangiography, is the preferred treatment for symptomatic gallstones in cardiothoracic organ transplant recipients. Although the optimum management of asymptomatic gallstones in these patients remains unclear, our favorable experience with a policy of reserving cholecystectomy for symptomatic cases seems noteworthy.

Minimal access surgery of the gastrointestinal tract.

In the last 5 years, surgery of the gastrointestinal tract has been revolutionized by the application of minimal access techniques. Following initial enthusiasm, which suggested that most abdominal surgery would ultimately be done via this approach, there is now need for appraisal and evaluation of the role of a number of these minimal access techniques when compared with open surgery. Undoubtedly, the most convincing and total application of minimal access techniques has been in the treatment of gallstone disease. Laparoscopic cholecystectomy is now standard therapy for cholelithiasis and endoscopic sphincterotomy with stone extraction is standard therapy for choledocholithiasis. Where the two conditions co-exist, operative cholangiography allows for the recognition of stones in the bile duct at the time of laparoscopic cholecystectomy and provides the potential avenue for treatment. Most major centres also would recommend routine operative cholangiography during laparoscopic cholecystectomy for the detection of unsuspected stones and as an extra safety procedure in the early identification of potential bile duct injuries. The efficacy of laparoscopic appendicectomy and laparoscopic or thoracoscopic treatment of achalasia of the oesophagus also is supported by data from well conducted prospective studies. Doubt remains regarding the advantage of laparoscopic surgery over other approaches in the treatment of gastro-oesophageal reflux, inguinal hernias and jaundice due to non-resectable cancer. For all three of these conditions, prospective trials are underway and the results of these trials should be assessed prior to widespread adoption of the laparoscopic techniques.(ABSTRACT TRUNCATED AT 250 WORDS)

The Case for Routine Operative Cholangiography During Laparoscopic Cholecystectomy

The debate over routine versus selective intraoperative cholangiography during laparoscopic cholecystectomy continues because of a paucity of objective data to support or refute the case for either approach. The introduction of fluoroscopic techniques during the performance of cholangiography is an important step forward because it decreases the operative time for the technique and because real-time visualization may also diminish the number of false-positive and false-negative results. Routine cholangiography improves the surgeon's ability to delineate the biliary anatomy when the need arises and undoubtedly facilitates the development of skills useful for the laparoscopic management of common bile duct calculi. Normal results on intraoperative cholangiography are also reassuring to the surgeon, given the current visual and tactile limitations of laparoscopy. As a result of these considerations as well as our procurement of a digital fluoroscopic system and the need to train surgical residents in cholangiographic techniques, we have adopted a policy of routine fluoroscopic intraoperative cholangiography on all patients undergoing laparoscopic cholecystectomy.

Early experience with minimally invasive surgery: a New Zealand audit.

The clinical and economic impact of minimally invasive surgery in New Zealand, especially laparoscopic cholecystectomy, has been profound but uncharted. A postal questionnaire was sent to all general surgeons in New Zealand (n = 214), in order to document the current levels of experience, adequacy of training, levels of equipment and sources of funding. In the case of laparoscopic cholecystectomy, further details were obtained relating to operative technique, complication rates and approaches to the management of choledocholithiasis. The response rate was 71%. From 27 centres, 71 of 106 active general surgeons were performing minimally invasive surgery. Of the 34 different procedures audited, cholecystectomy (3056), herniorrhaphy (178), and appendicectomy (141) were performed most often. Primary funding came from Area Health Boards (71%) and private hospital funds (25%) with 4% coming from other sources. Ten different camera/insufflator systems were used. Training was perceived to be adequate by the majority of surgeons (89%), although seven surgeons had received no specific training. Laparoscopic cholecystectomy technique included: prophylactic antibiotics (89% of surgeons), patients supine (80%), wound infiltration (80%), routine use of diathermy within triangle of Calot (36%) and a routine peritoneal drain (13%). Routine operative cholangiography was used rarely (7%) and 72% of surgeons had deliberately changed their policy with respect to its use. Twenty-two cases of laparoscopic biliary injury were identified by the survey, none of whom had operative cholangiography. The conversion rate was 13% for acute and 4% for elective laparoscopic cholecystectomy. This survey indicated the broad scope of minimally invasive surgery that is being undertaken, and highlights potentially important variations in surgical practice.

Cholecystectomy without operative cholangiography. Implications for common bile duct injury and retained common bile duct stones.

This study evaluated the selective use of endoscopic retrograde cholangiopancreatography (ERCP) in the context of laparoscopic cholecystectomy (LC) while minimizing the use of operative cholangiography. There has been a long-standing debate between routine and selective operative cholangiography that has resurfaced with LC. Prospective data were collected on the first 1300 patients undergoing LC at McGill University. Preoperative indications for ERCP were recorded, radiologic findings were standardized, and technical points for a safe LC were emphasized. A total of 106 patients underwent 127 preoperative ERCPs. Fifty patients were found to have choledocholithiasis (3.8%), and clearance of the common bile duct (CBD) with endoscopic sphincterotomy was achieved in 45 patients. The other five patients underwent open cholecystectomy with common duct exploration. Intraoperative cholangiography (IOC) was attempted in only 54 patients (4.2%), 6 of whom demonstrated choledocholithiasis. Forty-nine postoperative ERCPs were performed in 33 patients and stones were detected in 17 (1.3%), with a median follow-up time of 22 months. Endoscopic duct clearance was successful in all of these. The incidence of CBD injury was 0.38%, and a policy of routine operative cholangiography might only have led to earlier recognition of duct injury in one case. The rate of complication for all ERCPs was 9% and the associated median duration of the hospital stay was 4 days. The median duration of the hospital stay after open CBD exploration was 13 days. LC can be performed safely without routine IOC. The selective use of preoperative and postoperative ERCP will clear the CBD of stones in 92.5% of patients.

Routine operative cholangiography during laparoscopic cholecystectomy: feasibility and value in 107 patients.

Laparoscopic cholecystectomy is becoming a popular alternative to open cholecystectomy. However, the technical aspects of this new procedure increase the risk of injuring the bile ducts. The purpose of this study was to determine the feasibility and value of performing cholangiography during laparoscopic cholecystectomy. We retrospectively reviewed the clinical and operative cholangiographic findings of the first 107 patients undergoing laparoscopic cholecystectomy at Hôtel-Dieu de Montréal between August 1990 and August 1991. Operative cholangiography was attempted in 98% of patients; the success rate was 71%. Eight anatomic anomalies of the biliary tract that were of surgical importance were found as well as 10 cases of stones in the common bile duct, eight of which were unsuspected. No biliary tract injuries occurred. With experience, surgical cannulation of the cystic duct for injection of contrast material can be done quickly without major difficulty, and cholangiograms of excellent diagnostic quality can be obtained. Our results show that operative cholangiography is feasible and useful in patients undergoing laparoscopic cholecystectomy.

Laparoscopic treatment of gall-bladder disease

Summary. Laparoscopic cholecystectomy is now established as the treatment of choice for symptomatic gallstone disease and is applicable to 95% of cases. Residual controversial issues remain and these include the need or otherwise for routine operative cholangiography and the management of ductal calculi. There is a place for gall-bladder drainage by percutaneous or laparoscopic cholecystostomy in elderly poor risk patients with acute severe cholecystitis. The laparoscopic options for dealing with ductal calculi are extraction through the cystic duct and supraduodenal bile duct exploration. Most of the injuries sustained can be avoided by the adoption of safe techniques for inducing the pneumoperitoneum, by careful dissection and observation of the basic rules governing the use of endoscopic high frequency electrosurgery. Technical developments such as the argon beam spray coagulation will further reduce the incidence of electrocoagulation related complications.

Comparison between routine operative cholangiography and pre-operative infusion cholangiography at elective cholecystectomy — A 5-year follow-up

Comparison between routine operative cholangiography and pre-operative infusion cholangiography at elective cholecystectomy — A 5-year follow-up

Intraoperative endoscopy of the biliary tract.

This is a prospective series of 328 operations for biliary stone disease in 326 consecutive patients. The overall operative mortality was 0.6%. Routine operative cholangiography was utilized during cholecystectomy, and this identified 19 patients (5.9%) with silent common bile duct stones. Common bile duct explorations were positive in 62 of 74 operations (83.8%). Biliary endoscopy was routinely performed during bile duct exploration. Unsuspected retained common duct stones were discovered postoperatively in 4.5% of these patients. Biliary endoscopy proved essential in the management of 18 patients with radiographically demonstrated distal bile duct obstruction. With patency confirmed by endoscopy, inappropriate duodenotomy and sphincter ablation were avoided in each of these 18 patients.

Pre-operative intravenous cholangiography as an alternative to routine operative cholangiography in elective cholecystectomy

Pre-operative intravenous cholangiography as an alternative to routine operative cholangiography at elective cholecystectomy has been assessed in a retrospective manner in 286 patients. Most of the examinations were technically satisfactory (94.7%) and of these 1.8% proved incorrect. A small number of patients developed transient skin rashes (1.3%), the only side effect recorded. Preoperative intravenous cholangiography offers an alternative to routine operative cholangiography with the potential saving of both operating staff and radiologists' time, without sacrificing accuracy.

The case against routine operative cholangiography

We reviewed 500 consecutive cholecystectomies during which operative cholangiography was performed only when there were clinical indications for common duct exploration. Negative operative cholangiograms obviated the necessity for exploration in a substantial number of cases. Cholecystectomy without operative cholangiography was performed in 438 patients. From the average experience of those employing routine cholangiography (6 percent incidence of unsuspected stones), we presumably missed common duct stones in about 26 patients, but those stones either passed spontaneously or caused no problems. A single patient requiring reoperation for a retained stone was not a candidate for cholangiography at the original operation. No common duct injuries occurred in the series. We conclude that routine operative cholangiography is unnecessary for either finding unsuspected common duct stones or detecting ductal anomalies.