Use Of Intraoperative Cholangiography Research Articles

How I Do It: Robotic Choledochoscopy.

As the use of the robotic platform increases among general surgeons, the amount of robotic cholecystectomies is expected to increase as well. The use of intraoperative cholangiography is valuable in assessing for choledocholithiasis. We describe our technique of performing robotic intraoperative cholangiograms with choledochoscopy. Out technique aids in efficiency since no undocking is required. Preoperatively, the decision to perform a cholangiogram is made based on physical exam, labs, and imaging findings. The procedure begins with obtaining a critical view of safety. The robotic arms are positioned in a manner that allows all 4 robotic arms to remain docked. A ductotomy is made and the cholangiocatheter is introduced. The cholangiogram images are then interpreted and if a stone is seen in the common bile duct we will then perform a transcystic common bile duct exploration using the SpyGlass Discover digital. A complete cholangiogram is then performed. The cystic duct is secured and the gallbladder is removed from the liver bed. The patients are watched overnight and discharged on postoperative day 1. A robotic approach to performing a transcystic common bile duct exploration is a safe and reproducible treatment method for choledocholithiasis. Our approach offers an advantage since no undocking is required.

Comparison of laparoscopic cholecystectomy in children at paediatric centres and adult centres: a systematic review and meta-analysis.

Paediatric laparoscopic cholecystectomy (LC) is performed by both paediatric and adult surgeons. The aim of this review was to compare outcomes at paediatric centres (PCs) and adult centres (ACs). A literature search was conducted, in accordance with PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines, for papers published between January 2000 and December 2020. Statistical analysis was performed using Stata® version 16 (StataCorp, College Station, TX, US). A total of 92 studies involving 74,852 paediatric LCs met the inclusion criteria. Over half (59%) of the LCs were performed at ACs. No significant differences were noted in the male-to-female ratio, mean age or mean body mass index between PCs and ACs. The main indications were cholelithiasis (34.1% vs 34.4% respectively, p=0.83) and biliary dyskinesia (17.0% vs 23.5% respectively, p<0.01). There was no significant difference in the median inpatient stay (2.52 vs 2.44 days respectively, p=0.89). Bile duct injury was a major complication (0.80% vs 0.37% respectively, p<0.01). Reoperation rates (2.37% vs 0.74% respectively, p<0.01) and conversion to open surgery (1.97% vs 4.74% respectively, p<0.01) were also significantly different. Meta-analysis showed no significant difference in overall complications (p=0.92). The number of LCs performed, intraoperative cholangiography use and conversion rates were higher at ACs whereas bile duct injury and reoperation rates were higher at PCs. Despite a higher incidence of bile duct injury at PCs, the incidence at both PCs and ACs was <1%. In complex cases, a joint operation by both paediatric and adult surgeons might be a better approach to further improve outcomes. Overall, LC was found to be a safe operation with comparable outcomes at PCs and ACs.

The Use of Intraoperative Cholangiography During Cholecystectomy: A Systematic Review.

Cholecystectomy is a widespread surgical procedure for gallbladder diseases. Evolving techniques and technologies, such as intraoperative cholangiography (IOC), enhance safety and outcomes by providing real-time biliary system visualization during surgery. This systematic review explored available data on using IOC during cholecystectomy, highlighting its effectiveness, safety, and cost-effectiveness. To perform this systematic review, a thorough literature search was conducted using relevant keywords in electronic databases, such as PubMed, Medical Literature Analysis and Retrieval System Online (MEDLINE), Cochrane Library, Web of Science, and Google Scholar. We included studies published during the last 10 years exploring the use of IOC during cholecystectomy. The findings showed success rates of up to 90% with a median time of 21.9 minutes without complications. Most (90%) patients with acute gallstone pancreatitis underwent cholecystectomy with IOC, with unclear IOC results in 10.7% and failure in 14.7%. IOC failure factors included age, body mass index (BMI), male sex, concurrent acute cholecystitis, common bile duct (CBD) stone evidence on imaging, CBD diameter of >6 mm, total bilirubin of >4 mg/dL, abnormal liver tests, and gallstone pancreatitis. The detection of choledocholithiasis by IOC prompted trans-cystic duct exploration and endoscopic retrograde cholangiopancreatography (ERCP). Biliary abnormalities and stone identification were observed using IOC, and routine use increased bile duct stone detection while decreasing bile duct injury and readmission rates. The sensitivity, specificity, accuracy, positive predictive value, and negative predictive value of IOC for common bile duct stone detection were reported at 77%, 98%, 97.2%, 63%, and 99%, respectively. Routine IOC was projected to provide substantial quality-adjusted life years (QALY) and cost-effectiveness gains compared to selective IOC. Regarding safety, IOC was generally associated with reduced complication and open surgery conversion risks, with similar rates of CBD injury and bile leaks. These findings indicate that IOC enhances cholecystectomy outcomes through precision and decreasing complications.

Prevalence of Iatrogenic Bile Duct Injury Following Open and Laparoscopic Cholecystectomy Treatment Outcomes

Background and Aim:Iatrogenic bile duct injuries (IBDI) continue to be a difficult diagnostic and therapeutic problem. The prevalence of iatrogenic IBDI increased with the laparoscopic technique introduction for the cholecystolithiasis treatment. The study's objective was to determine the frequency of iatrogenic bile duct injuries (IBDI) following open and laparoscopic cholecystectomy treatment outcomes. Materials and Methods: This retrospective observational study was carried out on 131 bile duct injuries sustainable patients who underwent laparoscopic cholecystectomy at General Hospital, Lahore for the duration of six months from May 2021 to October 2021. All the patients who satisfied the inclusion criteria were enrolled in this study. Ethical approval and informed consent were taken from the institutional ethical committee and individual respectively. The data outcomes such as time details of laparoscopic cholecystectomy and injuries recognition, injury types, injuries definitive repair time, IBDI management, intraoperative cholangiography use, post-operative complications, laparoscopic cholecystectomy to open cholecystectomy conversion, bile duct injury, morbidity, postoperative outcomes, and mortality rate were recorded. SPSS version 20 was used for data analysis. Results: A total of 131 referred patients were treated for iatrogenic bile duct injury caused by open cholecystectomy (n = 60), and Laparoscopic cholecystectomy (n = 71). During laparoscopic cholecystectomy, bile duct injuries were identified in only 28 (39.4%) patients. Following the LC conversion to open operation, 50%successive procedures were deemed ineffective. In case of no recognizedinjury during LC, bile leak/peritonitis was developed in 70% of patients, with nearly half being referred and the remainder underwentvarious procedures recommended by their surgeon.The rest of the patient’sdeveloped and abnormal liver function, jaundice, cholangitis. About 43% of patients underwent IOC, but two-thirds of patients did not have an injury. Laparoscopic cholecystectomy developed bile duct injury was more severe compared to the IBDI in open cholecystectomy. One patient died during definitive repair and 92% of patients were recovered without any complications. Conclusion:The iatrogenic bile duct injury increasing rate is a major surgical intervention challenge. Multidisciplinary treatment should be followed for iatrogenic bile duct injury prevention and management. Bile duct injury could be effectively treated when suspected and confirmed patients are referred to tertiary care hospitals. Keywords: Iatrogenic bile duct injuries; Laparoscopic Cholecystectomy; Complications

Is Routine Intraoperative Cholangiography Necessary in Patients Undergoing Cholecystectomy? A Systematic Review and Meta-analysis

Introduction: The value of routine intraoperative cholangiography (IOC) for cholecystectomy remains controversial. The objective of this meta-analysis is to investigate the use of routine IOC in comparison to selective and no IOC in patients undergoing cholecystectomy. Methods: PubMed, Embase, Ovid MEDLINE, Cochrane Library and Google Scholar were searched up to June 2021. Two authors selected studies, extracted data and assessed the methodological quality independently. Randomised and longitudinal studies were included. Data were pooled for various outcomes and I2 statistics analysed heterogeneity. Results: Of 38 potential studies identified, 16 studies were included, involving 9196 patients, with 5669 (61.6%) patients undergoing routine IOC and 3527 (38.42%) patients undergoing selective or no IOC during cholecystectomy. There was a trend towards lower bile duct injury (BDI) in the routine IOC group compared to the selective (Odds Ratio (OR)=0.74, p=0.34 95% CI 0.39-1.37) as well as lower ‘other’ complications (OR=0.65, p=0.06, 95%CI=0.41 to 1.02. Choledocholithiasis detection rate was significantly superior for the routine IOC group compared to selective IOC (OR=2.89, p<0.0001, 95% CI 2.09-4.01). There were no differences in retained stones (OR=1.02, p=0.98, 95%CI=0.18-5.79). Conclusion: There were limited methodologically robust studies available. There was a trend towards lower BDI and complication rates in the routine IOC group compared to the selective. Routine IOC has superiority for bile duct stone detection compared to selective IOC or no IOC procedures. There was no significant difference in retained stones between the two groups. More studies are required to build the evidence in this area.

Intraoperative cholangiography: a stepping stone to streamlining the treatment of choledocholithiasis

An estimated 8-15% of patients undergoing cholecystectomy have concomitant common bile duct stones. In this 14-year study, we utilize data of patients at a high-volume tertiary care academic center and compare the clinical outcomes of patients undergoing intraoperative cholangiography (IOC) and endoscopic retrograde pancreatography (ERCP). The charts of 1715 patients in the institutional NSQIP database who underwent cholecystectomy between October 1st, 2005 and September 30th, 2019 were retrospectively reviewed. Patients who underwent cholecystectomy in relation to a malignancy diagnosis or who underwent an ERCP in a different index hospitalization were excluded. Main outcomes included hospital length of stay (LOS), post-operative morbidity, and rate of readmissions. Of the 1409 patients included in the final analysis, 185 patients underwent ERCP, while 95 patients underwent IOC. Use of IOC compared to preoperative ERCP resulted in a shorter LOS (2.6 vs. 5.3days, p < 0.001), lower rate of readmission (1.1% vs. 6.5%, p = 0.040), and similar rates of post-operative complications. Mean operative time increased by only 15min in the IOC compared to the ERCP group (129 vs.114min, p = 0.047). Additional variables that increased LOS on multivariable logistic regression included age, ASA classification, post-operative complications, and increased number of preoperative tests. This study demonstrates that use of IOC during cholecystectomy results in shorter LOS and fewer readmissions compared to ERCP. Future studies comparing these two approaches should focus on patient randomization, a cost-effectiveness analysis, and identifying barriers to implementation of a one-stage approach in the management of suspected choledocholithiasis.

TP6.1.4 Risk factors for post-cholecystectomy bile duct injuries: Systematic review and meta-analysis

Abstract Aims Bile duct injury (BDI) is a major complication of cholecystectomy resulting in long-term consequences. The relatively low incidence (0.23% – 1.5%) of BDI makes the identification of risk factors challenging. The aim of this study was to systematically analyse available literature on BDI post-cholecystectomy to provide an update on the incidence and determine current risk factors. Methods The study was pre-registered on PROSPERO (CRD42020177318). A search was conducted of MEDLINE, EMBASE, Scopus, Cochrane Central, Web of Science databases and the grey literature from inception to February 2020. 1583 unique papers were identified and screened for eligibility. English language, retrospective and prospective studies were included where the population age was &amp;gt; 16 and underwent cholecystectomy. Results Outcomes analysed were incidence of BDI and risk estimates for possible risk factors. 30 studies (6,420,667 patients) were included in the meta-analysis. Gender, BMI&amp;gt;30, acute cholecystitis (AC), emergent surgery, the operative approach, intraoperative cholangiography (IOC) and the impact of surgeon’s experience were analysed. Male gender and AC were determined to be statistically significant risk factors (OR 1.25 (1.13-1.39)) and 1.74 (1.27-2.39) respectively). Furthermore, IOC use was found to be significantly associated with BDI risk (OR 1.27 (1.17 – 1.37), while BMI&amp;gt;30, open surgical approach, emergent surgery and surgeon’s experience were not statistically significant; however, significant heterogeneity among included studies limited the interpretation of these factors. Conclusion Male gender and AC were found to be predictors of BDI, while better quality evidence is needed to show the effect of other factors.

When Should We Perform Intraoperative Cholangiography? A Prospective Assessment of 1000 Consecutive Laparoscopic Cholecystectomies.

Intraoperative cholangiography (IOC) has been historically used to detect common bile duct (CBD) stones, delineate biliary anatomy, and avoid or promptly diagnose bile duct injuries (BDIs) during laparoscopic cholecystectomy (LC). We aimed to determine the usefulness of routine IOC during LC in an urban teaching hospital. A consecutive series of patients undergoing LC with routine IOC from 2016 to 2018 was prospectively analyzed. Primary outcomes of interest were: CBD stones, BDI, and anatomical variations of the biliary tract. Secondary outcomes of interest were: IOC success rate, IOC time, and readmission for residual lithiasis. A comparative analysis was performed between patients with and without preoperative suspicion of CBD stones. A total of 1003 LC were analyzed; IOC was successful in 918 (91.5%) patients. Mean IOC time was 10 (4 to 30) minutes. Mean radiation received by the surgeon per procedure was 0.06 millisieverts (mSv). Normal IOC was found in 856 (93.2%) patients. CBD stones and aberrant biliary anatomy were present in 58 (6.3%) and 4 (0.4%) cases, respectively. Two patients (0.2%) underwent unnecessary CBD exploration because of false-positive IOC. Four patients (0.4%) with normal IOC were readmitted for residual CBD stones. Five (0.5%) minor BDI undetected by the IOC were diagnosed. Patients with preoperative suspicion of CBD stones had significantly higher rates of CBD stones detected on IOC as compared with those without suspicion (23.2% vs. 2.1%, P<0.0001). Routine use of IOC resulted in low rates of BDI diagnosis, aberrant biliary anatomy identification and/or CBD stones detection. Selection of patients for IOC, rather than routine use of IOC appears a more reasonable approach.

Acute cholecystitis in a left sided gallbladder safely managed by laparoscopic surgery

Left-sided gallbladder (LSGB) is a rare bile duct abnormality, usually found during a cholecystectomy. Symptoms usually do not differ from those of a normally positioned gallbladder, making the preoperative diagnosis extremely uncommon. We report the case of an acute cholecystitis in a patient whit LSGB, safely managed with laparoscopic surgery. A 24-year-old male patient was admitted to our institution with clinical and radiological signs of acute cholecystitis. The intraoperative finding of an acute cholecystitis in a LSGB made us modify ports positioning and a cholangiograhy was done by direct puncture of the gallbladder before hilum dissection. After the cystic duct was identified, a transcystic cholangiography was performed which confirmed a complete and clear bile duct anatomy and laparoscopic cholecystectomy was safely completed. The intraoperative finding of a LSGB makes the surgeon change some aspects of the usual technique to perform a safe cholecystectomy as LSGB significantly increases the risk of common bile duct injuries. Meticulous dissection of the gallbladder hilum to achieve a critical view of safety and the systematic use of intraoperative cholangiography are extremely important to perform a safe laparoscopic cholecystectomy.

Routine intraoperative cholangiography during laparoscopic cholecystectomy: application of the 2016 WSES guidelines for predicting choledocholithiasis

BackgroundRoutine use of intraoperative cholangiography (IOC) during laparoscopic cholecystectomy (LC) for detecting common bile duct stones remains controversial. The 2016 World Society of Emergency Surgery (WSES) guidelines on acute calculous cholecystitis proposed a risk stratification for choledocholithiasis. Our present study aimed to (1) examine the findings of common bile duct (CBD) stones in patients underwent LC with routine use of IOC, and (2) validate the 2016 WSES risk classes for predicting choledocholithiasis.MethodsAll patients had LC with IOC routinely performed from November 2012 to December 2017 were reviewed retrospectively. Patients were classified into high-, intermediate-, and low-risk groups based on the 2016 WSES risk classes with modification.ResultsA total of 990 patients with LC and routine IOC were enrolled. CBD stones were detected in 197 (19.9%) patients. The rate of CBD stone detected in low-, intermediate-, high-risk groups were 0%, 14.2%, and 89.6%, respectively. Predictors as following: evidence of CBD stones on abdominal ultrasound or computed tomography, CBD diameter > 6 mm, total bilirubin > 4 mg/dL, bilirubin level = 1.8–4 mg/dL, abnormal liver biochemical test result other than bilirubin, presence of clinical gallstone pancreatitis had statistical significance between patients with and without CBD stones. Major bile duct injury was found in 4 patients (0.4%). All 4 patients had uneventful recovery after repair surgery.ConclusionsBased on our study results, the 2016 WSES risk classes for choledocholithiasis could be an effective approach for predicting the risk of choledocholithiasis. Considering its advantages for detecting CBD stones and biliary injuries, the routine use of IOC is still suggested.

Management of Acute Disease in the Remnant Gallbladder: The Effectiveness of Repeat Laparoscopy

Introduction: Subtotal cholecystectomy has become a widely accepted alternative for patients presented with acute cholecystitis resulting in significant inflammation and anatomic distortion. Recurrent cholecystitis of the remnant gallbladder is an accepted complication of this procedure. International studies have shown completion cholecystectomy to be the definitive management of recurrent cholecystitis. Few investigators in the United States have focused on management of this scenario, and to this point open surgical approach has been recommended. Methods: Cholecystectomies undertaken by one hepatobiliary surgeon over a two-year period from 2017-2019 were reviewed. Cases of patients with previous cholecystectomy who then presented with acute cholecystitis and underwent laparoscopic completion cholecystectomy were compiled and reviewed to determine interval from initial cholecystectomy, operative time, use of intraoperative cholangiography, use of intraoperative indocyanine green (ICG), placement of drain, and total length of hospital stay (LOS). Results: Seven patients met inclusion criteria. The mean interval from initial cholecystectomy was 22 months (range 3-89 months with one patient presenting an unknown length of time from initial operation). Mean operative time was 119 minutes (range 79 minutes to 141 minutes). Five patients had an intraoperative cholangiogram and one case was completed with intraoperative ICG. A drain was left at the completion of three out of seven cases. Average LOS was less than one day (range 0-2) with three patients discharged in good condition post-operative day 0. Conclusions: Laparoscopy is a safe and effective approach to completion cholecystectomy for patients with recurrent cholecystitis that avoids an open surgical procedure.

Laparoscopic Common Bile Duct Exploration With Primary Closure After Failed Endoscopic Retrograde Cholangiopancreatography Without Intraoperative Cholangiography: A Case Series from a Referral Center in Bogota, Colombia.

Background: Despite the effectiveness of laparoscopic common bile duct (CBD) surgery, no case series details the use and advantages of laparoscopic CBD exploration (LCBDE) without use of intraoperative cholangiography (IOC) in endoscopic retrograde cholangiopancreatography (ERCP) failure. Therefore, we present a case series regarding our success with LCBDE in managing CBD stones (CBDSs) using laparoscopic technique without IOC. Materials and Methods: We performed a descriptive retrospective observational study. Patients with CBDSs, alone or along with gallbladder stones, were treated through LCBDE with primary CBD closure after failed ERCP. Results: All patients underwent LCBDE with choledocotomy and primary duct closure. Patients with gallbladder stones underwent laparoscopic cholecystectomy (78%). All procedures were successful, and no conversions occurred. Surgery duration averaged 106 minutes. Intraoperative bleeding averaged 15 cc, and no mortalities occurred. No patients required additional surgery or intensive care unit admission. Hospitalization duration averaged 5 days. Conclusions: Therefore, a laparoscopic approach with primary CBD closure after failed ERCP for complex CBDSs is safe and effective.

Should laparoscopy be the initial approach for completion cholecystectomy in recurrent cholecystitis after subtotal cholecystectomy?

Presenter: Ileana Horattas MD | Cleveland Clinic, Akron General Background: Subtotal cholecystectomy has become a widely accepted alternative for patients presented with acute cholecystitis resulting in significant inflammation and anatomic distortion. Recurrent cholecystitis of the remnant gallbladder is an accepted complication of this procedure. International studies have shown completion cholecystectomy to be the definitive management of recurrent cholecystitis. Few investigators in the United States have focused on management of this scenario, and to this point open surgical approach has been recommended. Methods: Cholecystectomies undertaken by one hepatobiliary surgeon over a two-year period from 2017-2019 were reviewed. Cases of patients with previous cholecystectomy who then presented with acute cholecystitis and underwent laparoscopic completion cholecystectomy were compiled and reviewed to determine interval from initial cholecystectomy, operative time, use of intraoperative cholangiography, use of intraoperative indocyanine green (ICG), placement of drain, and total length of hospital stay (LOS). Results: Seven patients met inclusion criteria. The mean interval from initial cholecystectomy was 22 months (range 3-89 months with one patient presenting an unknown length of time from initial operation). Mean operative time was 119 minutes (range 79 minutes to 141 minutes). Five patients had an intraoperative cholangiogram and one case was completed with intraoperative ICG. A drain was left at the completion of three out of seven cases. Average LOS was less than one day (range 0-2) with three patients discharged in good condition post-operative day 0. No patients required an open operation. Conclusion: Laparoscopy is a safe and effective approach to completion cholecystectomy for patients with recurrent cholecystitis that avoids an open surgical procedure.

Role of Intraoperative Cholangiography in Laparoscopic Cholecystectomy in Higher Risk Patients of Bile Duct Injuries

AbstractBackground: Intraoperative Cholangiography (IOC) during Laparoscopic Cholecystectomy (LC) is a radiologic contrast-based examination of the bile duct which can represent a systemic approach to avoid Bile Duct Injuries (BDIs).Aim of Study: The aim of this study was to evaluate the protective effect of selective use of IOC during laparoscopic cholecystectomy in patients with high risk for Bile Duct Injuries (BDIs).Patients and Methods: This was a prospective study included 23 patients who presented for laparoscopic chole-cystectomy and had risk factors for bile duct injuries, under-went LC with IOC. Cases were analyzed as regard operative details and clinical outcomes.Results: Cholangiography was successful in all the cases. The mean time of IOC added to LC was 22 minutes. There was a longer LC and IOC time in cases with positive CRP, pericholecystic fluid, mucocele and pyocele with positive significant differences. Although the pre-operative data 47.8% had history of obstructive jaundice, 21.7% a mucocele cases, 17.4% a pyocele cases, pericholecystic fluid in 30.4% and dilated CBD in 65.2%, only 13% showed abnormal IOC and needed further therapies (intraoperative ERCP in 2 cases and CBD exploration in 1 case). No bile duct injury in any case.Conclusion: Intraoperative Cholangiography (IOC) was found to be safe, taking only an additional time of 22 minutes to total operative time. Although the pre-operative data, only 13% of cases needed further therapies (ERCP or CBD explo-ration). The use of IOC could be considered to improve patient safety and long term results.

INTRAOPERATIVE CHOLANGIOGRAPHY DURING CHOLECYSTECTOMY RESULTS IN LOW EXPOSURE TO RADIATION: A RETROSPECTIVE COHORT STUDY.

This study aimed to determine the exposure to radiation delivered to the patient during routine intraoperative cholangiography (IOC) in cholecystectomy and examine the factors affecting radiation dose and fluoroscopy time (FT). From January 2016 to December 2017, 598 IOC examinations were performed. This study included 324 intraoperative cholangiographies performed with c-arm equipment not exceeding 10years of age. When residents performed the procedures, the mean kerma area product (KAP) was 0.36 (standard deviation [SD] 0.70) Gycm 2 and in specialist surgeons group 0.36 (SD 0.47) Gycm2, P=0.47. In residents group, the mean FT was 11.4 (SD 10.1) seconds and in specialist surgeons group, 9.2 (SD 11.9) seconds, P<0.01. Linear regression analysis showed association between increased KAP-values and the presence of common bile duct (CBD) stones and body mass index (BMI). Age, BMI, laparoscopic surgery, acute cholecystitis, presence of CBD stones, resident surgeon performing IOC and ASA III-IV were associated with higher FT. National diagnostic reference level for IOC has not been introduced in Finland so far. Our mean KAP values (0.36Gycm2) were 3-4 times lower and FT (10.1seconds) were 3-5 times lower than the few reported in the literature. Routine use of IOC during cholecystectomy results in relatively low-radiation dose performed either by residents or specialist surgeons, irrespective of whether CBD stones were visualized or not.

Selective Intraoperative Transcystic Cholangiogaraphy in Laparoscopic Cholecystectomy, 3 Years' Experience

Background: Use of intraoperative cholangiography (IOC), a contrast-based examination of the biliary system during laparoscopic cholecystectomy (LC) still represents a valuable approach to illustrate biliary duct anatomy, diagnose obstruction and avoid complications. Objective: The aim of work was to detect the advantages of IOC when used in selected cases during LC in diagnosis of biliary obstruction and prevention of biliary injuries. Patients and methods: 29 patients with specific criteria were included in the study to perform LC and IOC after preoperative magnetic resonance cholangio pancreatogaraphy (MRCP). Follow-up was done by clinical examination, serum bilirubin and U/S for one year. Collected data had been statistically analyzed. Results: IOC resulted in significant increase in mean surgical time with longer time in cases with pericholecystic fluid and mucocele. IOC still has a higher specificity, sensitivity and positive predictive value (PPV) (100, 87.5&100% respectively) over MRCP (65, 77.8&50% respectively) in prediction of choledocholithiasis. U/S, MRCP & IOC had high negative predictive values (NPV), good negative tests. History of obstructive jaundice had a low sensitivity, specificity and PPV (71.5, 63.6&38.5) but had a high NPV (87.5%) in detection of choledocholithiasis. Normal IOC saved 8 patients with history of obstructive jaundice from unnecessary endoscopic retrograde cholangiopancreatography (ERCP). No biliary injuries had been reported. Conclusion: selective IOC in high risk patients is useful in detection of choledocholithiasis, avoidance of ERCP in patients with non-specific common bile duct (CBD) dilatation and prevention of biliary injuries in cases with high risk for injury.

Double Cystic Duct as Rare Anatomic Variant

Summary The variations of the cystic duct are so common that only 30% of all humans present the classical anatomical arrangement between the common bile duct (CBD), the cystic duct, and adjacent arteries. Thus, it could be considered that anomalies of the biliary tree are a rule rather than an exception. Duplication of the cystic duct, however, is a very uncommon anatomical finding. In the Department of General and Digestive Surgery of the University Hospital Complex Albacete, a 73-year-old patient was admitted with symptoms of cholangitis. He underwent emergency surgery that found exacerbated chronic cholecystitis and dilation of the CBD. Cholecystectomy was performed with identification of a double cystic duct that drained separately in the CBD and exploration of the last revealed cholangitis without choledocholithiasis. The postoperative period progressed favourably, proceeding to discharge from the hospital with Kehr drainage closed. In conclusion, we consider that the routine use of intraoperative cholangiography when there is suspicion of anatomical variations of the biliary tree is mandatory to rule out lesions or alterations thereof.

For the 30th anniversary of laparoscopic cholecystectomy: problems remain

The review describes perioperative complications of laparoscopic cholecystectomy. Over the past 30 years, laparoscopy has become the «gold standard» for cholecystectomy and one of the most frequently performed procedures in abdominal surgery. Nevertheless, despite the advantages of the method, it has an «Achilles heel» - the frequency of iatrogenic damage to the extrahepatic bile ducts is 3-5 times higher than with an open cholecystectomy. This complication has a negative effect on the survival of patients after surgery, leads to deterioration in the quality of life and is a major source of legal costs in many countries. In general, the total range for any damage to the biliary tract during laparoscopic cholecystectomy is 0.32-0.52%, while the complication rate and mortality rate are 1.6-5.3% and 0.08-0.14%, respectively. Patients who have undergone a complete intersection of the hepaticoholedochus, become «bile cripples» for life. Recurrent cholangitis, strictures of anastomoses with a possible outcome in liver cirrhosis are quite likely in later periods after damage to the intrahepatic bile ducts. Technological efforts to improve the results of laparoscopic cholecystectomy reside. These include the routine use of intraoperative cholangiography, infrared fluorescent cholangiography, etc. Nevertheless, despite the growing number of methods designed to reduce these complications, evidence of their effectiveness remains limited. The most important factors ensuring the safety of laparoscopic cholecystectomy are recognized: understanding of anatomy, adequate exposure when using electrosurgery, psychological readiness to invite a senior colleague in time for help, the ability to recognize a situation that requires conversion and rejection of laparoscopy.

AB050. 46. A meta-analysis of the use of intraoperative cholangiography: time to revisit our approach to cholecystectomy

AB050. 46. A meta-analysis of the use of intraoperative cholangiography: time to revisit our approach to cholecystectomy

Bile duct injuries (BDI) in the advanced laparoscopic cholecystectomy era.

Laparoscopic cholecystectomy is the most commonly performed laparoscopic procedure. It is superior in nearly every regard compared to open cholecystectomies. The one significant aspect where the laparoscopic approach is inferior regards the association with bile duct injuries (BDI). The BDI rate with laparoscopic cholecystectomy is approximately 0.5%; nearly triple the rate compared to the open approach. We propose that 0.5% BDI rate with the laparoscopic approach is no longer accurate. The National Surgical Quality Improvement Program (NSQIP) registry was retrospectively reviewed. All laparoscopic cholecystectomies performed between 2012 and 2016 were extracted. A total of 217,774 cases meeting inclusion criteria were analyzed. The primary data points were the overall BDI incidence rate and time of diagnosis. BDI were identified by ICD-9 and ICD-10 codes. Secondary data points were variables associated with BDI. The BDI rate was 0.19%. 77% of cases were diagnosed after the index surgical admission. Intra-operative cholangiography (IOC) use was associated with a higher BDI rate and higher identification rate of a BDI intraoperatively (P value < 0.0001). Resident teaching cases were protective with a RR score of 0.56 (P value < 0.0001). The presence of cholecystitis increased the risk of a BDI with a RR score of 1.20 (P value < 0.0001). There was a low conversion rate of 0.04% however converted cases had a nearly hundredfold increase in BDI at 15% (P value < 0.0001). The performance of laparoscopic cholecystectomies in North America is no longer associated with higher BDI rates compared to open. IOC use still is not protective against BDI, and cholecystitis continues to be a risk factor for BDI. When a cholecystectomy requires conversion from a laparoscopic to an open approach the BDI increases a hundredfold; which may raise the concern if this approach is still a safe bailout method for a difficult laparoscopic dissection.