Routine cholangiography is not warranted during laparoscopic cholecystectomy.
ABSTRACT The role of intraoperative cholangiography during laparoscopic cholecystectomy was prospectively evaluated in 514 patients undergoing laparoscopic cholecystectomy. Before surgery, all patients were assigned to one of three groups depending on the likelihood of their having common bile duct stones. Stratification was based on objective historical, laboratory, or radiologic criteria. In 453 patients deemed unlikely to have stones, laparoscopic cholecystectomy was performed without cholangiography. Of these patients, four had retained stones (0.9%). In 25 patients likely to have stones, preoperative endoscopic retrograde cholangiopancreatography identified stones in six patients (24%). In 36 patients whose likelihood of having stones was deemed indeterminate, intraoperative cholangiography was performed at laparoscopic cholecystectomy. A common bile duct stone was identified in one patient (2.8%). One common bile duct injury occurred in the group deemed unlikely to have stones, and this injury would not have been prevented by intraoperative cholangiography. We conclude that preoperative assessment will identify common bile duct stones and that routine cholangiography is not warranted. Meticulous dissection of the cystic duct at its origin at the infundibulum will prevent common bile duct injury.
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ABSTRACT: RESUMEN Entre septiembre de 1998 y junio de 2000 se practicaron 786 colecistectomías, de las cuales 75 (9,5%) corresponden a abiertas y 711 (90,05%) a laparoscópicas. La colangiografía transcística intra-operatoria (CIO) fue considerada el gold standard para el diagnóstico de coledocolitiasis, la cual fue posible realizarla en el 79,4% (624 casos) del total de las colecistectomías, encontrándose 74 coledocolitiasis (11, 9%). De las 75 colecistectomías abiertas, se efectuaron 63 (84%) CIO y de las 711 laparoscópicas se realizaron 561 (71%) CIO. La incidencia de coledocolitiasis fue de 43% en el grupo de las abiertas versus el 8% en las laparoscópicas, considerando sólo las 624 colecistectomías en que se efectuó CIO. Se consideran y analizan como factores predictivos de coledocolitiasis: ictericia presente o como antecedente, vía biliar ecotomográfica mayor de 7 mm, fosfatasas mayor de 190 UL, bilirrubinemia total mayor de 1,5 mg%. En el grupo de pacientes sin factores de riesgo, la coledocolitiasis estuvo presente en el 6,6% y con cuatro factores presentes en el 85,7%. El hallazgo ecotomográfico de coledocolitiasis se correlacionó sólo con un 79% real. Este porcentaje asciende al 100% cuando se asocia a ictericia. Hubo dos secciones completas de la vía biliar, una después de realizarse la CIO. No hubo mortalidad operatoria. PALABRAS CLAVES: Colangiografía intraoperatoria, coledocolitiasis SUMMARY Between September 1998 and June 2000, 786 cholecystectomies were performed. Of them, 75 (9.5%) were done by the open approach and 711 (90.5%) were performed by laparoscopy. Intraoperative transcystic cholangiography (IOC) was considered the gold standard for the diagnosis of choledocholithiasis. Of the total total, IOC was performed in 624 (79.4%); 74 cases of choledocholithiasis (11.9%) were found. IOC was done in 63 of 75 open cholecystectomies (84%) and 561 of 711 (71%) laparoscopic cholecys-tectomies. The incidence of choledocholithiasis was 43% in open cholecystectomies versus 8% in laparoscopic cholecystectomies, considering only the 624 cholecystectomies in which IOC was done. The following are considered as predictive factors of choledocholithiasis: history of jaundice or jaundice at the time of physical exam, bile duct measuring over 7 mm in diameter by ultrasonographic exam, serum alkaline phosphatase above 190 UL and total serum bilirrubin above 1.5 mg/%. In the group of patients without risk factors, choledocholithiasis was found in 6.6% of them, whereas in patients with 4 risk factors the incidence was 85.7%. The ultrasonographic finding of choledocholithiasis was confirmed only in 79% of the cases. The percentage rises to 100% when jaundice is present. There were 2 cases of complete section of the biliary tract, one of them after IOC had been done. There was no operative mortality.
Article: Invited commentaryWorld Journal of Surgery 02/1997; 21(2). DOI:10.1007/BF03036492 · 2.35 Impact Factor
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ABSTRACT: Significant controversy exists regarding routine intraoperative cholangiography in preventing common duct injury during cholecystectomy. To investigate the association between intraoperative cholangiography use during cholecystectomy and common duct injury. Retrospective cohort study of all Texas Medicare claims data from 2000 through 2009. We identified Medicare beneficiaries 66 years or older who underwent inpatient or outpatient cholecystectomy for biliary colic or biliary dyskinesia, acute cholecystitis, or chronic cholecystitis. We compared results from multilevel logistic regression models to the instrumental variable analyses. Intraoperative cholangiography use during cholecystectomy was determined at the level of the patients (yes/no), hospitals (percentage intraoperative cholangiography use for all cholecystectomies at the hospital), and surgeons (percentage use for all cholecystectomies performed by the surgeon). Percentage of use at the hospital and percentage of use by surgeon were the instrumental variables. Patients with claims for common duct repair operations within 1 year of cholecystectomy were considered as having major common duct injury. Of 92,932 patients undergoing cholecystectomy, 37,533 (40.4%) underwent concurrent intraoperative cholangiography and 280 (0.30%) had a common duct injury. The common duct injury rate was 0.21% among patients with intraoperative cholangiography and 0.36% among patients without it. In a logistic regression model controlling for patient, surgeon, and hospital characteristics, the odds of common duct injury for cholecystectomies performed without intraoperative cholangiography were increased compared with those performed with it (OR, 1.79 [95% CI, 1.35-2.36]; P < .001). When confounding was controlled with instrumental variable analysis, the association between cholecystectomy performed without intraoperative cholangiography and duct injury was no longer significant (OR, 1.26 [95% CI, 0.81-1.96]; P = .31). When confounders were controlled with instrumental variable analysis, there was no statistically significant association between intraoperative cholangiography and common duct injury. Intraoperative cholangiography is not effective as a preventive strategy against common duct injury during cholecystectomy.JAMA The Journal of the American Medical Association 08/2013; 310(8):812-20. DOI:10.1001/jama.2013.276205 · 30.39 Impact Factor