Critical analysis of retained and residual common duct stones

Two-hundred and seven consecutive patients with suspected choledocholithiasis were treated at three university-affiliated hospitals. Twenty-one patients had residual common bile duct (CBD) stones documented after previous biliary tract operations and 28 patients had retained stones in the CBD on predischarge postoperative t-tube cholangiograms. Use of operative cholangiography was analyzed to determine correlation with the incidence of retained and residual CBD stones. Operative cystic duct cholangiography was not done in any patient who developed residual stones after simple cholecystectomy. Twenty-five of the 28 patients (86%) with retained stones either left the operating room with an abnormal postexploration cholangiogram or did not have a postexploration cholangiogram. Only three patients (10%) had falsely negative postexploration t-tube cholangiograms. The percentage of abnormal postoperative CBD exploration cholangiograms that showed filling defects as opposed to ampullary obstruction was significantly higher in patients with retained stones versus patients not having retained stones (P less than or equal to 0.0009). The vast majority of cases of retained and residual stones could be attributed to poor surgical judgment regarding either use or interpretation of operative cholangiography.     

The role of laparoscopy in the management of common bile duct obstruction in children

BACKGROUND: Laparoscopic common bile duct exploration is commonplace in adults; however, this procedure is not often performed in children. The goal of this study was to evaluate the results of laparoscopic common bile duct exploration in children. METHODS: Of 50 patients undergoing laparoscopic cholecystectomy, six patients (12%) had obstructing lesions of the common bile duct (CBD). Five children underwent laparoscopic common bile duct exploration, and one child had a preoperative endoscopic sphincterotomy and stone removal. RESULTS: The mean age at laparoscopic CBD exploration was 11.6 years (range, 5-16). The obstructing lesion was visualized by intraoperative cholangiography in all five patients. The mean operative time for laparoscopic cholecystectomy along with CBD exploration was 215 min (range, 160-282). The transcystic laparoscopic CBD exploration was performed using a 7-Fr, multichannel rigid, or 10-Fr flexible fiberoptic cystoscope. The stones were either pushed into the duodenum with the scope or extracted through the cystic duct using a 3-Fr Segura basket. In one patient, a candidial ball disintegrated during an attempt to remove it with the basket. A repeat cholangiogram at the end of each procedure showed an anatomically normal CBD with free flow of contrast into the duodenum. All patients enjoyed a quick recovery. They were started on a regular diet on the same day of surgery and discharged on the 1st or 2nd postoperative day. One patient with sickle cell disease developed a pulmonary infarction and required 5 additional days of hospitalization. One patient developed recurrent choledocholithiasis 6 months after laparoscopic exploration and was treated successfully with endoscopic sphincterotomy and stone extraction. CONCLUSIONS: Laparoscopic CBD exploration can be performed safely at the time of the cholecystectomy in children. Endoscopic sphincterotomy before cholecystectomy is not necessary. We recommend laparoscopic CBD exploration for obstructing lesions of the CBD. Endoscopic sphincterotomy should be reserved for recurrent lesions of the CBD after laparoscopic cholecystectomy.     

The role of endoscopic retrograde cholangiopancreatography and cholangiography in the laparoscopic era.

OBJECTIVE: The authors reviewed the results of endoscopic retrograde cholangiopancreatography (ERCP) and intraoperative cholangiography in a series of patients who underwent laparoscopic cholecystectomy. SUMMARY BACKGROUND DATA: The indications for preoperative and postoperative ERCP and intraoperative cholangiography as adjuncts to laparoscopic cholecystectomy are evolving. The debate regarding the use of selective or routine intraoperative cholangiography has intensified with the advent of laparoscopic cholecystectomy. METHODS: The authors reviewed the records of 343 consecutive patients who underwent laparoscopic cholecystectomy during a 1-year period. Historical, biochemical, and radiologic findings for the patients who underwent ERCP and intraoperative cholangiography were analyzed. RESULTS: Three hundred forty- three patients underwent laparoscopic cholecystectomy during the period reviewed. Preoperative ERCP was performed in 42 patients. Twenty-seven of these patients (64%) had common bile duct (CBD) stones, which were cleared with a sphincterotomy. Intraoperative cholangiography was performed for 101 patients (29%). Three cholangiograms had false- positive results (3%), leading to two CBD explorations, in which no CBD stones were found, and one normal ERCP. Six patients underwent postoperative ERCP, three for the removal of retained CBD stones (0.9%), all of which were cleared with a sphincterotomy. Fifteen patients had gallstone pancreatitis, six of whom had CBD stones (40%) that were cleared by ERCP. There were 33 complications (10%) and no CBD injuries. CONCLUSION: The use of routine intraoperative cholangiography is discouraged in view of its low yield and the significant rate of false positive cholangiogram results.     

Current management of common bile duct stones in a teaching community hospital

The advent of laparoscopic cholecystectomy (LC) has complicated management of common bile duct (CBD) stones. While LC is routine, laparoscopic CBD exploration (LCBDE) is not, and an algorithm to manage suspected choledocholithiasis has not been uniformly accepted. We evaluated current management of choledocholithiasis. Patients suspected of having CBD stones over a 2-year period were evaluated, and 42 studies in the literature were reviewed. Thirty-two patients were identified. Fourteen patients (44%) had LC with intraoperative cholangiogram (IOC) with no preoperative studies. IOC revealed CBD stones in nine (64%). Seven had CBD exploration (CBDE) at cholecystectomy, and two had postoperative endoscopic retrograde cholangiopancreatography (ERCP). CBDE was successful in five cases, and ERCP was successful in one. Eighteen patients (56%) underwent preoperative ERCP. Five (28%) had no CBD stones. ERCP removed stones in nine patients, and four had open CBDE after failed ERCP. Current literature supports LC with IOC without any preoperative studies. Laparoscopic CBDE is highly successful but depends on surgeon experience. Removing CBD stones with ERCP is also very successful but is associated with increased cost, hospital stay, and complications. We conclude that LC with IOC should be performed without preoperative ERCP when choledocholithiasis is suspected. If found, stones should be removed laparoscopically if possible.     

Identification of bile duct stones in patients undergoing laparoscopic cholecystectomy.

To identify patients with common bile duct stones, all patients considered for laparoscopic cholecystectomy in this unit undergo intravenous cholangiography (IVC) with tomography and, more recently, operative cholangiography. To date 100 consecutive patients with symptomatic gallstones have undergone laparoscopic cholecystectomy with no specific exclusion criteria. Eight patients of 100 were found to have duct stones on IVC with one false-positive. These IVC data were compared with data from 52 patients who also had operative cholangiograms performed. One stone was detected on operative cholangiography that was not identified on IVC. No additional information was gained from operative cholangiography. These data suggest that preoperative IVC is adequate for the detection of duct stones in patients considered for laparoscopic cholecystectomy.     

LAPAROSCOPIC CHOLECYSTECTOMY AND MANAGEMENT OF CHOLEDOCHOLITHIASIS

The advent of laparoscopic cholecystectomy (LC) has led to a reassessment of the approach to the management of choledocholithiasis. In a consecutive series of 418 patients undergoing LC, common bile duct (CBD) stones were suspected pre-operatively in 130 patients. Forty-five of the patients (35%) were found to have CBD stones on either pre-operative endoscopic retrograde cholangiopancreatography (ERCP; 20) or on operative cholangiography (OC; 25). Common bile duct stones were detected on OC in a further 12 of 288 patients (4.2%) without pre-operative suspicion of choledocholithiasis. Of the total of 57 patients with CBD stones, the duct was cleared by pre-operative ERCP and endoscopic sphincter-otomy (ES) in 15 patients. In 13 patients, two of whom had had a pre-operative ERCP and ES, duct clearance was achieved by relaxing the sphincter pharmacologically and flushing the CBD via the OC catheter. One patient had an on-table ERCP and ES with successful stone extraction during LC. Eleven patients were converted to open operation with bile duct exploration. Sixteen patients had a postoperative ERCP. In five patients the CBD stones had passed spontaneously in the time between LC and ERCP. Ten patients required ES to clear the duct of stones. One patient had a failed ERCP and is still awaiting a repeat. The remaining patient was scheduled, but did not return for follow-up ERCP. In summary, pre-operative ERCP was indicated in less than 10% of patients in this series. It was possible to deal with over one-third of CBD stones found at LC by the simple technique of pharmacological relaxation of the spincter of Oddi and flushing the duct through the cholangiogram catheter. Of the patients who required follow-up ERCP, one third had passed their CBD stones by the time of the examination and the rest required ES for stone extraction. Less than 3% of the entire series of patients were converted to open operation for exploration of the common bile duct.     

The utility of laparoscopic common bile duct exploration in the treatment of choledocholithiasis

Laparoscopic common bile duct exploration (CBDE) was performed in 24 patients over a 23-month period. Fourteen of these patients were suspected preoperatively of harboring common bile duct (CBD) calculi. Of these, endoscopic sphincterotomy was unsuccessful in eight. Laparoscopic CBDE was performed either transcystically or via a choledochotomy. In all cases, completion cholangiography demonstrated that the CBD was free of stones. All patients were sent home with drains placed in their extrahepatic biliary system. Mean hospital stay was 2.7 days. There was no mortality. The overall morbidity rate was 29.1%. It included one trocar site infection (4.1%), four cases of mild postoperative amylasemia (16.6%), and two cases of retained stones (8.3%) seen in two patients on follow-up tube cholangiography that were successfully extracted percutaneously. The authors feel that laparoscopic CBDE is a safe and effective method of CBD stone removal that offers an alternative to preoperative ERCP and sphincterotomy.     

Laparoscopic surgery and the common bile duct

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

The laparoscopic approach to cholecysto-choledocholithiasis.The "rendez-vous " technique

A combined method of endoscopic sphincterotomy (ES) with common bile duct (CBD) stone extraction and laparoscopic cholecystectomy under general anesthesia for a single-session treatment of patients with colecysto-choledocholithiasis is described. The so called "rendez-vous" technique consists in: standard laparoscopic cholecystectomy with intraoperative cholangiography followed by ES if common bile duct stones are detected. The sphincterotome is driven across the papilla through a wire guide inserted by transcystic route. Nine patients were scheduled for "rendez-vous" approach. At intraoperative cholangiography 4 have had CBD stones. Endoscopic sphincterotomy and CBD clearance were successful in all patients. No complication was encountered. Mean postoperative hospital stay was 5 days. The laparo-endoscopic "rendez-vous" approach is feasible, it reduces the number of unnecessary ERCP examinations, it lowers the morbidity related with endoscopic sphincterotomy and shortens the hospital stay.     

Prospective evaluation of a selective approach to cholangiography for suspected common bile duct stones

INTRODUCTION

Common bile duct (CBD) stones can cause serious morbidity or mortality, and evidence for them should be sought in all patients with symptomatic gallstones undergoing cholecystectomy. Routine intra-operative cholangiography (IOC) involves a large commitment of time and resources, so a policy of selective cholangiography was adopted. This study prospectively evaluated the policy of selective cholangiography for patients suspected of having choledocholithiasis, and aimed to identify the factors most likely to predict the presence of CBD stones positively.

PATIENTS AND METHODS

Data from 501 consecutive patients undergoing laparoscopic cholecystectomy (LC) for symptomatic gallstones, of whom 166 underwent IOC for suspected CBD stones, were prospectively collected. Suspicion of choledocholithiasis was based upon: (i) deranged liver function tests (past or present); (ii) history of jaundice (past or present) or acute pancreatitis; (iii) a dilated CBD or demonstration of CBD stones on imaging; or (iv) a combination of these factors. Patient demographics, intra-operative findings, complications and clinical outcomes were recorded.

RESULTS

Sixty-four cholangiograms were positive (39%). All indications for cholangiogram yielded positive results. Current jaundice yielded the highest positive predictive value (PPV; 86%). A dilated CBD on pre-operative imaging gave a PPV of 45% for CBD calculi; a history of pancreatitis produced a 26% PPV for CBD calculi. Patients with the presence of several factors suggestive of CBD stones yielded higher numbers of positive cholangiograms. Of the 64 patients having a laparoscopic common bile duct exploration (LCBDE), four (6%) required endoscopic retrograde cholangiopancreatography (ERCP) for retained stones (94% successful surgical clearance of the common bile duct) and one (2%) for a bile leak. Of the 335 patients undergoing LC alone, three (0.9%) re-presented with a retained stone, requiring intervention. There were 12 (7%) requiring conversion to open operation.

CONCLUSIONS

A selective policy for intra-operative cholangiography yields acceptably high positive results. Pre-operatively, asymptomatic bile duct stones rarely present following LC; thus, routine imaging of the biliary tree for occult calculi can safely be avoided. Therefore, a rationing approach to the use of intra-operative imaging based on the pre-operative indicators presented in this paper, successfully identifies those patients with bile duct stones requiring exploration. Laparoscopic bile duct exploration, performed by an experienced laparoscopic surgeon, is a safe and effective method of clearing the bile duct of calculi, with minimal complications, avoiding the necessity for an additional intervention and prolonged hospital stay.     

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

Determining the most appropriate management approach for patients with unsuspected choledocholithiasis may be difficult because of the subjective nature of this decision in the absence of clinical data. Treatment of incidental choledocholithiasis during laparoscopic cholecystectomy was reviewed during a 25-month period. Operative cholangiograms were analyzed retrospectively to determine if associations exist between common bile duct stone characteristics and the intraoperative treatment selected by the operating surgeon. Cholangiographic data included quantification of common bile duct stones, stone dimension, position, and presence of radiopaque contrast flow into the duodenum. Two hundred thirty-six laparoscopic cholecystectomy patients underwent operative cholangiography; 25 (11%) demonstrated choledocholithiasis. Seven patients were converted to open common bile duct exploration (group I), 16 patients were referred for postoperative endoscopic retrograde cholangiopancreatography (group II), and two patients were observed (group III). Evaluation of the operative cholangiograms revealed multiple common bile duct stones (> 1) in 86% (6 of 7) in group I, 25% (4 of 16) in group II, and none in group III. All patients in group I had at least one stone larger than 5 ml in greatest diameter, whereas only 33 % (6 of 18) in groups II and III combined had stones larger than 5 ml. Group I had significantly (P = 0.027) more representation of delayed or no contrast flow during operative cholangiography compared to groups II and III. The intraoperative decision to proceed with laparoscopic cholecystectomy and rely on postoperative endoscopic retrograde cholangiopancreatography for stone retrieval rather than open common bile duct exploration was associated with (1) a single common bile duct stone, less than or equal to 5 ml in size on operative cholangiogram and (2) normal contrast flow into the duodenum. Open common bile duct exploration was more frequently associated with the demonstration of multiple or large (>5 ml) stones. A periampullary stone did not discriminate among treatment choices. Presented at the Annual Scientific Meeting of the Southern California Chapter of the American College of Surgeons, Santa Barbara, Calif., January 19–21, 1996.     

Retained common bile duct stones. Endoscopic papillotomy is the preferred approach

In six patients who had undergone cholecystectomy and common bile duct exploration, the postoperative T-tube cholangiogram demonstrated stones. Endoscopic cholangiography demonstrated a normal common bile duct in 2 patients and stones in 4 patients. In the latter group, endoscopic papillotomy and stone extraction were successful.     

Laparoscopic transcystic biliary calculus extraction with Dormia basket

We describe transcystic common bile duct (CBD) stone extraction using Dormia basket in patients with preoperatively unexpected CBD stones during laparoscopic cholecystectomy (LC). We perform intraoperative cholangiography (IOC) selectively. Stone extraction was successful five times and we converted to open procedure in one patient because of the size of the stone. Mild postoperative acute pancreatitis developed once. No other complication was detected. Procedures performed if CBD stone is detected intraoperatively are evaluated in the article, including indications and difficulties of the Dormia basket method. We suggest the introduction of the method as an alternative treatment for unexpected CBD stones during laparoscopic cholecystectomy.     

Selective cholangiography. Current role in laparoscopic cholecystectomy.

The initial 22-month experience with laparoscopic cholecystectomy in 400 patients employing an algorithm of selective cholangiographic evaluation is reported. Preoperative or postoperative endoscopic retrograde cholangiography was performed whenever stones were suspected clinically. Preoperative endoscopic retrograde cholangiography was performed in 44 patients (11%), in whom 14 (3.5%) had an endoscopic sphincterotomy with extraction of common bile duct stones. Intraoperative cholangiography was performed in only eight patients (2%) almost exclusively to acquire experience with the technique, and all cholangiograms were normal. Laparoscopic cholecystectomy was successfully completed in 96% of the patients. There were no deaths in this series, and major complications occurred in only 5% of patients. Two patients (0.5%) had a significant common bile duct injury that was recognized and successfully repaired at the initial operation. No late common bile duct strictures have been recognized. Six patients (1.5%) underwent postoperative endoscopic retrograde cholangiography for suspected common bile duct stones, with three patients requiring endoscopic sphincterotomy and stone extraction. This experience suggests that the use of preoperative and postoperative endoscopic retrograde cholangiography can be based on clinical presentation and laboratory evaluation and does not need to be performed routinely. Routine intraoperative cholangiography is not necessary in most patients undergoing laparoscopic cholecystectomy. The authors conclude that laparoscopic cholecystectomy can be performed safely with the selective use of cholangiography.     

Assessment of the common bile duct before cholecystectomy using ultrasound and biochemical measurements: validation based on follow-up.

The selective use of operative cholangiography with cholecystectomy is controversial. We have combined measurement of the serum bilirubin, alkaline phosphatase and alanine aminotransferase with ultrasound measurement of the bile duct diameter to assess the common bile duct before cholecystectomy. Direct contrast cholangiography was not performed if the results of these measurements were normal on the day before operation. There were 253 patients assessed in this way before laparoscopic cholecystectomy. Patients with known bile duct stones were excluded, but those with a previous history of jaundice, pancreatitis or abnormal liver function tests were included. In 47 cases abnormalities were found and X-ray cholangiograms were performed; only six patients were found to have bile duct stones. Follow-up of all 253 patients, including repeating the preoperative measurements after 12 months in 93, found only two patients with evidence that common duct stones had been missed and these two stones passed spontaneously. No bile duct injuries have occurred. We conclude that preoperative assessment of the bile duct using ultrasound and liver function tests safely obviates the need for 'routine' operative cholangiography.     

Common bile duct evaluation in the era of laparoscopic cholecystectomy. 1050 cases later.

OBJECTIVE: The authors documented the evolution of common bile duct (CBD) evaluation after the development of laparoscopic cholecystectomy (LC) and CBD exploration. Emphasis was placed on stratification of CBD stone risk so that subgroups could be selected appropriately for no further studies, preoperative endoscopic retrograde cholangiogram (ERC), or intraoperative intervention. METHODS: Data were accumulated by the authors on presentation, findings, and outcomes of 1050 patients who underwent cholecystectomies. Risk stratification was based on the history, ultrasound findings, biochemical derangements, and operative findings. RESULTS: Fifty-seven per cent of patients met criteria to be "no/low" risk for CBD stones (CBD diameter < 5 mm, normal liver enzymes, and no history of acute cholecystitis, jaundice, or pancreatitis); in these patients, cholangiograms were not obtained, and there was no clinical evidence of CBD stones observed in follow-up at 45 months (sensitivity = 100%). As techniques developed for laparoscopic CBD exploration, there was a decreased incidence of open cholecystectomy (p < 0.05) and preoperative ERC (p < 0.05). The rate of operative cholangiogram increased from 13% to 23% during the series (p < 0.01). There were no CBD injuries or late strictures. The only bile leak occurred from a peripheral segmental duct in the gallbladder bed and was resolved with a laparotomy and suture. There were no transfusions. Three retained stones were documented in patients who had false-normal operative cholangiograms. CONCLUSIONS: Criteria were defined that delineate a "no/low" risk group of LC patients for whom operative cholangiograms were not indicated for excluding CBD stones. The routine use of operative cholangiography as a means of preventing CBD injury was not substantiated by this study. The indications for preoperative ERC should continue to decrease as laparoscopic techniques evolve.     

Abnormal cholangiograms during laparoscopic cholecystectomy

Background: Laparoscopic common bile duct exploration (LCBDE) is more expensive and time consuming than its conventional counterpart. Therefore, it should only be performed when there is near certainty that stones are present. The purpose of this study was to identify patients who should be spared LCBDE despite an abnormal intraoperative cholangiogram. Methods: Of 700 consecutive laparoscopic cholecystectomies performed between 1989 and 1994 by a single surgeon (R.J.F.), 41 had abnormal intraoperative cholangiograms (6%). All 41 patients were treated by either immediate CBDE (19) (conventional or laparoscopic) or had postoperative follow-up cholangiograms (22). The patients were retrospectively assigned to one of three groups. Group I patients had a single ``soft' indicator of choledocholithiasis. Group II patients had one or more of the following: (1) a highly suspicious abnormal intraoperative cholangiogram, (2) two or more ``soft' indicators of choledocholithiasis, or (3) preoperative clinical findings such as elevated liver function studies or positive preoperative radiological studies. Group III patients had proven choledocholithiasis. Results: In group I, there were 11 patients, none of whom underwent immediate CBDE. Eight of the 11 (73%) had normal follow-up cholangiograms due to either spontaneous stone passage or a false-positive intraoperative cholangiogram. There were 27 patients in group II; 19 underwent immediate CBDE with 100% stone recovery. The remaining 8 had delayed treatment and in five stones were recovered, while three had normal postoperative cholangiograms suggesting spontaneous stone passage. In group III, all three had negative follow-up cholangiograms despite proven choledocholithiasis. Spontaneous stone passage in this group seemed highly likely. Conclusions: The finding of a single soft indicator results in a low rate of stone recovery postoperatively, and these patients should not undergo LCBDE. In this series, spontaneous stone passage seemed highly likely in at least 3/22 (14%) and possibly as high as 14/22 (64%). Received: 29 March 1996/Accepted: 29 July 1996     

Intravenous cholangiography,ERCP, and selective operative cholangiography in the performance of laparoscopic cholecystectomy

Between March 1990 and March 1993 some 822 consecutive patients underwent an attempt at laparoscopic cholecystectomy. Intravenous cholangiography (IVC), ERCP, and selective intraoperative cholangiography (IOC) were used in the evaluation of common bile duct (CBD) stones. Two hundred thirteen patients (26%) were identified preoperatively with either abnormal liver functions or a dilated common bile duct suggestive of CBD stones. IVC was performed in 143 patients (67%). Choledocholithiasis was identified in 14 patients (10%). Preoperative therapeutic ERCP was successful in all 14 patients (100%). Diagnostic ERCP was attempted in 61 patients and successful in 59 (97%). Choledocholithiasis was identified in 25 patients (41%). Successful extraction was accomplished in 23 patients (92%). Transcystic common bile duct exploration was used effectively in the patients with an unsuccessful ERCP. IOC was attempted in 50 patients and successful in 48 (96%). Choledocholithiasis was identified in three (6%). A retained CBD stone was present in eight patients (1%). There was one level I CBD injury (0.122%). The use of IVC, selective ERCP, and selective IOC is a reasonable approach in the performance of laparoscopic cholecystectomy.     

Operative cholangiography during laparoscopic cholecystectomy: considerations about routine or selective policy

Operative cholangiography (OC) during laparoscopic cholecystectomy (LC) is still a matter of debate regarding its routine or selective use. The present report is based upon a series of 30 selective cholangiographies performed in 290 LC during the years 1999-2004. Indications to OC were decided according to clinical data, liver chemistries, ultrasonographic (US) and intraoperative findings. In cases of unequivocal common bile duct (CBD) stones, a preoperative ERCP was performed and OC was not applied to confirm clearing of the biliary tract. OC was successful in 26 cases (86.6%): in 18 cases a normal cholangiogram was obtained and in 3 cases stones were detected into CBD. These patients underwent a postoperative successful ERCP at a variable interval of time. In 4 cases cholangiograms showed a delayed transit and in a single case a lack of contrast into the duodenum. Such occurrence was due to morphine derivatives employed during anesthesia. The Authors evaluate advantages and drawbacks of routine and selective OC according to personal and other Authors experience. Decision on selective or routine policy should be taken according to each surgeon experience and local facilities. Each laparoscopic surgeon must be able to perform and interpret an OC, specially if he has in mind to develop competence in laparoscopic CBD exploration.     

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

Background 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. Methods 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. Results 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. Conclusion 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. Presented at the 12^th meeting of the EAES, Barcelona, Spain, June 2004