Intraoperative cholangiography revisited.

The charts of 1351 patients undergoing cholecystectomy at our institutions from 1985 through 1989 were reviewed retrospectively to evaluate the indications for and the success of intraoperative cholangiography. A total of 800 patients underwent intraoperative cholangiography. They were divided into two groups based on the absence (CR-) or presence (CR+) of clinical and/or operative criteria suggestive of the existence of common bile duct stones. Intraoperative cholangiography in CR- patients was of limited benefit, being negative (normal) in 95.7%, true-positive (abnormal) in 3.3%, and false-positive in 1%. False-positive intraoperative cholangiography resulted in unnecessary common bile duct explorations. Intraoperative cholangiography in CR+ patients proved useful, avoiding unnecessary common bile duct exploration in 55%. In those select CR+ patients with palpable common bile duct stones or cholangitis, little additional information was gained by the intraoperative cholangiography. We conclude that routine screening intraoperative cholangiography in CR- patients be reconsidered, as should the use of intraoperative cholangiography in CR+ patients with a palpable common bile duct stone or cholangitis. Intraoperative cholangiography in the remainder of CR+ patients proved beneficial and should be continued.     

Does routine intraoperative cholangiography prevent bile duct transection?

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

Endoscopic cholangiography and stone removal prior to cholecystectomy. A more cost-effective approach than operative duct exploration?

Would economic benefit result from performing endoscopic cholangiography and removal of common bile duct stones prior to cholecystectomy in patients who are suspected preoperatively of having choledocholithiasis? In this study, 173 patients had cholecystectomy and 30 (17%) had common bile duct exploration. Records of these patients were reviewed as were those of 31 patients who had only endoscopic cholangiography and endoscopic stone removal. Cost estimates were based on local charges. Cholecystectomy with common bile duct exploration was $6730 more per patient than cholecystectomy alone. Endoscopic cholangiography and endoscopic stone removal was 87% successful in removing duct stones. Had endoscopic cholangiography and endoscopic stone removal been performed preoperatively in patients undergoing cholecystectomy who had suspected choledocholithiasis, 21 of 30 common bile duct explorations could theoretically have been eliminated. This would have saved $85,526 or $2851 per patient undergoing common bile duct exploration. Our analysis suggests that patients who require cholecystectomy and have suspected choledocholithiasis may be treated more cost-effectively by performing endoscopic cholangiography and endoscopic stone removal immediately prior to cholecystectomy than by cholecystectomy and operative common bile duct exploration.     

Is preoperative evaluation of the biliary tree necessary in uncomplicated gallstone disease? Results of a randomized trial.

AIM: To analyse if preoperative radiology is of value in patients with uncomplicated gallstone disease. MATERIAL: 312 patients intended for laparoscopic cholecystectomy were randomly allocated to undergo preoperative radiology (intravenous cholangiography or magnetic resonance cholangiography) or to a control group. Intraoperative cholangiography was not used routinely in either group. RESULTS: There was no bile duct injury and no difference in complication frequency between the two groups. The incidence of common bile duct stones was 3.8% within the first postoperative year with no statistical difference between the two groups. CONCLUSIONS: Routine preoperative evaluation of the bile tree seems unnecessary before laparoscopic cholecystectomy in patients with uncomplicated gallstone disease.     

Präoperative Diagnostik vor laparoskopischer Cholezystektomie Gibt es eine Indikation zur routinemäßigen i.v.-Cholangiographie?

In a retrospective study including 163 patients we investigated the necessity of i.v. cholangiography in preoperative routine diagnostic workup prior to laparoscopic cholecystectomy. We evaluated the evidence of i.v. cholangiography concerning the anatomy of the biliary system, the evidence of common bile duct or cystic duct stones and the influence on the further therapeutic procedure. While the common bile duct could be demonstrated in 96.3%, the cystic duct could be visualized in only 54.6%. One out of two patients with a short cystic duct was identified. Stones in the gallbladder were recognized in 72.4% of cases, while only two out of three patients with common bile duct stones were diagnosed. In nine cases a deep junction of the cystic duct was found, but there was no influence on further operative procedure. Thus we found no improvement after routine use of i.v. cholangiography concerning the evidence of common bile duct stones or avoidance of intraoperative lesions of the common bile duct. The routine use of i.v. cholangiography prior to laparoscopic cholecystectomy is therefore not justified.     

Preoperative ultrasonic of common bile duct stones and its importance to surgical management--result of a prospective controlled trial

The biliary tract was examined by sonography in 192 nonselected surgical patients with clinically suspected gallbladder stone disease. This study was carried out to assess the potentiality of ultrasonic examination in the detection of common bile duct stones. All patients were operated on with sonographic monitoring during surgery. Common bile duct stones can be detected with high accuracy only in patients with an obstructive jaundice and a dilated common duct. In these, the sensitivity was found to be 70%, whereas that for the whole group of patients was as low as 28%. Accuracy in the ultrasonic detection of common bile duct stones is limited, and operative cholangiography seems to retain its position as the most reliable method of exploring common bile duct stones.     

Selective intraoperative cholangiography during laparoscopic cholecystectomy: how selective?

The necessity for intraoperative cholangiography during laparoscopic cholecystectomy has been debated for some time. Numerous retrospective studies favor selective intraoperative cholangiography. Surgeons in favor of the selective policy differ in their personal selective criteria. The aim of this prospective study was to evaluate whether intraoperative cholangiography can be safely omitted during laparoscopic cholecystectomy on all patients who fit a standard set of criteria: normal liver function tests, common bile duct diameter less than 10 mm, and no history of gallstone pancreatitis or jaundice. We undertook a prospective study on 155 consecutive patients treated in a county teaching hospital with symptomatic gallbladder disease who met the above standard set of criteria. One hundred and fifty-five patients meeting these criteria underwent laparoscopic cholecystectomy during a 2-year period from February 1996 through February 1998. Data analyzed included patient history, laboratory and ultrasound findings, operative results, postoperative stay, and intraoperative and postoperative complications. The patients were followed by periodic interviews, physical examination, liver function tests, and/or biliary ultrasound for up to 3 1/2 years with a mean follow-up of 26 months for retained common bile duct stones. Intraoperative cholangiography was performed in only one of the 155 patients studied to confirm common bile duct injury. There were four postoperative complications (2.6%) and one common bile injury (0.6%). Postoperative stay averaged one day. No patients, by history, biliary ultrasound, liver function tests or endoscopy, were found to have retained common bile duct stones during the follow-up period. Our study shows that intraoperative cholangiography is not necessary for patients undergoing laparoscopic cholecystectomy who have normal liver functions tests, common bile duct diameter less than 10 mm, and no history of gallstone pancreatitis or jaundice.     

A prospective study of common bile duct calculi in patients undergoing laparoscopic cholecystectomy: natural history of choledocholithiasis revisited

OBJECTIVE: To define the incidence of problematic common bile duct calculi in patients undergoing laparoscopic cholecystectomy. SUMMARY BACKGROUND DATA: In patients selected for laparoscopic cholecystectomy, the true incidence of potentially problematic common bile duct calculi and their natural history has not been determined. We evaluated the incidence and early natural history of common bile duct calculi in all patients undergoing laparoscopic cholecystectomy with intraoperative and delayed postoperative cholangiography. METHODS: Operative cholangiography was attempted in all patients. In those patients in whom a filling defect was noted in the bile duct, the fine bore cholangiogram catheter was left securely clipped in the cystic duct for repeated cholangiography at 48 hours and at approximately 6 weeks postoperatively. RESULTS: Operative cholangiography was attempted in 997 consecutive patients and was accomplished in 962 patients (96%). Forty-six patients (4.6%) had at least one filling defect. Twelve of these had a normal cholangiogram at 48 hours (26% possible false-positive operative cholangiogram) and a further 12 at 6 weeks (26% spontaneous passage of calculi). Spontaneous passage was not determined by either the number or size of calculi or by the diameter of the bile duct. Only 22 patients (2.2% of total population) had persistent common bile duct calculi at 6 weeks after laparoscopic cholecystectomy and retrieved by endoscopic retrograde cholangiopancreatography. CONCLUSIONS: Choledocholithiasis occurs in 3.4% of patients undergoing laparoscopic cholecystectomy but more than one third of these pass the calculi spontaneously within 6 weeks of operation and may be spared endoscopic retrograde cholangiopancreatography. Treatment decisions based on assessment by operative cholangiography alone would result in unnecessary interventions in 50% of patients who had either false positive studies or subsequently passed the calculi. These data support a short-term expectant approach in the management of clinically silent choledocholithiasis in patients selected for LC.     

胆总管结石残留的因素分析及防治

目的 探讨胆囊结石胆囊切除术后胆总管结石残留的原因及处理方法。方法 1994年1月2000年9月间1027例胆囊结石病人在我院施行胆囊切除术,同时行胆总管切开探查术者246例,证实有胆总管结石者205例;对其中14例术后胆总管结石残留患者的临床资料进行对比分析。结果 结石残留组病人的76％为60岁或以上,64％并发急性胆管炎,50％术中取出胆总管结石3－5枚,仅14％行术中纤维胆道镜探查取石,与无结石残留病人相比差异均有显著性意义（P＜0．05）。13例残留结石经术后胆总管T管造影发现并分别行1－2次术后纤胆镜取石后完全清除;另1例自然排出。结论 胆总管结石残留多发生于年龄较大、胆总管结石较多、并发急性胆管炎的患者;术中纤胆镜的应用有助于防止结石残留。胆总管T管造影能可靠地诊断残留结石。术后经T管瘘道纤胆镜取石是治疗残留结石安全有效的方法。     

Intraoperative endoscopy of the biliary tract

Summary 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.     

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.     

Intraoperative cholangiography in laparoscopic cholecystectomy for acute cholecystitis

In our prospective study we wanted to prove whether the safety of laparoscopic treatment of acute cholecystitis could be improved by intraoperative cholangiography. From July 1993 to June 1998 210 patients with acute cholecystitis underwent a laparoscopic cholecystectomy. In 23 cases (10.9%) a conversion was necessary. 189 patients underwent a laparoscopic cholangiography. In 2 cases (1.1%) an incision of the common bile duct was detected which had been mistaken for the cystic duct. So the cutting of the common bile duct could be prevented. In 12 patients (6.3%) unknown common bile duct stones were found. The complication rate was 9.5% without any mortality or major injury of the common bile duct.     

术中胆道造影在腹腔镜胆囊切除术中的应用

目的 :探讨术中胆道造影在腹腔镜胆囊切除术 (LC)中应用的临床价值。方法 :回顾总结 6 7例LC术中行胆道造影的技术要点。结果 :LC术中行胆道造影 6 7例 ,发现胆管结石 19例 ,近端胆囊管小结石 1例 ,乳头部狭窄 1例 ,胆道畸形 2例 ,假阳性 3例 ,准确率 95 5 %。结论 :有选择的在LC中胆道造影可以避免胆管残留结石及胆囊管残株结石 ,减少不必要的胆管阴性探查 ,发现乳头部狭窄 ,辨明胆道解剖 ,避免胆道损伤。     

经胆囊管探查减压在肝囊型包虫手术中的应用

目的 探讨经胆囊管探查减压在肝囊型包虫手术中处理隐匿型胆漏的疗效.方法 回顾性分析新疆医科大学第一附属医院从2002年6月到2008年6月手术治疗的819例肝囊型包虫病人中实施胆道探查的172例资料,对术后平均住院日、术后残腔并发症(胆漏、残腔积液、残腔感染)、胆道并发症(胆道梗阻、胆道狭窄、胆道感染、胆漏)进行比较分析.结果 经胆囊管探查减压组(A组)术后残腔并发症、术后平均住院日与胆总管探查"T"管减压组(B组)无明显差异,但胆道并发症两组具有统计学意义(P<0.05).结论 经胆囊管探查减压在肝囊型包虫手术中具有操作简单、安全、有效,术后彻底解决残腔胆漏,并可避免传统T管减压相关并发症等优点.     

Can three-dimensional helical CT cholangiography before laparoscopic cholecystectomy be a substitute study for endoscopic retrograde cholangiography?

The study investigated the usefulness of three-dimensional helical computed tomography (3D-CT) before laparoscopic cholecystectomy (LSC) when compared with that of endoscopic retrograde cholangiography (ERC). Forty-five patients referred for LSC, who had undergone 3D-CT cholangiography and ERC simultaneously, participated in the study. Endoscopic retrograde cholangiography and 3D-CT cholangiography were compared in each patient with regard to opacification of the biliary tree, stones, and anatomic variations. Three-dimensional helical CT cholangiography and ERC imaging for predicting operative difficulties in LSC also were compared. The common bile duct and cystic duct were shown in the patients by the images, but the gallbladder was shown in 43 patients (96%) with use of 3D-CT cholangiography and in 36 patients (80%) with use of ERC. A third or more peripheral branches were shown completely with use of 3D-CT cholangiography in 33 patients (73%) and in 32 patients (71%) with use of ERC. Cystic duct stones were found in two of three patients with use of 3D-CT cholangiography and ERC. Common bile duct stones in five of seven patients were detected with use of 3D-CT cholangiography, but all of the common bile duct stones were detected with use of ERC. Anatomic variations of the bile duct were shown in three of four patients by 3D-CT cholangiography and in all patients with use of ERC. No significant differences in findings of the angle of bifurcation and presence of Heister valves between operative easy and complex cases were shown by 3D-CT cholangiography and ERC, despite the more accurate assessment of the cystic duct anatomy with use of 3D-CT cholangiography than with use of ERC. Three-dimensional helical CT cholangiography is useful clinically in preoperative assessment of biliary anatomy, but it is not reliable in the detection of common bile duct stones, and it is not helpful in predicting technical difficulty during LSC.     

腹腔镜胆囊切除术中胆道造影的应用价值

目的 评价术中胆道造影技术在腹腔镜胆囊切除术中的应用价值。方法 腹腔镜胆囊切除术中经胆囊管插管行胆道造影共1226例,其中1180例造影成功,成功率为95．5％。结果 术中造影共发现胆总管结石78例,胆管损伤7例,副肝管2例。结论 腹腔镜胆囊切除术中胆道造影简单易行,显影清楚,能提高手术质量,降低胆管损伤发生率。     

术中胆道造影在腹腔镜胆囊切除术中的应用价值

目的 评价术中胆道造影技术在腹腔镜胆囊切除术中的应用价值。方法 腹腔镜胆囊荨除术中经胆囊管插管行胆道造影共１４６６例,１３８２例造影成功,成功率为９４．２７％。结果 术中造影发现胆总管结石９２例,胆管损伤８例,副肝管１例。结论术中造影操作迅速,安全,显影清晰成功率高,能降低胆管损伤发生率;提高腹腔胆囊切除术的质量,值得推广应用。     

Die Spiral-CT-Cholangiographie ist für die Routinediagnostik vor laparoskopischer Cholecystektomie nicht geeignet

INTRODUCTION: The purpose of this prospective controlled study was to evaluate the diagnostic potential of spiral computed tomographic (CT) cholangiography in patients undergoing laparoscopic cholecystectomy. METHODS: 60 patients (17 men, 43 women, mean age 54.5 years, range 15-84 years) with symptomatic cholecystolithiasis were included in this study. After infusion of meglumine jodoxamate, all patients underwent upper abdominal spiral CT. The results of the spiral CT scan were then compared with endoscopic retrograde cholangiography (ERC) or intraoperative cholangiography. RESULTS: In 53 patients (88%) CT cholangiography was considered to be technically adequate for interpretation, but was suboptimal in 4 patients (7%) and nondiagnostic in 3 patients (5%), respectively. CT cholangiography showed a stone free common bile duct in 51 patients which was correct in all cases. CT cholangiography predicted a common bile duct stone in 6 patients which proved to be correct in 4 patients but was found to be incorrect in 2 patients. CONCLUSION: Spiral CT cholangiography is useful for the diagnosis of common bile duct stones. Because of the low positive predicting value routine use before laparoscopic cholecystectomy is not justified.     

选择性胆道造影在腹腔镜胆囊切除术中的应用体会

目的 评价选择性术中胆道造影在腹腔镜胆囊切除术中的应用价值。方法 腹腔镜胆囊切除术中经胆囊管插管行胆道造影共88例。结果 造影均成功。术中造影发现胆总管结石5例,无胆管损伤。结论 选择性术中胆道造影,对降低胆总管结石残留,避免胆管损伤,提高腹腔镜胆囊切除术的疗效有重要价值。     

OPERATIVE CHOLANGIOGRAPHY: EVALUATION OF ITS ROUTINE USE IN 569 CHOLECYSTECTOMIES1

From 1974 till 1979, 569 cholecystectomies with routine operative cholangiography were performed in the university surgical unit, Kwong Wah Hospital, Hong Kong, for non-malignant diseases of the gallbladder. Gallstones were present in 522 cases. Acalculous cholecystitis occurred in 47 cases. At least one of the clinical or operative indications to explore the common bile duct was present in 312 of the patients. However, in this group of patients in whom routine operative cholangiography was done, exploration of the common bile duct was performed in only 147, thus avoiding unnecessary exploration of the duct in 165 cases (52.8%). In the remaining 257 patients in whom there was no indication to explore the common bile duct, operative cholangiography revealed unexpected stones in the common bile duct in 14 (5.5%). After choledochotomy, post exploratory operative T-tube cholangiography was performed to rule out overlooked stones, which were present in six cases (6/161, i.e., 3.7%). Postoperative T-tube cholangiography performed on the 12th to the 14th postoperative day showed retained stones in 17 cases, giving an incidence of known retained stones of 11% (17/161) of cholecystectomies with exploration of the common bile ducts, or 3% (17/569) in the whole series of