Cost analysis and effectiveness comparing the routine use of intraoperative fluorescent cholangiography with fluoroscopic cholangiogram in patients undergoing laparoscopic cholecystectomy

Background

Despite the standardization of laparoscopic cholecystectomy (LC), the rate of bile duct injury (BDI) has risen from 0.2 to 0.5 %. Routine use of intraoperative cholangiography (IOC) has not been widely accepted because of its cost and a lack of evidence concerning its use in preventing BDI. Fluorescent cholangiography (FC), which has recently been advocated as an alternative to IOC, is a novel intraoperative procedure involving infrared visualization of the biliary structures. This study evaluated costs and effectiveness of routinely implemented FC and IOC during LC.

Materials and methods

Between February and June 2013, the authors prospectively collected the data of all patients undergoing laparoscopic cholecystectomy. We retrospectively reviewed and compared the use of FC and IOC. Procedure time, procedure cost, and effectiveness of the two methods were analyzed and compared. The surgeons involved in the cases completed a survey on the usefulness of each method.

Results

A total of 43 patients (21 males and 22 females) were analyzed during the study period. Mean age was 49.53 ± 14.35 years and mean body mass index was 28.35 ± 8 kg/m². Overall mean operative time was 64.95 ± 17.43 min. FC was faster than IOC (0.71 ± 0.26 vs. 7.15 ± 3.76 min; p < 0.0001). FC was successfully performed in 43 of 43 cases (100 %) and IOC in 40 of 43 cases (93.02 %). FC was less expensive than IOC (US$14.10 ± 4.31 vs. US$778.43 ± 0.40; p < 0.0001). According to the survey, all surgeons found routine use of FC useful.

Conclusion

In this study, FC was effective in delineating important anatomic structures. It required less time and expense than IOC, and was perceived by the surgeons to be easier to perform, and at least as useful as IOC. Further prospective studies are warranted to evaluate the effectiveness of FC in decreasing BDI.     

Selective vs routine use of intraoperative cholangiography. An argument

We reviewed the course of 314 patients who underwent cholecystectomy at a University Hospital in 1985. Two hundred eighty-five patients underwent cholecystectomy for cholelithiasis. Preoperatively elevated liver function test results, history of jaundice or pancreatitis, or operative findings of palpable common bile duct stone or dilated extrahepatic ducts were criteria for indicated cholangiography. Of 142 patients who had cholangiography with negative results, only 31 were indicated by these criteria. In 93 patients not having cholangiography performed, the criteria were met in only 8 patients. Of 38 patients who underwent common bile duct exploration, only 29 had stones. As operative time, morbidity, and cost were demonstrably increased in patients undergoing cholangiography, a selective approach is advocated. The number of unnecessary common bile duct explorations might be cut by almost half, while the incidence of finding clinically unsuspected yet significant common bile duct stones is negligible.     

Results of routine intraoperative cholangiography

Most bile duct injuries result from an incorrect interpretation of bile duct anatomy. In 500 laparoscopic cholecystectomies we used a modified technique of cholecystcholangiography. This method is very easy and needs only 5 minutes. We found variants of bile duct anatomy in 74 cases and occult bile duct stones in 20 patients. We recommend this method which decreases the risk of bile duct injuries and gives the opportunity to approximate the golden standard of conventional cholecystectomy.     

The utility of intraoperative cholangiography with acute cholecystitis

An increasingly important subset of patients with biliary tract disease are those with acute cholecystitis. The indications for both routine or selective intraoperative cholangiography (IOC) during elective cholecystectomy may not be appropriate for this group. The utility of IOC in the presence of acute cholecystitis was examined. The medical records of 223 patients with histologically confirmed acute cholecystitis were reviewed. Clinical and laboratory criteria included age, sex, white blood cell count (WBC), serum bilirubin and alkaline phosphatase levels. In 52 (23%) patients, IOC was not attempted and was technically unsuccessful in 15 (7%) patients. IOC was successful in 156 (70%) patients and, of these, six (4%) had a false-positive examination. The remainder are divided into two groups. Group 1 (131 patients) had true-negative IOC, whereas Group 2 (19 patients) had true-positive IOC as evidenced by stone recovery upon surgical exploration. When comparing Group 2 with Group 1, the mean preoperative laboratory values are higher; these differences do not reach statistical significance. Further, within Group 2, five (26%) patients did not demonstrate any clinical or laboratory elevations suggestive of common duct pathology. Thus, in acute cholecystitis, laboratory criteria do not appear to discriminate between the presence or absence of choledocholithiasis. IOC is advocated as an integral component of the operative procedure.     

Technique of intraoperative laparoscopic cholangiography]

Since laparoscopic cholecystectomy has been established at our institution, the routine use of intraoperative cholangiography was abandoned but preoperative intravenous cholangiography and sonography are mandatory. However, these investigations are not always conclusive and in some cases not applicable. We have therefore started to use selective intraoperative laparoscopic cholangiography for laparoscopic cholecystectomy. Our technique and the materials required for this peroperative investigation are described in the present article.     

选择性术中胆道造影的临床应用价值

目的 探讨选择性术中胆道造影在胆石症病人中的临床应用价值。方法 通过对75例术中胆道造影的胆石症病人和62例胆道但未行术中胆道造影的胆石症病人的对比研究。比较两组术后胆道残石的发生率。结果 发现在有胆道相对探查指征的病人经胆囊管造影的阴性率为64.7%，曾行术中造影的胆石症病人的术后残石率为2.0%，而未行术中造影的胆石症病人的残石率为15.5%。结论 选择性术中胆道造影可降低胆道阴性探查率，避免不必要的胆道探查，还可降低胆道残石发生率。     

术中胆道造影的临床应用

术中胆道造影在胆道结石中的应用日趋广泛 ,在降低胆道术后残余结石和避免胆道损伤等方面有重要价值。现将我院从 1988～ 1998年间收治的 32 4例胆道结石病人进行术中胆道造影的情况报告如下。1　临床资料1.1　一般资料　我院 1988年至 1998年间共收治行术中胆道造影的胆道结石病人 32 4例。其中男 142例 ,女 182例。年龄 2 5～ 76岁。病程 2～ 15年。1.2　方法　所有病人都进行术中胆道造影 ,造影剂为 2 0 %～ 2 5 %泛影葡胺 2 0～ 40 ml。方法为 :1胆囊管残端插管造影186例 :切除胆囊后 ,于胆囊管残端插入细硅胶管 ,注入造影剂。 2术中 T…     

Radiation exposure during laparoscopic cholecystectomy with routine intraoperative cholangiography

Background  For many years, intraoperative cholangiography during cholecystectomy to aid definition of the biliary anatomy and to detect choledocholithiasis has been advocated. Although radiation exposure in fluoroscopic procedures is a concern, few available data exist regarding the radiation exposure incurred during intraoperative cholangiography. This study aimed to determine the average radiation exposure sustained during this procedure. Methods  Radiation dose data were recorded between 5 September 2007 and 21 July 2008 for 108 consecutive patients undergoing laparoscopic cholecystectomy with intraoperative cholangiography. Dose area product values were used to calculate the entrance skin dose, an indicator of potential skin damage, and the effective dose, an indicator of long-term cancer risk, for each patient. Results  The median age of the 108 patients (67% females) included in the data analysis was 51 years (range, 17–87 years). The mean entrance skin dose during intraoperative cholangiography was 0.0069 ± 0.0066 Gy, and the mean effective dose was 0.18 ± 0.17 mSv. No results exceeded the threshold of 2 Gy for skin damage, and the lifetime risk for the development of new cancer due to intraoperative cholangiography was less than 0.001%. Conclusion  Radiation doses administered during intraoperative cholangiography are safe and do not represent a contraindication to this procedure.     

Selective intraoperative cholangiography. A case for its use on an anatomic basis

The routine use of intraoperative cholangiography has vastly improved the results of common duct exploration by reducing the number of negative explorations. The controversy surrounding the use of routine versus selective intraoperative cholangiography has centered on the incidence of unsuspected common-duct stones. A prospective study was designed to examine both preoperative clinical data and intraoperative anatomical information to determine criteria that would identify patients who would not require cholangiography. One hundred consecutive patients undergoing cholecystectomy were included in the study. When considering patients without preoperative clinical data suspicious for common duct stones three anatomical conditions were identified in which common duct stones would not be present: cystic duct less than 3 mm; smallest stone size greater than 6 mm; a single stone. Using intraoperative criteria as a basis for cholangiography, 44 per cent of patients without clinical suspicion of common duct stones would be spared an intraoperative cholangiogram. It is the authors' opinion that the addition of anatomic findings to preoperative clinical data can further reduce or eliminate the risk of unsuspected stones while sparing a large number of patients the risk and expense of routine intraoperative cholangiography and possible negative duct exploration.     

术中胆道造影在腹腔镜胆囊切除术中的应用价值

目的：研究对于有胆总管探查指征的病人行腹腔镜下胆囊切除术（laparoscopic cholecystectomy,LC)时手术中胆道造影（intraoperative cholangiography,IOC)的应用价值。方法：收集我院外科1991－1999年2395例腹腔镜胆囊切除术病人中有选择性行手术中胆道造影的201例病人资料。分析术前术中存在的胆总管探查原因，手术中通过经胆囊管插管造影的结果对比，评估腹腔镜胆囊切除术术中胆道造影的应用价值。结果：在所有201例手术前或手术中有总管探查指征的病人行LC手术时，术中经胆囊造影，共有65例病人有阳性发现，其中只有21例行中转开腹手术，结论：腹腔镜胆囊切除术术中胆道造影有很好的实用价值，正确使用可扩大腹腔镜胆囊切除术的手术适应症。     

术中胆道造影在小切口胆囊切除术中的临床价值

目的 探讨术中胆道造影(IOC)在小切口胆囊切除术(MC)中的临床应用价值.方法 对1992-2006年在小切口胆囊切除术中行胆道造影506例的临床资料进行回顾性分析.结果 造影成功493例,成功率97.4%,术中发现胆道结石49例,胆管变异4例,胆道损伤4例,扩大切口16例.结论 术中胆道造影在小切口胆囊切除术中可防止术后胆管残石发生,避免不必要胆管探查,减少扩大切口的机会,明确胆管变异,预防并及时发现胆管损伤,降低MC并发症,提高MC质量,有较高的临床应用价值.     

腹腔镜胆囊切除术中胆管造影的应用分析

目的探讨腹腔镜胆囊切除术中胆管造影技术的应用及其临床价值。方法对我院2004年1月~2005年10月在腹腔镜胆囊切除术中经胆囊管插管行胆管造影106例的临床资料进行回顾性分析。结果本组造影成功98例,成功率为95.3%。术中造影发现胆总管结石8例、胆囊管结石2例、胆总管损伤1例。结论术中胆管造影操作迅速、安全,显影清晰,成功率高,能降低胆管损伤的发生率,值得推广应用。     

术中胆道造影在腹腔镜胆囊切除术中应用价值

目的探讨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在切除胆囊前,常规在C型臂X线下行胆道造影,并及时采集、保存图像,以了解肝外胆管内有无结石存在。若发现结石,继而行中转开腹胆总管探查取石术。结果施行的76例术中胆道造影中,发现胆总管结石5例,其中胆总管下段多发结石2例,胆总管内单发结石2例,胆总管内一长柱状结石1例。5例胆总管结石取出术后均放置T型管,随访T管造影复查,未见结石残留。结论腹腔镜胆囊切除术常规行术中胆道造影可有效地防止胆道结石残留,避免了不必要的胆管探查,减少了胆管损伤和术后并发症的发生,减少了患者的住院费用和住院时间,且术中胆道造影操作简单、迅速、安全,除有禁忌证外,应常规应用术中胆道造影。