One discussion this week included cholangiography (IOC) versus magnetic resonance cholangiopancreatography (MRCP) for the evaluation of the common bile duct during cholecystectomy.

References: Lin C, et al. Initial cholecystectomy with Cholangiography Decreases Length of Stay Compared to Preoperative MRCP or ERCP in the Management of Choledocholithiasis. American Surgery. 2015 July;81(7):726-731.

Sirinek KR, Schwesinger WR. Has intraoperative cholangiography during laparoscopic cholecystectomy become obsolete in the era of preoperative endoscopic retrograde and magnetic resonance cholangiopancreatography? Journal of the American College of Surgeons. 2015 Apr;220(4):522-528.

Summary: There are several treatments available for choledocholithiasis, but the optimal treatment is highly debated.  In a study of 126 patients with suspected choledocholithiasis, Lin et al (2015) found that:

• 97 patients who underwent initial LC ± IOC had an average LOS of 3.9 days
• IOC was negative in 47.4% of patients, and they had a shorter LOS compared with positive IOC patients (2.93 vs 4.82, P < 0.001)
• Laparoscopic common bile duct exploration was successful in 64.7% and had a shorter LOS compared with postoperative ERCP patients (P = 0.01)
• Preoperative MRCP was performed in 21 patients with an average LOS of 6.48 days
• Preoperative ERCP was performed in 8 patients with an average LOS of 7 days

In conclusion, initial LC+IOC was associated with a shorter LOS compared to preoperative MRCP or ERCP (Lin et al, 2015).

Additionally, a retrospective analysis of 7,427 patients undergoing laparoscopic cholecystectomy (LC) over 10 years  at a single tertiary care center evaluates the changing practice patterns over time of IOC, MRCP, and ERCP (Sirinek and Schwesinger, 2015).

Despite a shift from IOC and preoperative ERCP to preoperative MRCP alone or with ERCP, a significant percentage (7.6%) of patients still underwent IOC in 2013. Use of IOC during LC has decreased but is not considered obsolete, rather, it remains a valuable tool for the evaluation of bile duct anatomy, bile duct injury, or suspected choledocholithiasis. Intraoperative cholangiography during uncomplicated LC should be emphasized in teaching programs to insure general surgery resident competency with the procedure.

Additional Reading: Badger WR, et al. Utility of MRCP in clinical decision making of suspected choledocholithiasis: An institutional analysis and literature review. American Journal of Surgery. 2017 Aug;214(2):251-255.