What is the utility of routine intraoperative cholangiography during laparoscopic cholecystectomy?

SAGES still recommends that practicing general surgeons learn how to do IOC (though once a surgeon is past their learning curve, it is not necessarily routinely recommended that it be done ‘routinely’).

Hope WW, et al. SAGES clinical spotlight review: intraoperative cholangiography. Surg Endosc. 2017 May;31(5): 2007-2016. Full-text for Emory users.

“The following clinical spotlight review regarding the intraoperative cholangiogram is intended for physicians who manage and treat gallbladder/biliary pathology and perform laparoscopic cholecystectomy. It is meant to critically review the technique of intraoperative cholangiography, alternatives for intraoperative biliary imaging, and the available evidence supporting their safety and efficacy.”

See also:

Acute pancreatitis after elective laparoscopic cholecystectomy: retrospective study. (SAGES) View poster.

“Acute pancreatitis is a relative rare complication after elective laparoscopic cholecystectomy (0.1%). The fact that both patients who had pancreatitis did not have cholangiogram indicates that intraoperative cholangiogram was not the inciting factor.”

Morgan S, Traverso LW. Intraoperative cholangiography and postoperative pancreatitis. Surg Endosc. 2000 Mar;14(3):264-6. Full-text for Emory users.

Methods: We studied the relationship between IOC and pancreatitis by reviewing the case histories of 500 patients (1992-97) who underwent cholecystectomy at our institution. In 82% of cases, the cholecystectomies were done laparoscopically, whereas, 7% were converted to an open procedure. An IOC was performed in 435/500, or 87%. During these studies, common bile duct (CBD) stones (or the possibility of a stone) were noted in 14% of the cases. An intraoperative CBD investigation was required in nine of 435 cases or 8.5%, while 28/435 (9.2%) underwent postoperative endoscopic retrograde cholangiopancreatography (ERCP).

Results: Follow-up was available in 90% of our patients (452/500). We found six cases of postoperative pancreatitis; only three of 452 (0.6%) occurred <1 year after cholecystectomy. None of these patients had a preoperative history of pancreatitis. In all six cases, there appeared to be an etiology for the pancreatitis unrelated to IOC.

Conclusion: We could find no statistical association between IOC and postoperative pancreatitis. Postoperative pancreatitis is uncommon at our institution, where routine IOC is employed. Therefore, we conclude that IOC does not cause pancreatitis.

Lai HY, et al. Routine intraoperative cholangiography during laparoscopic cholecystectomy: application of the 2016 WSES guidelines for predicting choledocholithiasis. Surg Endosc. 2021 Feb 1. doi: 10.1007/s00464-021-08305-4. Epub ahead of print.

Full-text for Emory users.

Background: Routine use of intraoperative cholangiography (IOC) during laparoscopic cholecystectomy (LC) for detecting common bile duct stones remains controversial. The 2016 World Society of Emergency Surgery (WSES) guidelines on acute calculous cholecystitis proposed a risk stratification for choledocholithiasis. Our present study aimed to (1) examine the findings of common bile duct (CBD) stones in patients underwent LC with routine use of IOC, and (2) validate the 2016 WSES risk classes for predicting choledocholithiasis.

Methods: All patients had LC with IOC routinely performed from November 2012 to December 2017 were reviewed retrospectively. Patients were classified into high-, intermediate-, and low-risk groups based on the 2016 WSES risk classes with modification.

Results: A total of 990 patients with LC and routine IOC were enrolled. CBD stones were detected in 197 (19.9%) patients. The rate of CBD stone detected in low-, intermediate-, high-risk groups were 0%, 14.2%, and 89.6%, respectively. Predictors as following: evidence of CBD stones on abdominal ultrasound or computed tomography, CBD diameter > 6 mm, total bilirubin > 4 mg/dL, bilirubin level = 1.8-4 mg/dL, abnormal liver biochemical test result other than bilirubin, presence of clinical gallstone pancreatitis had statistical significance between patients with and without CBD stones. Major bile duct injury was found in 4 patients (0.4%). All 4 patients had uneventful recovery after repair surgery.

Conclusions: Based on our study results, the 2016 WSES risk classes for choledocholithiasis could be an effective approach for predicting the risk of choledocholithiasis. Considering its advantages for detecting CBD stones and biliary injuries, the routine use of IOC is still suggested.

Created 08/20/21; updated 09/24/21.

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