“The aim of this document is to provide evidence-based recommendations for the endoscopic evaluation and treatment of choledocholithiasis based on rigorous review and synthesis of the contemporary literature, using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework. The GRADE framework is a system for rating the quality of evidence and strength of recommendations that is comprehensive and transparent and has been recently adopted by the American Society for Gastrointestinal Endoscopy (ASGE). This document addresses the following 4 clinical questions:”
1. “What is the diagnostic utility of EUS versus MRCP to confirm choledocholithiasis in patients at intermediate risk of choledocholithiasis?
2. In patients with gallstone pancreatitis, what is the role of early ERCP?
3. In patients with large choledocholithiasis, is endoscopic papillary dilation after sphincterotomy favored over sphincterotomy alone?
4. What is the role of ERCP-guided intraductal therapy (EHL and laser lithotripsy) in patients with large and difficult choledocholithiasis?”
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.”
Dageforde LA, Lillemoe KD. (2020). Management of Acute Cholangitis. In: Cameron JL, Cameron AM (Eds), Current Surgical Therapy, 13th ed. Elsevier: Philadelphia.
“Recent literature advocates for primary closure of the common bile duct after elective CBDE because of complications from T-tube placement. But in patients with cholangitis, placement of a T-tube is necessary for biliary decompression and allows easy access for future cholangiogram if the obstruction does not resolve. T-tube drainage has been associated with bile leak and requires externalization of the tube for several days until postoperative cholangiography demonstrates resolution of obstruction. Primary closure can lead to stricture and bile leak and result in no direct access to the biliary tree for future investigations.”
Fig. 2. Insertion of a T-tube in the common bile duct with subsequent closure using absorbable monofilament suture (4-0 or 5-0). The T-tube is prepared in one of the ways shown. From: Zollinger RM, Jr, Zollinger RM. Atlas of Surgical Operations. 7th ed. New York: McGraw-Hill; 1993.