Evaluation of operative cholangiography in 2043 patients undergoing laparoscopic cholecystectomy: a case for the selective operative cholangiogram

Clinical Utility of Definitive Diagnostic Tests for Choledocholithiasis in Pediatric Patients with Mild Gallstone Pancreatitis

BACKGROUND

Gallstone pancreatitis was historically considered a risk factor for choledocholithiasis (CD). However, recent studies of adult patients evidenced a weak association between gallstone pancreatitis and CD. The aim of this study was to analyze this association in pediatric patients.

METHODS

We conducted a retrospective study on patients with mild gallstone pancreatitis who underwent any definitive testing for CD (MRCP, ERCP, IOC), managed between March 2010 and September 2022. Patients were classified according to the presence or absence of risk factors for CD (total bilirubin ≥2 mg/dl; common bile duct >6 mm on ultrasound; and/or CD on ultrasound). We evaluated the diagnosis of CD on definitive testing in both groups and analyzed the predictive capacity of the presence of risk factors.

RESULTS

Eighty-four patients were included in the final analysis. Seventy-nine percent were females. The median age was 13 (4-17) years. Forty-seven (55.9%) patients had one or more risk factors. The definitive testing confirmed 13 (15.5%) cases of CD, 12 (25.5%) in the group of patients with risk factors and 1 (2.7%) in those without risk factors. The sensitivity, specificity, positive predictive value and negative predictive value of the presence of associated risk factors were 92.3, 50.7, 25.5 and 97.3%, respectively.

CONCLUSION

Pediatric patients with gallstone pancreatitis without associated risk factors have a very low incidence of CD. In these patients we suggest performing a laparoscopic cholecystectomy without intraoperative cholangiography or any other definitive test for CD.

LEVEL OF EVIDENCE

Level II, retrospective study.

Outcomes following common bile duct exploration versus endoscopic stone extraction before, during and after laparoscopic cholecystectomy for patients with common bile duct stones

BACKGROUND

Laparoscopic common bile duct exploration (LCBDE) and endoscopic retrograde cholangiopancreatography (ERCP) are two methods of retrieving common bile duct (CBD) stones. The best method for CBD stone removal is debatable. The aim of this study was to compare outcomes following LCBDE and/or ERCP, including laparoscopic cholecystectomy.

METHODS

Data were collected retrospectively for patients undergoing LCBDE and/or ERCP at a single centre from 2008 to 2018. Patients were grouped by intention-to-treat (single-stage LCBDE, pre-operative-, intra-operative-, or post-operative ERCP) and eventual plan (surgical or endoscopic). Outcomes included complication rates (minor Clavien-Dindo 1/2, major Clavien-Dindo 3/4, non-biliary complications) and mortality.

RESULTS

Of 671 patients, 578 patients received LCBDE and 93 patients received ERCP as primary care. Endoscopic clearance had significantly higher complications and mortality compared to surgical clearance. On an intention-to-treat basis LCBDE had the lowest minor-, major- and non-biliary complications, and mortality (5.2%, 6.1%, 2.9% and 0.5%, respectively), whilst pre-operative ERCP the worst (39.6%, 27.1%, 29.2% and 8.3%, respectively) (p=<0.001). LCBDE and postERCP had similar major complications and mortality.

CONCLUSION

Surgical clearance of CBD stones was potentially safer than endoscopic clearance. Pre-operative ERCP had the worst outcomes. LCBDE and postERCP are likely to have similar short-term patient outcomes.

Outcomes following balloon sphincteroplasty as an adjunct to laparoscopic common bile duct exploration

BACKGROUND

Laparoscopic common bile duct exploration (LCBDE) at the time of cholecystectomy is an efficient pathway for management of choledocholithiasis. Performing this safely under one anesthetic offers advantages over a two-step process with cholecystectomy and endoscopic retrograde cholangiopancreatography (ERCP). Despite the proven efficacy of LCBDE, endoscopy continues to be predominantly utilized. Simplifying the intervention may drive LCBDE adoption. To this end, we refined a stepwise intraoperative pathway that utilizes over the wire balloon catheters to dilate the Sphincter of Oddi to facilitate stone passage into the duodenum. To determine the efficacy during the initial adoption phase on a general surgery service, we reviewed our experience with LCBDE balloon sphincteroplasty as part of this pathway.

METHODS

We retrospectively reviewed the records of patients who underwent LCBDE with balloon sphincteroplasty at a single tertiary care center over a three-year period. Preoperative demographics, imaging/laboratory results, intra and postoperative outcomes were reviewed.

RESULTS

Choledocholithiasis was managed with transcystic balloon sphincteroplasty during LCBDE in 28 cases over a three-year period. The cohort included 16 women and 12 men with a mean age of 47 years (range = 19-89). Operative indications included cholecystitis (n = 11, 39%), choledocholithiasis (n = 13, 47%), cholelithiasis (n = 2, 7%), and gallstone pancreatitis (n = 2, 7%). The stones were successfully cleared by the balloon sphincteroplasty technique in 75% of the cases. The average fluoroscopy time during LCBDE was 338 s (± 214). The average operating room time was 173 min (± 35). Mean length of stay was 58 h (± 46). There were no intra- or postoperative complications.

CONCLUSION

Wire ready cholangiography followed by balloon sphincteroplasty with saline/contrast flush is a simple and safe way to clear the common bile duct. This technique is a gateway for further expansion and adoption of LCBDE.

Selective intraoperative cholangiography should be considered over routine intraoperative cholangiography during cholecystectomy: a systematic review and meta-analysis

Background

Decades of debate surround the use of intraoperative cholangiography (IOC) during cholecystectomy. To the present day, the role of IOC is controversial as regards decreasing the rate of bile duct injury (BDI). We aimed to review and analyse the available literature on the benefits of IOC during cholecystectomy.

Methods

A systematic literature search was performed until 19 October 2020 in five databases using the following search keys: cholangiogra* and cholecystectomy. The primary outcomes were BDI and retained stone rate. To investigate the differences between the groups (routine IOC vs selective IOC and IOC vs no IOC), we calculated weighted mean differences (WMD) for continuous outcomes and relative risks (RR) for dichotomous outcomes, with 95% confidence intervals (CI).

Results

Of the 19,863 articles, 38 were selected and 32 were included in the quantitative synthesis. Routine IOC showed no superiority compared to selective IOC in decreasing BDI (RR = 0.91, 95% CI 0.66; 1.24). Comparing IOC and no IOC, no statistically significant differences were found in the case of BDI, retained stone rate, readmission rate, and length of hospital stay. We found an increased risk of conversion rate to open surgery in the no IOC group (RR = 0.64, CI 0.51; 0.78). The operation time was significantly longer in the IOC group compared to the no IOC group (WMD = 11.25 min, 95% CI 6.57; 15.93).

Conclusion

Our findings suggest that IOC may not be indicated in every case, however, the evidence is very uncertain. Further good quality research is required to address this question.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00464-022-09267-x.

The efficacy and safety of preoperative cholangiography via percutaneous transhepatic gallbladder drainage (PTGBD) for difficult laparoscopic cholecystectomy (LC)

BACKGROUND

Percutaneous transhepatic gallbladder drainage (PTGBD) is an important procedure for initial treatment of severe acute cholecystitis (AC) that is contraindicated for early laparoscopic cholecystectomy (LC). We presented our primary experience on a new approach of cholangiography via PTGBD (PTGBD-C) for preoperative delineation of biliary anatomy.

METHODS

A retrospective analysis was conducted on 93 patients who received PTGBD followed by LC for AC, with allocation into 2 groups that were PTGBD with (PTGBD-C group, 32 patients) or without (PTGBD-N group, 61 patients) cholangiography. All the clinical data, including demographics, cholangiography findings, operations, and complications, were collected and analyzed.

RESULTS

Cholangiography was attempted in 32 patients with a success of 31 cases, and the most common complication was transient fever in 3 patients. PTGBD-C group of patients showed significantly less operation time (83.2 ± 22.32 vs. 106.5 ± 40.25 min, P = 0.041) and conversion rate (0 vs. 2). There was no statistical difference in terms of postoperative hospitalization and complications.

CONCLUSIONS

PTGBD-C is a feasible and safe procedure for severe AC patients with delayed LC. It has advantages of direct cholangiography, being easy to perform and cost-effective, thus should be considered for clinical usage.

Routine versus selective intraoperative cholangiography during cholecystectomy: systematic review, meta-analysis and health economic model analysis of iatrogenic bile duct injury

Background

Bile duct injury (BDI) is a severe complication following cholecystectomy. Early recognition and treatment of BDI has been shown to reduce costs and improve patients’ quality of life. The aim of this study was to assess the effect and cost-effectiveness of routine versus selective intraoperative cholangiography (IOC) in cholecystectomy.

Methods

A systematic review and meta-analysis, combined with a health economic model analysis in the Swedish setting, was performed. Costs per quality-adjusted life-year (QALY) for routine versus selective IOC during cholecystectomy for different scenarios were calculated.

Results

In this meta-analysis, eight studies with more than 2 million patients subjected to cholecystectomy and 9000 BDIs were included. The rate of BDI was estimated to 0.36 per cent when IOC was performed routinely, compared with to 0.53 per cent when used selectively, indicating an increased risk for BDI of 43 per cent when IOC was used selectively (odds ratio 1.43, 95 per cent c.i. 1.22 to 1.67). The model analysis estimated that seven injuries were avoided annually by routine IOC in Sweden, a population of 10 million. Over a 10-year period, 33 QALYs would be gained at an approximate net cost of €808 000 , at a cost per QALY of about €24 900.

Conclusion

Routine IOC during cholecystectomy reduces the risk of BDI compared with the selective strategy and is a potentially cost-effective intervention.

Intraoperative cholangiography with filling defects: comparative complication analysis of postoperative transcystic duct (TCD) catheter maintenance

BACKGROUND

This is a retrospective cohort of patients undergoing laparoscopic cholecystectomy with intraoperative cholangiography (IOC) with positive findings for filling defects. We comparatively assessed differences in complication risks for patients that had their cholangiography catheter maintained in its transcystic duct (TCD) position postoperatively. This is a practice proposed to overcome the limited availability of Endoscopic Retrograde Cholangiopancreatography (ERCP) as well as to avoid surgical exploration of the common bile duct.

METHODS

Retrospective medical record review of all positive IOC from January 2015 to December 2018 were assessed. Patients' demographic and perioperative data from the hospital stay period in which the cholecystectomy occurred until the last surgical ambulatory visit for perioperative characteristics were compared between groups (with vs. without TCD catheter). Complications were operationalized using the Clavien-Dindo scale.

RESULTS

Univariate analysis of complications showed a 2.4-fold risk increase in complications (95% CI 1.13-5.1) between comparison groups. Number of ERCPs (18 vs. 30), and MRCPs (5 vs. 17) were not significantly different between maintaining or not the TCD catheter postop, respectively. Stratified analysis followed by exact logistic regression supported the findings that maintaining the TCD catheter postoperatively increased complication rates (OR = 5.34, 95% CI 1.22, 29.83, p = 0.022), adjusting for potential confounders.

CONCLUSION

The maintenance of the TCD catheter postoperatively did not prove to be effective in significantly reducing the number of ERCP nor associated complications. Also, outcomes inherited from the practice caused adverse events that surpassed its potential benefits. Moreover, expectant follow-up is reasonable for patients with evidence of common bile duct stones, even in setting with limited resource availability. We do not recommend this practice, even in settings where there are limited resources of more modern management of choledocholithiasis.

Laparoscopic Ultrasonography Versus Magnetic Resonance Cholangiopancreatography in Laparoscopic Surgery for Symptomatic Cholelithiasis and Suspected Common Bile Duct Stones

BACKGROUND

There continues to be controversy regarding the optimal screening modality in patients with symptomatic cholelithiasis and suspected common bile duct (CBD) stones. The aim of this study was to assess the diagnostic accuracy of laparoscopic ultrasonography (LUS) compared to magnetic resonance cholangiopancreatography (MRCP).

METHODS

Both LUS and MRCP were performed to evaluate the CBD stones and biliary anatomy in 200 patients undergoing laparoscopic surgery. Pre-, intra-, and postoperative data were collected prospectively and reviewed retrospectively.

RESULTS

Coexisting CBD stones were identified in 64 of 200 (32%) patients by surgical exploration or postoperative ERCP. For the detection of CBD stones, LUS yielded a positive predictive value of 100%, a negative predictive value of 99.3%, a sensitivity of 98.4%, and a specificity of 100%. Preoperative MRCP had a positive predictive value of 87.9%, a negative predictive value of 95.5%, a sensitivity of 90.6%, and a specificity of 94.1%. The non-random concordance between MRCP and LUS was considered to be excellent with a kappa coefficient of 0.92 (p < 0.01).

CONCLUSIONS

LUS can reduce the need for MRCP examination and can become the primary imaging method for the evaluation of CBD stones in laparoscopic surgery.

Selective intraoperative cholangiography during laparoscopic cholecystectomy in children is justified

AIMS

Intraoperative cholangiograms (IOC) during laparoscopic cholecystectomy have been advocated to detect biliary anomalies and intraductal calculi. However, IOC increases operative time and patient irradiation, and therefore is not universally used. We hypothesise selective IOC may be a valuable tool in children.

METHODS

A retrospective case note review was performed of all children who underwent laparoscopic cholecystectomy at a single institution by a single surgeon between January 2011 and March 2017. Demographics, radiological imaging, indications for surgery and IOC, and clinical outcomes were collected. Chi-Squared and Wilcoxon Rank Sum tests were used for comparisons.

RESULTS

Sixty-two patients were reviewed. Median follow-up was 2 months (0.1-60), and 53 (85%) had complete symptom resolution following surgery. Twenty-two patients underwent IOC. Six (27%) had anomalies undetected by preoperative imaging. IOC identified common bile duct (CBD) stones in 2 patients which were cleared at laparoscopy. One patient required subsequent ERCP for impacted stones. One patient has a long common channel and pancreatitis. Two patients have CBD strictures. These last 3 are awaiting biliary reconstruction. Presence of CBD dilatation or ductal stones on preoperative ultrasound were significantly associated with positive findings at IOC. No complications resulted from IOC. Patients who did not undergo IOC did not represent with missed anomalies.

CONCLUSIONS

Despite using multimodal preoperative imaging, IOC detected biliary anomalies requiring further treatment in 6/62 (10%) of patients undergoing laparoscopic cholecystectomy. Our data support the use of IOC in selective patients with CBD dilatation or suspicion of ductal stones on preoperative imaging.

LEVEL OF EVIDENCE

Study of Diagnostic Test: Level III.

Can clinical factors predict the need for intervention after a positive intraoperative cholangiogram?

OBJECTIVE

To determine whether clinical factors such as the elevation or decline of biochemical liver tests and bile duct dilation can help to identify patients who will truly benefit from therapeutic endoscopic retrograde cholangiopancreatography (ERCP) following a positive intraoperative cholangiography (IOC) study.

METHODS

All cholecystectomies during a 3-year period were examined retrospectively for positive intraoperative cholangiograms. Sonographic findings of bile duct dilation and transaminase levels at admission, including trends during the course of hospitalization and prior to ERCP, were evaluated.

RESULTS

Of 369 patients with intraoperative cholangiogram studies, 80 (21.7%) were positive. Prior to surgery, a sonogram showed biliary dilation in 50 (62.5%) and ERCP demonstrated actual stones in 27 (61.4%) out of 44 patients. In 24 patients with persistent elevation in transaminases and no biliary dilation, ERCP revealed stones in 12 (50.0%). Sonographic finding of biliary dilation had a positive predictive value (PPV) of 61.4% and a negative predictive value (NPV) of 60.0%. Persistent elevation in transaminases had a PPV of 59.3%. A 50% decline in transaminases had a NPV of 41.2%. Overall, only 39 (48.8%) of all patients with a positive intraoperative cholangiogram study required therapeutic ERCP.

CONCLUSIONS

Elevated transaminases and sonographic biliary dilation have poor predictive values for choledocholithiasis. Thus, patients with a positive intraoperative cholangiogram may benefit from additional studies, such as endoscopic ultrasound or magnetic resonance cholangiopancreatography prior to ERCP.

Endoscopic retrograde cholangiopancreatography versus intraoperative cholangiography for diagnosis of common bile duct stones

BACKGROUND

Endoscopic retrograde cholangiopancreatography (ERCP) and intraoperative cholangiography (IOC) are tests used in the diagnosis of common bile duct stones in people suspected of having common bile duct stones. There has been no systematic review of the diagnostic accuracy of ERCP and IOC.

OBJECTIVES

To determine and compare the accuracy of ERCP and IOC for the diagnosis of common bile duct stones.

SEARCH METHODS

We searched MEDLINE, EMBASE, Science Citation Index Expanded, BIOSIS, and Clinicaltrials.gov to September 2012. To identify additional studies, we searched the references of included studies and systematic reviews identified from various databases (Database of Abstracts of Reviews of Effects (DARE)), Health Technology Assessment (HTA), Medion, and ARIF (Aggressive Research Intelligence Facility)). We did not restrict studies based on language or publication status, or whether data were collected prospectively or retrospectively.

SELECTION CRITERIA

We included studies that provided the number of true positives, false positives, false negatives, and true negatives for ERCP or IOC. We only accepted studies that confirmed the presence of common bile duct stones by extraction of the stones (irrespective of whether this was done by surgical or endoscopic methods) for a positive test, and absence of common bile duct stones by surgical or endoscopic negative exploration of the common bile duct, or symptom-free follow-up for at least six months for a negative test as the reference standard in people suspected of having common bile duct stones. We included participants with or without prior diagnosis of cholelithiasis; with or without symptoms and complications of common bile duct stones; with or without prior treatment for common bile duct stones; and before or after cholecystectomy. At least two authors screened abstracts and selected studies for inclusion independently.

DATA COLLECTION AND ANALYSIS

Two authors independently collected data from each study. We used the bivariate model to summarise the sensitivity and specificity of the tests.

MAIN RESULTS

We identified five studies including 318 participants (180 participants with and 138 participants without common bile duct stones) that reported the diagnostic accuracy of ERCP and five studies including 654 participants (125 participants with and 529 participants without common bile duct stones) that reported the diagnostic accuracy of IOC. Most studies included people with symptoms (participants with jaundice or pancreatitis) suspected of having common bile duct stones based on blood tests, ultrasound, or both, prior to the performance of ERCP or IOC. Most studies included participants who had not previously undergone removal of the gallbladder (cholecystectomy). None of the included studies was of high methodological quality as evaluated by the QUADAS-2 tool (quality assessment tool for diagnostic accuracy studies). The sensitivities of ERCP ranged between 0.67 and 0.94 and the specificities ranged between 0.92 and 1.00. For ERCP, the summary sensitivity was 0.83 (95% confidence interval (CI) 0.72 to 0.90) and specificity was 0.99 (95% CI 0.94 to 1.00). The sensitivities of IOC ranged between 0.75 and 1.00 and the specificities ranged between 0.96 and 1.00. For IOC, the summary sensitivity was 0.99 (95% CI 0.83 to 1.00) and specificity was 0.99 (95% CI 0.95 to 1.00). For ERCP, at the median pre-test probability of common bile duct stones of 0.35 estimated from the included studies (i.e., 35% of people suspected of having common bile duct stones were confirmed to have gallstones by the reference standard), the post-test probabilities associated with positive test results was 0.97 (95% CI 0.88 to 0.99) and negative test results was 0.09 (95% CI 0.05 to 0.14). For IOC, at the median pre-test probability of common bile duct stones of 0.35, the post-test probabilities associated with positive test results was 0.98 (95% CI 0.85 to 1.00) and negative test results was 0.01 (95% CI 0.00 to 0.10). There was weak evidence of a difference in sensitivity (P value = 0.05) with IOC showing higher sensitivity than ERCP. There was no evidence of a difference in specificity (P value = 0.7) with both tests having similar specificity.

AUTHORS' CONCLUSIONS

Although the sensitivity of IOC appeared to be better than that of ERCP, this finding may be unreliable because none of the studies compared both tests in the same study populations and most of the studies were methodologically flawed. It appears that both tests were fairly accurate in guiding further invasive treatment as most people diagnosed with common bile duct stones by these tests had common bile duct stones. Some people may have common bile duct stones in spite of having a negative ERCP or IOC result. Such people may have to be re-tested if the clinical suspicion of common bile duct stones is very high because of their symptoms or persistently abnormal liver function tests. However, the results should be interpreted with caution given the limited quantity and quality of the evidence.

Has intraoperative cholangiography during laparoscopic cholecystectomy become obsolete in the era of preoperative endoscopic retrograde and magnetic resonance cholangiopancreatography?

BACKGROUND

Preoperative ERCP, magnetic resonance cholangiopancreatography (MRCP), and intraoperative cholangiography (IOC) are standard procedures in evaluating patients with suspected choledocholithiasis. This study evaluates the changing practice patterns over time of these 3 procedures in a large cohort of patients undergoing laparoscopic cholecystectomy (LC) at a single tertiary care center.

STUDY DESIGN

Data from all patients undergoing an LC with or without preoperative ERCP, MRCP, or an IOC from January 1, 2004 to December 31, 2013 were retrospectively reviewed from billing data obtained by CPT code and analyzed by chi-square testing.

RESULTS

During 10 years, 7,427 patients underwent successful LC. The number of patients undergoing successful IOC (11.9% to 7.6%) or preoperative ERCP (7.2% to 1.5%) decreased significantly during that time interval (p < 0.01). In the last 6 years, 4,506 patients underwent successful LC. The number of patients from this group undergoing a preoperative MRCP (0.9% to 8.6%) or MRCP and ERCP (0.4% to 3.6%) increased significantly (p < 0.001).

CONCLUSIONS

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.

Hepatic subcapsular biloma: a rare complication of laparoscopic cholecystectomy

The development of an intra-abdominal bile collection (biloma) is an infrequent complication of laparoscopic cholecystectomy (LC). These bilomas develop in the subhepatic space most often secondary to iatrogenic injury of the extrahepatic ducts. We present a case of hepatic subcapsular biloma following LC and we discuss its etiology and management. Early diagnosis is crucial and percutaneous drainage under CT guidance should be employed to resolve this complication.

Laparoscopic treatment for unsuspected common bile duct stones by transcystic sphincter of Oddi pneumatic balloon dilation and pressure-washing technique

BACKGROUND

Unsuspected common bile duct stones (CBDS) are found in 4-5 % of patients with cholelithiasis. The optimal strategy for the treatment of asymptomatic CBDS, diagnosed during laparoscopic cholecystectomy (LC), is not yet well established. A one-stage solution is preferable to solve the CBDS during the LC and to avoid the exposure of patients to the risks of a second procedure, such as complications or failure.

METHODS

We attempted to remove CBDS by transcystic sphincter of Oddi pneumatic balloon dilation and common bile duct pressure-washing in all cases of intraoperative identification of CBDS since September 2008.

RESULTS

In 29 cases, unsuspected CBDS was identified by intraoperative cholangiography; in 28 cases a single stone with a mean diameter of 4.3 mm (range = 3-6) was detected and in one case three 5-8-mm-diameter stones were identified. Clearance of the common bile duct was obtained in 27 cases (96 %), with a mean operative time of 54 min (range = 36-90) and mean length of hospital stay of 2.5 days.

CONCLUSION

Treatment of unsuspected CBDS detected by intraoperative cholangiography during LC with this original technique was safe and effective and a viable alternative of the transcystic endoscopic approach.

Is routine intraoperative cholangiogram necessary in the twenty-first century? A national view

INTRODUCTION

Intraoperative cholangiogram (IOC) can define biliary ductal anatomy. Routine IOC has been proposed previously. However, current surgeon IOC utilization practice patterns and outcomes are unclear.

METHODS

Nationwide Inpatient Sample 2004-2009 was queried for patients with acute biliary disease undergoing cholecystectomy (CCY). Analyses only included surgeons performing ≥10 CCY/year. We dichotomized surgeons into a routine IOC group vs. selective. Outcomes included bile duct injury, complications, mortality, length of stay, and cost.

RESULTS

Of the nonweighted patients, 111,815 underwent CCY. A total of 4,740 actual surgeon yearly volumes were examined. On average, each surgeon performed 23.6 CCYs and 7.9 IOCs annually, using IOC in 33 % of cases. The routine IOC group used IOC for 96 % of cases, whereas selective IOC group used IOC ∼25 % of the time. Routine IOC surgeons had no difference in mortality (0.4 %) or rate of bile duct injury (0.25 vs. 0.26 %), but higher overall complications (7.3 vs. 6.8 %, p = 0.04). Patients of routine IOC surgeons received more additional procedures and incurred higher costs.

CONCLUSION

Routine IOC does not decrease the rate of bile duct injury, but is associated with significant added cost. Surgeons' routine use of IOC is correlated with increased rates of postsurgical procedures, and is associated with increased overall complications. These data suggest routine IOC may not improve outcomes.

Systematic review of intraoperative cholangiography in cholecystectomy

BACKGROUND

Intraoperative cholangiography (IOC) is used to detect choledocholithiasis and identify or prevent bile duct injury. The aim of this study was systematically to review the randomized clinical trials of IOC for these two indications.

METHODS

MEDLINE, Embase, the Cochrane Library, clinicaltrials.gov and the World Health Organization database of clinical trials were searched systematically (January 1980 to February 2011) to identify trials. Two authors performed the literature search and extracted data independently. Primary endpoints were bile duct injury and retained common bile duct (CBD) stones diagnosed at any stage after surgery. Preliminary meta-analysis was undertaken, but the trials were too methodologically heterogeneous and the outcome events too infrequent to allow meaningful meta-analysis.

RESULTS

Eight randomized trials were identified including 1715 patients. Six trials assessed the value of routine IOC in patients at low risk of choledocholithiasis. Two trials randomized all patients (including those at high risk) to routine or selective IOC. Two cases of major bile duct injury were reported, and 13 of retained CBD stones. No trial demonstrated a benefit in detecting CBD stones. IOC added a mean of 16 min to the total operating time.

CONCLUSION

There is no robust evidence to support or abandon the use of IOC to prevent retained CBD stones or bile duct injury. Level 1 evidence for IOC is of poor to moderate quality. None of the trials, alone or in combination, was sufficiently powered to demonstrate a benefit of IOC. Further small trials cannot be recommended.

Intraoperative ERCP: What role does it have in the era of laparoscopic cholecystectomy?

In the treatment of patients with symptomatic cholelithiasis and choledocholithiasis (CBDS) detected during intraoperative cholangiography (IOC), or when the preoperative study of a patient at intermediate risk for CBDS cannot be completed due to the lack of imaging techniques required for confirmation, or if they are available and yield contradictory radiological and clinical results, patients can be treated using intraoperative endoscopic retrograde cholangiopancreatography (ERCP) during the laparoscopic treatment or postoperative ERCP if the IOC finds CBDS. The choice of treatment depends on the level of experience and availability of each option at each hospital. Intraoperative ERCP has the advantage of being a single-stage treatment and has a significant success rate, an easy learning curve, low morbidity involving a shorter hospital stay and lower costs than the two-stage treatments (postoperative and preoperative ERCP). Intraoperative ERCP is also a good salvage treatment when preoperative ERCP fails or when total laparoscopic management also fails.

To 'gram or not'? Indications for intraoperative cholangiogram

BACKGROUND

The purpose of this study was to evaluate the current practice patterns and results for use of intraoperative cholangiogram (IOC) during laparoscopic cholecystectomy (LC).

METHODS

We performed a retrospective review of all patients who underwent LC between January 1, 2005 and December 31, 2009. Data variables included: preoperative laboratory and radiographic studies, indication for and findings of IOC, and perioperative management of choledocholithiasis and retained common bile duct (CBD) stones.

RESULTS

There were 1,308 patients who underwent LC by 23 surgeons, of whom 266 also had an IOC (20%) performed. The majority had ultrasonography performed, 242 had an abdominal compute tomography (CT) scan, and 129 patients had a hepatobiliary iminodiacetic acid (HIDA) scan. Indications for an IOC included: diagnosis of choledocholithiasis or gallstone pancreatitis (n = 116), abnormal liver function tests (n = 187), and a dilated CBD ≥ 10 mm (n = 182). Of the 266 IOCs, 36 patients (13.5%) had a CBD stone with the majority (n = 26; 72%) having normal preoperative imaging studies. Only 6 patients (17%) with a CBD calculi on IOC underwent successful clearance of the calculi at the time of LC. Twenty-nine of the remaining 30 patients with a retained calculus on IOC underwent postoperative endoscopic retrograde cholangiopancreatography (ERCP) with extraction of the calculi. Of the 1,042 LCs performed without an IOC, 31 patients (3%) were diagnosed with a retained stone managed successfully by ERCP.

CONCLUSION

Our data reveals that the selective use of IOC is helpful in diagnosing and clearing CBD calculi, that the use of preoperative CBD size aids in selecting patients for IOC, and that choledocholithiasis identified with IOC or after discharge can be managed successfully with ERCP.

Predictive value and main determinants of abnormal features of intraoperative cholangiography during cholecystectomy

BACKGROUND

The major issue with intraoperative cholangiography (IOC) is whether its diagnostic accuracy for common bile duct (CBD) stones matches that of other diagnostic procedures, and thus, whether it will become a routine diagnostic procedure. The current study aimed to address the main determinants of CBD stone diagnosis in IOC among an Iranian population.

METHODS

In a retrospective review database-based study conducted in Taleghani Hospital in Tehran between 2006 and 2008, baseline data and perioperative information of 2060 patients (male to female ratio 542:1518, mean age 53.7 years) who were candidates for cholecystectomy and underwent concomitant IOC for confirming CBD stones were reviewed. The predictive power of this procedure for diagnosis of abnormal biliary ducts with the focus on biliary stones was determined.

RESULTS

Overall mortality and morbidity following cholecystectomy in the study population were 0.6% and 2.6%, respectively. Both early mortality and morbidity due to cholecystectomy were higher in male than female. The prevalence of CBD stones in IOC was 3.4% (5.2% in male and 2.8% in female, P=0.008). Among those without gallstones, 8.7% had CBD stones and only 3.1% had concomitant gallstones and CBD stones. The main predictors of stone appearance as an abnormal feature of IOC during cholecystectomy were: advanced age (OR=1.022, P=0.001), male gender (OR=1.498, P=0.050), history of abdominal surgery (OR=1.543, P=0.040) and preoperative endoscopic retrograde cholangiopancreatography (OR=5.400, P<0.001).

CONCLUSIONS

IOC is a safe and accurate method for the assessment of bile duct anatomy and stones. Therefore, the routine use of IOC within cholecystectomy seems reasonable and is recommended.

Assessment of positive perioperative cholangiography in patients undergoing elective laparoscopic cholecystectomy

OBJECTIVE

To evaluate the positivity of cholangiography in patients without formal indication of this exam undergoing elective cholecystectomy.

METHODS

We included, in the study, 100 patients whose clinical, laboratory and imaging not older than 10 days before the operation showed no change and therefore kept us unsuspicious of choledocholithiasis. The cholangiographies were analyzed and examined by the surgical team, the radiologist and the authors. The reports were compared and correlated with patients' previous clinical and laboratory findings.

RESULTS

The incidence of preoperatively unsuspected choledocholithiasis was only one case (1%).

CONCLUSION

The use of selective cholangiography is safe and should be used in the treatment of calculous cholecystitis.

Elective Laparoscopic Cholecystectomy without Routine Intraoperative Cholangiography: A Retrospective Analysis of 1101 Consecutive Cases

Background:

Laparoscopic cholecystectomy (LC) is today the operation of choice for symptomatic gallstone disease. Before the laparoscopic era intraoperative cholangiography (IOC) was generally considered as a fundamental step in cholecystectomy while nowadays the role of IOC is controversial: is there a need for IOC to specify anatomy of biliary tree in order to avoid bile duct injuries (BDI) and to detect possible common bile duct (CBD) stones or not?

Patients and Methods:

We studied retrospectively all the elective LCs done in Turku City Hospital for Surgery during the ten years (1992–2001). Cholecystectomy was performed to 1101 patients, 874 (79%) female and 227 (21%) male patients, mean age 53y (range 15–89). LC was possible in 1022 (93%) cases while 79 (7%) had to be converted to open procedure. The number and severity of bile duct injuries were recorded. The cases with endoscopic retrograde cholangiopancreatography (ERCP) and/or magnetic resonance cholangiopancreatography (MRCP) during the follow-up and the findings in ERCP and MRCP were recorded from patient records and radiological database.

Results:

IOC was performed in 32 operations (20 in LC and 12 after conversion) and CBD stones were found in seven patients. There were four primary BDIs: two CBD injuries and two minor bile leaks. During a mean follow-up of 72 months (range 36–144) ERCP was performed in 16 and MRCP in three patients. Three patients underwent both MRCP and ERCP. CBD stones were detected in ten patients and a postoperative late CBD stricture was found in one case.

Conclusions:

According to our data, both the incidence of BDIs (0.5%) and symptomatic postoperative CBD stones (0.9%) remain low without the routine use of IOC.

Role of intra operative cholangiogram in current day practice

The role of Intra Operative Cholangiogram during laparoscopic cholecystectomy remains controversial. This review discusses the modalities used in the pre- and peri-operative assessment of Common Bile Duct. It also discusses the advantages and disadvantages of selective and routine IOC. In this review we explore the role of Intra Operative Cholangiogram in current day practice.

Open cholecystectomy

Open cholecystectomy is employed most commonly when severe inflammation precludes identification of critical anatomy during laparoscopic cholecystectomy. Several other situations, however, still require a laparotomy to remove the gallbladder. A current challenge is to teach young surgeons how to safely manage complex gallbladder disease, when there is minimal experience with open biliary surgery during residency.

For patients with predicted low risk for choledocholithiasis undergoing laparoscopic cholecystectomy, selective intraoperative cholangiography and postoperative endoscopic retrograde cholangiopancreatography is an effective strategy to limit unnecessary procedures

BACKGROUND

There is debate about whether intraoperative cholangiography (IOC) should be performed routinely or selectively during laparoscopic cholecystectomy (LC) in patients with suspected choledocholithiasis. The timing of endoscopic retrograde cholangiopancreatography (ERCP) in these patients also is an issue. We reviewed the experience in our center, where a management algorithm limiting ERCP in relation to LC was adopted.

METHODS

We retrospectively reviewed every LC performed by one surgeon during 6 years and the related ERCPs.

RESULTS

A total of 264 LCs were performed. In 30 patients, stones were cleared or excluded by preoperative ERCP. In the remaining 234 LCs, 31 of 34 IOCs were successfully performed. Two of 31 IOCs were positive for bile duct stones; stone removal was successful in each patient at subsequent ERCP. Only 10 of 201 patients who did not have IOC required postsurgical ERCP within 10 weeks of LC, 3 of whom had common bile duct stones at ERCP.

CONCLUSIONS

For patients who underwent LC, we performed selective IOC with postoperative ERCP for positive studies. Review of our experience using this algorithm showed it to be a powerful tool in limiting unnecessary ERCPs. Our data suggest that routine preoperative ERCP cannot be justified. Selective IOC during LC misses relatively few cases of biliary stones; these can be managed quickly by experienced endoscopists.

Clipless laparoscopic cholecystectomy by ultrasonic dissection

BACKGROUND

Ultrasonically activated devices have been used in gallbladder dissection in the laparoscopic cholecystectomy with encouraging results. The aim of this study was to compare between the safety and efficacy of the harmonic shears and the commonly used clip and cautery technique in achieving safe closure and division of the cystic duct in the laparoscopic cholecystectomy.

METHODS

In this prospective study, 120 patients with symptomatic gallstone disease were randomly assigned to either the harmonic scalpel laparoscopic cholecystectomy group (HS group=60 patients) where closure and division of the cystic duct was achieved solely by the harmonic shears or the clip and cautery laparoscopic cholecystectomy group (C&C group=60 patients).

RESULTS

Neither minor nor major bile leaks were encountered in either group. Similarly, no bile-duct injuries were encountered in the present study. The incidence of gallbladder perforation was statistically significantly higher in the C&C group, compared to the HS group (30 vs. 10%, respectively; P=0.002). The median operative time was statistically significantly shorter in the HS group than in the C&C group (32 vs. 40 minutes, respectively; P=0.000). No statistically significant difference was found in the incidence of postoperative complications between both groups.

CONCLUSIONS

The harmonic shears are as safe and effective as the commonly used clip and cautery technique in achieving safe closure and division of the cystic duct in the laparoscopic cholecystectomy. Further, it provides a superior alternative to the currently used high-frequency monopolar technology in terms of shorter operative time and lower incidence of gallbladder perforation.

Preoperative determinants of common bile duct stones during laparoscopic cholecystectomy

INTRODUCTION

The aim of this study is to determine whether there are any clinical or biochemical predictors of common bile duct (CBD) stones in patients undergoing laparoscopic cholecystectomy.

METHODS

A prospective database of nearly 1000 laparoscopic cholecystectomies performed under the care of a single surgeon with a standardised technique between 1999 and 2006, was analysed. Clinical presentation, ultrasound and immediate preoperative biochemical results as well as the operative cholangiogram findings were reviewed. Routine cholangiography was attempted in most patients and the primary outcome variable was the detection of bile duct stones. The data was analysed using chi-squared test for categorical variables. The significant variables on univariate analysis were further characterised to identify the independent predictors of bile duct stones using a logistic regression model (significance p < 0.05).

RESULTS

A total of 757 of 988 patients (77%) underwent cholangiography. Male-to-female ratio was 1 : 3 with a median age of 54 years (range: 17-93). Ten per cent of patients had bile duct stones identified on cholangiography. On univariate analysis, jaundice (p = 0.019), cholangitis (p < 0.001), alanine transaminase > 100 (p = 0.024), alkaline phosphatase (ALP) > 350 (p < 0.001) and CBD > 10 mm (p = 0.01) were significant markers for predicting bile duct stones. Bilirubin > 30 (x2 normal) was found not to be significant (p = 0.145). On a logistic regression model, ALP > 350 and/or cholangitis were found to be independent predictive factors of CBD stones (odds ratio 6.1).

CONCLUSIONS

If a policy of routine intra-operative cholangiography is not adopted, a history of cholangitis or a raised ALP immediately preoperatively should lead to a high suspicion of CBD stones.

Operative cholangiography in two-port needlescopic cholecystectomy

We report the use of operative cholangiography in two-port needlescopic (minilaparoscopic) cholecystectomy. A prospective series of 11 patients underwent two-port needlescopic cholecystectomy with operative cholangiography. In ten cases, operative cholangiography was successfully performed. There were no conversions. No additional ports were required. No related complications were noted. Two cases positive for common bile duct stones were identified. The median operative time was 92.5 minutes. Operative cholangiography in two-port needlescopic cholecystectomy is safe and feasible.

Indications for selective intraoperative cholangiography

The indications for selective intraoperative cholangiography (IOC) include a clinical history of jaundice, pancreatitis, elevated bilirubin level, abnormal liver function test results, increased amylase levels, a high lipase level, or dilated common bile duct on preoperative ultrasonography. Although these clinical features are widely accepted as indications for IOC, they have not been tested for their ability to predict choledocholithiasis. Charts were reviewed for a 6-month time period in 2003 at Parkland Memorial Hospital for all patients undergoing cholecystectomy. Univariate analysis and logistic regression were used to determine which factors predicted choledocholithiasis. Of the 572 patients undergoing cholecystectomies during the study period, 189 underwent IOC and common bile duct stones were found in 57. Only preoperative hyperbilirubinemia or ultrasonograph identification of common bile duct dilation reliably predicted choledocholithiasis. There were 13 cases of choledocholithiasis that would not have been identified by preoperative hyperbilirubinemia or an enlarged common bile duct. However, common bile duct stones were clinically significant in only 2 of the 13 cases. One of these was treated with postoperative endoscopic retrograde cholangiopancreatography, and the other was treated with laparoscopic common bile duct exploration. Preoperative identification of a dilated common bile duct or elevated bilirubin levels can be the sole criteria for performing IOC on a selective basis in patients without malignancy. Reliance on a history of remote jaundice, pancreatitis, elevated liver function test values, or pancreatic enzymes results in unnecessary IOCs.

Laparoscopic cholecystectomy after the learning curve: what should we expect?

BACKGROUND

The introduction of laparoscopic cholecystectomy (LC) in the late 1980s was accompanied an increase in common bile duct (CBD) injuries. This retrospective analysis of 2,005 cholecystectomies performed at a single institution investigates the factors that have contributed to a record of zero CBD injuries in 1,674 consecutive LC.

METHODS

The medical records of 1,285 consecutive patients operated on from 7 July 1996 to 6 June 2003 were obtained. We also examined the peer review records of an additional 720 LC performed between 1 January 1990 and 7 July 1996.

RESULTS

There were no CBD injuries among 1,674 consecutive LC patients spanning the period since 1990. Of the 954 patients who underwent LC since 1996, six had a cystic duct leak and five had a duct of Luschka leak. Intraoperative cholangiography (IOC) was performed in 20.2% of cases (n = 193/954). Seventy of 157 patients who underwent cholangiography alone demonstrated one or more stones in the CBD (44.6%). In 40 patients (58.0%), endoscopic retrograde cholangio pancreatography (ERCP) was uniformly successful in clearing intraoperatively identified stones. In36.2% of cases, the stones were removed via laparoscopic CBD exploration (CBDE) (n = 25). In 5.8% of positive cases, the stones were removed via open CBDE (n = 4). Among 761 patients who did not undergo IOC, seven patients (0.92%) returned to the hospital for retained stones. Three of these patients had elevated liver function tests (LFT) preoperatively (1.3%) and four had normal LFT (1.1%).

CONCLUSIONS

Injuries of the CBD can be avoided by performing an extensive dissection of the triangle of Calot and by developing a critical view of the operative field to ensure the patient's safety during LC. If all LFT are normal and IOC is not performed, the occurrence of clinically significant stones postoperatively is minimal; in this group, only four patients had retained stones. Thus, in the face of normal LFT, routine IOC is unnecessary for a low CBD injury rate, and a return to the hospital for retained bile duct stones is rarely required, regardless of the number of times ductal stones are found on routine cholangiography. This implies that the significance of the stones discovered at IOC is questionable in most cases, thereby providing an argument against routine cholangiography. Most discovered CBD stones can be treated by ERCP, thus obviating the need for the T-tube drainage associated with CBDE. The 21st century finds LC to be a mature and safe surgical procedure.

PROSPECTIVE COMPARISON OF ROUTINE AND SELECTIVE OPERATIVE CHOLANGIOGRAPHY

BACKGROUND

In a rural centre with limited resources and no endoscopic retrograde cholangiopancreatography facilities, a prospective cohort study was established to compare policies of routine and selective intraoperative cholangiography (IOC) in order to develop a local protocol.

METHODS

Patients undergoing laparoscopic cholecystectomy from 1 February 1995 to 30 November 2002 were allocated to undergo routine or selective IOC according to birth date. Those with known common bile duct (CBD) stones were excluded. Selective IOC was performed on the basis of abnormal liver function tests or a dilated CBD on ultrasound. Study end points after 12 months follow-up were retained CBD stones, CBD injury, operating times and the effect of IOC on the management of patients with persistent biliary symptoms postoperatively.

RESULTS

Of the 148 patients in the routine group, 94 underwent IOC and CBD stones were shown in 12. Of the 155 in the selective group, IOC was performed in 34 of 45 eligible patients and stones were shown in five. Sixteen patients re-presented with recurrent biliary symptoms or jaundice postoperatively and eight had proven retained CBD stones, of whom only one had undergone (false-negative) IOC. There was no significant difference in mean operating time (56 vs 61 min; t-test P = 0.15). There was one CBD injury in each group, both incurred after successful IOC.

CONCLUSIONS

There was no difference between policies of routine or selective IOC in relation to operating times, retained CBD stone rates or CBD injury. However, the authors found management of patients with recurrent biliary symptoms easier if an IOC had been performed, and IOC was easier to perform when the staff were expecting it. Thus a policy of routine IOC has been adopted.

Endoscopic ultrasonograpy for choledocholithiasis and biliary malignancy

Endoscopic ultrasound (EUS) is a valuable tool in gastrointestinal endoscopy, with various applications such as diagnosis, staging, and evaluation of the pancreaticobiliary system. EUS has comparable sensitivity to magnetic resonance cholangiopancreatography and endoscopic retrograde cholangiopancreatography (ERCP) for detection of choledocholithiasis. EUS may be considered for evaluation for choledocholithiasis as prelude to ERCP when there is a low to intermediate suspicion for common bile duct stones or when there is an increased risk for complications from ERCP. Endosonography may also be useful in the evaluation of cholangiocarcinoma. Intraductal ultrasound within the bile duct may help differentiate malignant from benign strictures. EUS-guided fine needle aspiration can be helpful in the diagnosis of cholangiocarcinoma, especially in the region of the hilum.

Is laparoscopic intraoperative cholangiogram a matter of routine?

BACKGROUND

Intraoperative cholangiography during laparoscopic cholecystectomy reveals the anatomy of the biliary tree and any stones contained within it. The use of intraoperative cholangiography may be routine for all laparoscopic cholecystectomy. An alternative approach is a selective policy, performing intraoperative cholangiography only for those cases in which choledocholithiasis is suspected on clinical grounds, or those for which the anatomy appears unclear at operation. The literature pertaining to both approaches is reviewed, to delineate their respective merits.

METHODS

Relevant articles in English were identified from the Medline database, and reviewed.

RESULTS

The literature reviewed consisted of retrospective analyses. Overall the incidence of unsuspected retained stones was 4%, but only 15% of these would go on to cause clinical problems. The incidence of complete transection of the common bile duct was rare for both routine and selective intraoperative cholangiography policies, and did not differ between them. Rates of minor bile duct injury did not differ between groups, but was more likely to be recognized in the routine group than the selective (P = 0.01).

CONCLUSIONS

Routine intraoperative cholangiography yields very little useful clinical information over and above that which is obtained with selective policies. Large numbers of unnecessary intraoperative cholangiography are performed under routine intraoperative cholangiography policy, and therefore a selective policy is advocated.

Surgeons' anonymous response after bile duct injury during cholecystectomy

BACKGROUND

Bile duct injuries remain one of the most devastating injuries during laparoscopic cholecystectomy. Few studies target surgeons who have experienced bile duct injuries for their insight, their perspective, and their suggestions concerning this problem.

METHODS

A confidential questionnaire was sent to all practicing general surgeons under the age of 65 years in British Columbia, Canada.

RESULTS

Seventy-five percent of surgeons responded to the survey. Of the 114 questionnaires completed, more than 97% of respondents had completed formal training in laparoscopic cholecystectomy. One half of surgeons reported experience with laparoscopic bile duct injury. A significant difference in years in practice between surgeons with injury and surgeons without injury was noted. The majority of injuries occurred after the surgeons's first 100 cholecystectomies performed. The first thoughts of surgeons after injury uniformly concerned the patient's well being. The next most common thoughts were in relation to obtaining help or a second opinion from another surgeon. Surgeons cited inflammation and short or anomalous cystic ducts as the most responsible factors contributing to injury. The majority of surgeons felt that these injuries are unavoidable and less than half felt that it was always a surgical error. Fewer than 15% thought injuries could be avoided by performing a cholangiogram. Surgeons suggested meticulous dissection and less haste to divide structures may prevent an injury. Surgeons recommend educating colleagues to remove the stigma of failure associated with conversion to laparotomy.

CONCLUSIONS

General surgeons in British Columbia have a one in two chance of experiencing a bile duct injury in their career. There were more injuries in surgeons who had already been in practice for 10 years at the time of introduction of laparoscopic cholecystectomy. The injuries are likely to occur despite high volumes of procedures and increased experience. The incidence of bile duct injuries does not seem to be different in surgeons who perform routine cholangiography and most surgeons feel that cholangiography would have little effect on injury incidence. Surgeons tend to have patient-centered concerns after injury and little concern for medicolegal issues. The majority of surgeons felt that these injuries could not be anticipated and as such it is an inherent risk of this procedure.

Prospective study of scoring system in selective intraoperative cholangiography during laparoscopic cholecystectomy

AIM: To evaluate of scoring system in predicting choledocholithiasis in selective intraoperative cholangiography (IOC) during laparoscopic cholecystectomy (LC).

METHODS: The scoring system of predicting choledocholithiasis was developed during the retrospective study in 264 cases, and was tested in 184 to evaluate its predictive value in choledocholithiasis.

RESULTS: The scoring system was developed in a retrospective study of 264 cases, the statistical analyses showed the predictive factors included sex, transaminase levels, alkaline phosphatase level, bilirubin level, and common bile duct diameter on ultrasonography. The scoring system was used in 184 cases prospectively, of which, 3 of 162 (1.9%) cases scoring < 3 had choledocholithiasis, 17 of 22 (77.3%) cases scores≥3 had choledocholithiasis. A case of scores≥3 or more prospectively should be considered highly intraoperative cholangiography during laparoscopic cholecystectomy.

CONCLUSION: The scoring system can predict choledocholithiasis and is helpful in selection patietns for intraoperative cholangiography.

Preoperative ultrasonographic assessment of the number and size of gallbladder stones: is it a useful predictor of asymptomatic choledochal lithiasis?

OBJECTIVE

To evaluate whether preoperative ultrasonographic assessment of the number and size of gallbladder stones can identify patients at increased risk of having asymptomatic common bile duct stones.

METHODS

Ultrasonographic data for 300 consecutive patients undergoing laparoscopic cholecystectomy were analyzed. Patients were divided into a group in which multiple small (< or = 5 mm) or multiple variably sized (both < or = 5 and > 5 mm) gallbladder stones were present ("positive" stones) and a group with multiple large (> 5 mm) or single gallbladder stones, considered "negative." The ultrasonographic description was compared with surgical findings; finally, the prevalence of asymptomatic common bile duct stones in the 2 groups was compared.

RESULTS

Ultrasonographic classification of gallbladder stones was confirmed at surgery in 285 cases (95%). Asymptomatic common bile duct stones were diagnosed in 9.5% of patients with an ultrasonographic diagnosis of positive gallbladder stones and in only 2.3% of patients with a diagnosis of negative gallbladder stones (P < .05).

CONCLUSIONS

Ultrasonography is able to accurately show gallbladder stones; the appearance of multiple small and variably sized gallbladder stones represent a risk factor for synchronous asymptomatic common bile duct stones.

Bile duct injury during laparoscopic cholecystectomy: results of a national survey

OBJECTIVE

To determine whether surgical residency training has influenced the occurrence of common bile duct injuries during laparoscopic cholecystectomy, and to asses the anatomic and technical details of bile duct injuries from the practices of surgeons trained in laparoscopic cholecystectomy after residency versus surgeons trained in laparoscopic cholecystectomy during residency.

SUMMARY BACKGROUND DATA

Shortly after the introduction of laparoscopic cholecystectomy, the rate of injury to the common bile duct increased to 0.5%, and injuries were more commonly reported early in each surgeon's experience. It is not known whether learning laparoscopic cholecystectomy during surgery residency influences this pattern.

METHODS

An anonymous questionnaire was mailed to 3,657 surgeons across the United States who completed an Accreditation Council for Graduate Medical Education (ACGME)-approved residency between 1980 and 1990 (group A) or 1992 and 1998 (group B). All surgeons in group A learned laparoscopic cholecystectomy after residency, and all those in group B learned laparoscopic cholecystectomy during residency. Information obtained included practice description, number of laparoscopic cholecystectomies completed since residency, postgraduate training in laparoscopy, and annual volume of laparoscopic cholecystectomy in the surgeon's hospital. In addition, technical details queried included the completion of a cholangiogram, the interval between injury and identification, the method of repair, and the site of definitive treatment. The primary endpoint was the occurrence of a major bile duct injury during laparoscopic cholecystectomy (bile leaks without a major bile duct injury were not tabulated).

RESULTS

Forty-five percent (n = 1,661) of the questionnaires were completed and returned. Mean practice experience was 13.6 years for group A and 5.4 years for group B. At least one injury occurrence was reported by 422 surgeons (37.6%) in group A and 143 surgeons (26.5%) in group B. Forty percent of the injuries in group A occurred during the first 50 cases compared with 22% in group B. Thirty percent of bile duct injuries in group A and 32.9% of all injuries in group B occurred after a surgeon had performed more than 200 laparoscopic cholecystectomies. Independent of the number of laparoscopic cholecystectomies completed since residency, group A surgeons were 39% more likely to report one or more biliary injuries and 58% more likely to report two or more injuries than their counterparts in group B. Bile duct injuries were more likely to be discovered during surgery if a cholangiogram was completed than if cholangiography was omitted (80.9% vs. 45.1%). Sixty-four percent of all major bile duct injuries required biliary reconstruction, and most injuries were definitively treated at the hospital where the injury occurred. Only 14.7% of injuries were referred to another center for repair.

CONCLUSIONS

Accepting that the survey bias underestimates the true frequency of bile duct injuries, residency training decreases the likelihood of injuring a bile duct, but only by decreasing the frequency of early "learning curve" injuries. If one accepts a liberal definition of the learning curve (200 cases), it appears that at least one third of injuries are not related to inexperience but may reflect fundamental errors in the technique of laparoscopic cholecystectomy as practiced by a broad population of surgeons in the United States. Intraoperative cholangiography is helpful for intraoperative discovery of injuries when they occur. Most injuries are repaired in the hospital where they occur and are not universally referred to tertiary care centers.

Butyrylcholinesterase activity in plasma of rats and rabbits fed high-fat diets

1. Comparative studies with rats and rabbits were carried out to address the question as to whether the amount of dietary fat affects butyrylcholinesterase (EC 3.1.1.8.) activity in plasma. 2. Plasma butyrylcholinesterase activities were about 5-fold higher in rabbits than rats. 3. Ad libitum feeding of diets enriched with corn oil caused increased body weights in rabbits but not in rats 4. Plasma butyrylcholinesterase activities of rats were increased with increasing intakes of corn oil. In rabbits, such an effect could not be demonstrated conclusively. 5. Evidence is presented that in rats the substitution of dietary corn oil for isocaloric amounts of either carbohydrates or protein produces similar increases in plasma butyrylcholinesterase activity. 6. This suggests that among macronutrients the amount of fat primarily determines butyrylcholinesterase activity in the plasma of rats.