Ann Hepatobiliary Pancreat Surg.  2023 May;27(2):166-171. 10.14701/ahbps.22-099.

Systematic intraoperative cholangiography during elective laparoscopic cholecystectomy: Is it a justifiable practice?

• Esposito F
• Scoleri I
• Cattan R
• Cook MC
• Sacrieru D
• Meziani N
• Prete MD
• Kabbej M

• KMID: 2542580
• DOI: http://doi.org/10.14701/ahbps.22-099

Abstract

Backgrounds/Aims
Routine execution of intraoperative cholangiography (IOC) in laparoscopic cholecystectomy (LC) is considered a good practice to help early identification of biliary duct injuries (BDIs) or common bile duct (CBD) stones. This study aimed to determine the impact of IOC during LC.
Methods
This is a retrospective, monocentric study, including patients with a LC performed from January 2020 to December 2021.
Results
Of 303 patients, 215 (71.0%) were in the IOC group and 88 (29.0%) in the no-IOC group. IOC was incomplete or unclear in 10.7% of patients, with a failure rate of 14.7%. Operating time was 15 minutes longer in the IOC group (p = 0.01), and postoperative complications were higher (5.1% vs. 0.0%, p = 0.03). There were three BDIs (0.99%), all included in the IOC group; only one was diagnosed intraoperatively, and the other two were identified during the postoperative course. Regarding identifying CBD stones, IOC showed a sensitivity of 77%, a specificity of 98%, an accuracy of 97.2%, a positive predictive value of 63% and a negative predictive value of 99%.
Conclusions
Systematic IOC has shown no specific benefits and prolonged operative duration. IOC should be performed on selected patients or in situations of uncertainty on the anatomy.

Keyword

Cholangiography; Laparoscopic cholecystectomy; Bile duct injuries; Common bile duct stones

Figure

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  Fig. 1 Flowchart of the study population. IOC, intraoperative cholangiography.

Reference

1. Flum DR, Cheadle A, Prela C, Dellinger EP, Chan L. 2003; Bile duct injury during cholecystectomy and survival in medicare beneficiaries. JAMA. 290:2168–2173. DOI: 10.1001/jama.290.16.2168. PMID: 14570952.

2. Mangieri CW, Hendren BP, Strode MA, Bandera BC, Faler BJ. 2019; Bile duct injuries (BDI) in the advanced laparoscopic cholecystectomy era. Surg Endosc. 33:724–730. DOI: 10.1007/s00464-018-6333-7. PMID: 30006843.

3. Swedish Agency for Health Technology Assessment and Assessment of Social Services (SBU). Intraoperative cholangiography in cholecystectomy: a systematic review and assessment of medical, economic, social and ethical aspects [Internet]. Stockholm: Swedish Agency for Health Technology Assessment and Assessment of Social Services (SBU);2018. cited 2021 Jun 17. Available from: https://pubmed.ncbi.nlm.nih.gov/34464042/. PMID: 34464042.

4. Fédération de chirurgie viscérale et digestive. 2014; Risk management to decrease bile duct injury associated with cholecystectomy: measures to improve patient safety. J Visc Surg. 151:241–244. DOI: 10.1016/j.jviscsurg.2014.04.003. PMID: 24810713.

5. Rystedt JML, Wiss J, Adolfsson J, Enochsson L, Hallerbäck B, Johansson P, et al. 2021; Routine versus selective intraoperative cholangiography during cholecystectomy: systematic review, meta-analysis and health economic model analysis of iatrogenic bile duct injury. BJS Open. 5:zraa032. DOI: 10.1093/bjsopen/zraa032. PMID: 33688957. PMCID: PMC7944855.

6. Ford JA, Soop M, Du J, Loveday BP, Rodgers M. 2012; Systematic review of intraoperative cholangiography in cholecystectomy. Br J Surg. 99:160–167. DOI: 10.1002/bjs.7809. PMID: 22183717.

7. Ding GQ, Cai W, Qin MF. 2015; Is intraoperative cholangiography necessary during laparoscopic cholecystectomy for cholelithiasis? World J Gastroenterol. 21:2147–2151. DOI: 10.3748/wjg.v21.i7.2147. PMID: 25717250. PMCID: PMC4326152.

8. Michael Brunt L, Deziel DJ, Telem DA, Strasberg SM, Aggarwal R, Asbun H, et al. 2020; Safe cholecystectomy multi-society practice guideline and state-of-the-art consensus conference on prevention of bile duct injury during cholecystectomy. Surg Endosc. 34:2827–2855. DOI: 10.1007/s00464-020-07568-7. PMID: 32399938.

9. Van Dijk AH, De Reuver PR, Besselink MG, Van Laarhoven KJ, Harrison EM, Wigmore SJ, et al. 2017; Assessment of available evidence in the management of gallbladder and bile duct stones: a systematic review of international guidelines. HPB (Oxford). 19:297–309. DOI: 10.1016/j.hpb.2016.12.011. PMID: 28117228.

10. Agresta F, Campanile FC, Vettoretto N, Silecchia G, Bergamini C, Maida P, et al. 2015; Laparoscopic cholecystectomy: consensus conference-based guidelines. Langenbecks Arch Surg. 400:429–453. DOI: 10.1007/s00423-015-1300-4. PMID: 25850631.

11. European Association for the Study of the Liver (EASL). 2016; EASL Clinical Practice Guidelines on the prevention, diagnosis and treatment of gallstones. J Hepatol. 65:146–181. DOI: 10.1016/j.jhep.2016.03.005. PMID: 27085810.

12. Strasberg SM, Brunt LM. 2010; Rationale and use of the critical view of safety in laparoscopic cholecystectomy. J Am Coll Surg. 211:132–138. DOI: 10.1016/j.jamcollsurg.2010.02.053. PMID: 20610259.

13. Amott D, Webb A, Tulloh B. 2005; Prospective comparison of routine and selective operative cholangiography. ANZ J Surg. 75:378–382. DOI: 10.1111/j.1445-2197.2005.03393.x. PMID: 15943720.

14. Fletcher DR, Hobbs MS, Tan P, Valinsky LJ, Hockey RL, Pikora TJ, et al. 1999; Complications of cholecystectomy: risks of the laparoscopic approach and protective effects of operative cholangiography: a population-based study. Ann Surg. 229:449–457. DOI: 10.1097/00000658-199904000-00001. PMID: 10203075. PMCID: PMC1191728.

15. Rhaiem R, Piardi T, Renard Y, Chetboun M, Aghaei A, Hoeffel C, et al. 2019; Preoperative magnetic resonance cholangiopancreatography before planned laparoscopic cholecystectomy: is it necessary? J Res Med Sci. 24:107. DOI: 10.4103/jrms.JRMS_281_19. PMID: 31949458. PMCID: PMC6950362.

16. Zang J, Yuan Y, Zhang C, Gao J. 2016; Elective laparoscopic cholecystectomy without intraoperative cholangiography: role of preoperative magnetic resonance cholangiopancreatography - a retrospective cohort study. BMC Surg. 16:45. DOI: 10.1186/s12893-016-0159-9. PMID: 27411676. PMCID: PMC4944431.

17. Joyce WP, Keane R, Burke GJ, Daly M, Drumm J, Egan TJ, et al. 1991; Identification of bile duct stones in patients undergoing laparoscopic cholecystectomy. Br J Surg. 78:1174–1176. DOI: 10.1002/bjs.1800781008. PMID: 1835665.

18. Williams E, Beckingham I, El Sayed G, Gurusamy K, Sturgess R, Webster G, et al. 2017; Updated guideline on the management of common bile duct stones (CBDS). Gut. 66:765–782. DOI: 10.1136/gutjnl-2016-312317. PMID: 28122906.

19. Hakuta R, Hamada T, Nakai Y, Oyama H, Kanai S, Suzuki T, et al. 2020; Natural history of asymptomatic bile duct stones and association of endoscopic treatment with clinical outcomes. J Gastroenterol. 55:78–85. DOI: 10.1007/s00535-019-01612-7. PMID: 31473828.

20. Conrad C, Wakabayashi G, Asbun HJ, Dallemagne B, Demartines N, Diana M, et al. 2017; IRCAD recommendation on safe laparoscopic cholecystectomy. J Hepatobiliary Pancreat Sci. 24:603–615. DOI: 10.1002/jhbp.491. PMID: 29076265.

21. de'Angelis N, Catena F, Memeo R, Coccolini F, Martínez-Pérez A, Romeo OM, et al. 2021; 2020 WSES guidelines for the detection and management of bile duct injury during cholecystectomy. World J Emerg Surg. 16:30. DOI: 10.1186/s13017-021-00369-w. PMID: 34112197. PMCID: PMC8190978.

22. Goldstein SD, Lautz TB. 2020; Fluorescent cholangiography during laparoscopic cholecystectomy: shedding new light on biliary anatomy. JAMA Surg. 155:978–979. DOI: 10.1001/jamasurg.2020.3003. PMID: 32857120.

23. Lehrskov LL, Westen M, Larsen SS, Jensen AB, Kristensen BB, Bisgaard T. 2020; Fluorescence or X-ray cholangiography in elective laparoscopic cholecystectomy: a randomized clinical trial. Br J Surg. 107:655–661. DOI: 10.1002/bjs.11510. PMID: 32057103.

24. Dip F, LoMenzo E, Sarotto L, Phillips E, Todeschini H, Nahmod M, et al. 2019; Randomized trial of near-infrared incisionless fluorescent cholangiography. Ann Surg. 270:992–999. DOI: 10.1097/SLA.0000000000003178. PMID: 30614881.

25. Hauer-Jensen M, Karesen R, Nygaard K, Solheim K, Amlie EJ, Havig O, et al. 1993; Prospective randomized study of routine intraoperative cholangiography during open cholecystectomy: long-term follow-up and multivariate analysis of predictors of choledocholithiasis. Surgery. 113:318–323.

26. Murison MS, Gartell PC, McGinn FP. 1993; Does selective peroperative cholangiography result in missed common bile duct stones? J R Coll Surg Edinb. 38:220–224.