Exploration of the common bile duct—the relevance of the clinical picture and the importance of peroperative cholangiography

Abstract

A series of 500 cholecystectomies performed over a 7-year period was reviewed retrospectively. The reliability of preoperative clinical features such as jaundice and pancreatitis was assessed in determining the presence of choledocholithiasis, and was found to be of limited value. Investigations such as intravenous cholangiography and liver function tests were found also to be inaccurate in the detection of common duct stones as was the appearance of the duct at operation. The usefulness of the peroperative cholangiogram in the detection of common duct stones that would otherwise have been overlooked is emphasized. Common duct stones would have remained undetected in 25 per cent of patients with choledocholithiasis. Despite the use of routine peroperative cholangiography common duct stones were overlooked in 11.25 per cent of patients who underwent exploration.

Factors Predictive of Bile Duct Stones in Patients with Acute Calculous Cholecystitis

“…Several studies have defined clinical and laboratory criteria for the identification of patients with increased risk for harbouring bile duct calculi in connection with cholecystectomy with or without signs of bile duct obstruction [10, 12, 13, 14, 15, 16, 17, 18, 19, 20, 53], but few have studied patients with acute cholecystitis. It would be most gratifying, however, to identify patients with acute cholecystitis at increased risk of having bile duct stones, especially as the use of routine POC does not seem to have reduced the rate of duct explorations (over 20%) [27], as compared with the duct exploration rate in the era of no or occasional cholangiographic support [54].…”

“…It has been performed either routinely [1, 2, 3, 4] or selectively [5, 6, 7, 8, 9, 10, 11, 12, 13] to detect bile duct calculi or anomalies, to avoid unnecessary bile duct explorations and retained stones as well as peroperative duct injuries. Except for cholangiography, identification of patients with bile duct stones can be achieved by patients’ clinical features [10, 13, 14, 15, 16, 17, 18], liver function tests [10, 12, 15, 16, 17, 18, 19, 20] or peroperative findings [10, 13, 14, 16, 18, 19]. …”

Do all patients with abnormal intraoperative cholangiogram merit endoscopic retrograde cholangiopancreatography?

“…The incidence of CBD stones detected at the time of cholecystectomy ranges from 8% to 15% [1,4,8,14,15]. Intraoperative chlangiography (IOC) is performed during laparoscopic cholecystectomy to evaluate the CBD for stones using contrast injection through a catheter introduced into the cystic duct.…”

¿Cuál es la prevalencia de litiasis de la vía biliar principal en pacientes con colecistolitiasis sintomática?

“…La litiasis de la vía biliar principal (LVBP), es la complicación más frecuente de la colecistolitiasis sintomática, con valores de prevalencias reportadas entre 4% y 15% [3][4][5][6][7][8] . De no ser tratada, la LVBP puede generar complicaciones graves como colangitis y pancreatitis 9 .…”