Is Routine Intraoperative Cholangiogram Necessary in the Twenty-First Century? A National View

Abstract

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.

The Incidence and Surgical Treatment of Gallstone Cholecystitis in Rural Saudi Arabia

“…In counter argument, Polat et al .who demonstrated that in up to 12% patients findings of CBD stones during cholecystectomy were documented and recommend routine IOC to identify duct anatomy in order to reduce the incidence of CBD injury (8) . This recommendation was also supported by Ragulin-Coyne et al with similar conclusions (9) . Moreover, complications from missed gallstones, such as biliary pancreatitis can dramatically increase the cost of patient's management and hospitalization by 10 fold, as well as morbidity and mortality.…”

Near-infrared fluorescent cholangiography facilitates identification of biliary anatomy during laparoscopic cholecystectomy

“…Flum et al recommended routine IOC based on cost effectiveness in terms of dollar per life-year saved from BDI [23]. On the contrary, opponents of routine IOC contend that it results in higher complication rates, cost, and rates of additional postsurgical procedures, without a proven reduction in BDI rates or mortality [24]. Also, limitations including radiation exposure, increased operative time, and technical difficulties with the procedure are real concerns for many surgeons.…”

The Trends of Gallstone Surgical Treatment in Saudi Arabian Province: Is the Local Practice Up to Date?

“…This recommendation supported by the Ragulin-Coyne et al (2013), who reached similar conclusions (9). Moreover, gallstone complications, such as biliary pancreatitis and CBD injury during laparoscopic cholecystectomy can dramatically increase the cost of recurrent hospitalization by 10 fold, as well as morbidity and mortality of patients with the gallstone pathology.…”