Operative cholangiography: A reappraisal based on a review of 400 cholangiograms

Abstract

In the period 1957-72, 426 patients were operated upon for calculous disease of the biliary tract. For various reasons pre-exploratory operative cholangiography was not performed in 26 patients, but in the remaining 400 patients this examination was the major determinant as to whether or not the common duct contained calculi, and hence required exploration. Analysis of this series of 400 patients shows that without operative cholangiography (a) ductal stones would have been overlooked in 16 of the 78 patients with stones in the common duct (4 per cent of the whole series; 20-5 per cent of those with stones in the common bile duct); (b) exploration of the common duct would have been required in a further 48 (15 per cent) of the 322 patients without stones in the common duct, giving a positive yield from operative cholangiography in 64 patients (16 per cent) in the whole series. Negative exploration of the common duct was performed in only 31 patients, that is 29 per cent of the patients whose duct was explored but only 7-8 per cent of the whole group. The criteria by which an operative cholangiogram should be assessed were re-evaluated in the light of the findings in these 400 patients. In general the criteria of normality previously described were affirmed, and the following points established: a. In the absence of a filling defect the diameter of the duct is the most important indication of the presence of a stone. b. There is a statistically significant increase in the diameter of the common duct with age, and though not great this could, if neglected, give rise to error in the interpretation of the cholangiogram in younger patients. c. Even within the overall normal range of duct diameter (less than 12 mm) the wider the duct, the greater is the chance of it harbouring a stone. d. Impaired flow of contrast material into the duodenum is significantly related to duct diameter. e. Impaired flow of contrast material into the duodenum and failure to delineate the terminal segment of the duct tend to occur together; they may occur in a duct free of stones and if they are the only abnormality the examination should be repeated after the inhalation of amyl nitrite. This study confirms that operative cholangiography is the most accurate method at present available of determining whether or not the common duct contains a stone (or stones), and hence requires exploration.

Pre‐operative Ultrasound Measurement of Bile Duct Diameter: Basis for Selective Cholangiography

“…10 It should be noted that both of these studies, as well as the present one, included only patients having primary cholecystectomy. on operative cholangiograms to exceed 17 mm had stones.…”

Scoring system to predict asymptomatic choledocholithiasis before laparoscopic cholecystectomy

“…The attempts proposed in the literature to combine different indicators have resulted in complicated proceedings using multivariate analysis [3,19] or discriminant functions [46], implying the use of a computer program, which is not always available during the diagnostic workup. In recent years, some authors have maintained that the risk of migration of gallbladder stones to the biliary tree is higher the smaller and/or more numerous they are, rather than if the stones are single or large [13,19,44,45,50]. Taking into consideration the results of these studies, in our study gallstones were evaluated by ultrasound examination and were classified as dangerous or not dangerous on the basis of number and size.…”

“…On the basis of the literature [13,19,44,45,50], gallstones were classified as dangerous or not dangerous: multiple gallstones were classified as dangerous when they were micro, small, or heterogeneous in size; multiple gallstones were considered not dangerous when they were medium-or large-sized; and a single stone, irrespective of dimension, was classified as not dangerous.…”

Guidelines on the management of common bile duct stones (CBDS)

“…First, it accurately defines anatomy and may therefore allow surgeons to minimise the risk of ductal injury, or at a least take prompt remedial action when such injury occurs 165. Second, it may detect asymptomatic ductal stones 166 – 168…”