The long-term follow-up of patients with positive intraoperative cholangiograms during laparoscopic cholecystectomy

Abstract

We read with interest the article by Wagner et al. [3]. The authors successfully highlighted that simple transcystic maneuvers may clear common bile duct (CBD) stones in 71% of cases with a positive intraoperative cholangiogram that would otherwise have a postoperative endoscopic retrograde cholangiopancreatography (ERCP). It remained unclear why patients who had open common bile duct exploration (CBDE) were excluded from the group of patients with attempted transcystic clearance and whether a decision to proceed to open CBDE was made on cholangiographic evidence. Simple transcystic manipulation of CBD stones has been shown to be effective, as evidenced by retained stone clearance in an xray department following saline flushing through a T-tube after 1 mg glucagon injection[1]. In our experience, 52 of 279 abnormal cholangiograms were clear after flushing with glucagon injection (18.6%) and a further 37 were clear after dormia basket trawling under fluoroscopy (13.3%) prior to the insertion of a choledochoscope. However, this was achieved in a series of 1,408 all-comers treated by single-session management, 28% of whom were emergent admissions with deranged LFTs and/or jaundice. In units without the equipment and expertise for performing laparoscopic choledochoscopic bile duct exploration, the normal practice would be preoperative magnetic resonance cholangiopancreatography (MRCP) followed by ERCP for patients with suspected CBD stones. The authors have demonstrated that simple transcystic manipulation can clear the ducts to avoid unnecessary cost and prolonged inpatient stay. The simple techniques described should be easily performed by most surgeons practicing laparoscopic cholecystectomy.The article also stressed the importance of intraoperative cholangiogram as a diagnostic modality deemed by many surgeons as inconsequential. Recent reviews have shown unsuspected retained stones to occur in approximately 4% of patients with gallstones and only 15% of those go on to cause clinical problems [2]. In our experience, 59 patients had abnormal cholangiograms out of 589 with no preoperative clinical, biochemical, or radiological risk (10%). Since a MRCP is almost always required to demonstrate the presence of a CBD stone prior to ERCP, an intraoperative cholangiogram could further save costs by detecting clinically silent stones that might become symptomatic following a laparoscopic cholecystectomy. In all cases, the authors have shown laparoscopic transcystic manipulation to be more cost-effective than postoperative ERCP with similar long-term outcomes, which is a welcome conclusion to balance the rising expenditure on MRCP and reliance on duct clearance by ERCP with its high comorbidity. References 1. Mahmud S, McGlinchey I, Kasem H, Nassar AH (2001) Radiological treatment of retained bile duct stones following recent surgery using glucagon. Surg Endosc 15: 1359-1360 2. Metcalfe MS, Ong T, Bruening MH, Iswariah H, Wemyss-Holden SA, Maddern GJ (2004) Is laparoscopic intraoperative cholangiogram a matter of routine? ...