342 HPB INTERNATIONAL
Is there a Role for Preoperative Infusion
or Intraoperative Cholangiography?
ABSTRACT
Hammarstrfim, E-K., Holmin, T., Stridbeck, H. and Ihse,
I. (1996) Routine preoperative infusion cholangiography
versus intraoperative cholangiography at elective cholecys-
tectomy: A prospective study in 995 patients, Jounral ofthe
American College of Surgeons; 182, 408-416.
Background: There has been a resurgence of inter-
est in recent years in preoperative infusion cholan-
giography (PIC). The role of routine PIC compared
to routine intraoperative cholangiography (IOC) has
not been clearly defined.
Study design: In our department between 1985 and
1991, 1,042 of 1,576 consecutive patients with biliary
calculous disease had elective cholecystectomy: 694
patients were prospectively scheduled for PIC, and
348 patients were randomly allocated to IOC. The
patients in the PIC and IOC groups were similar
with regard to age, history of biliopancreatic
complications, and laboratory findings. The cost of
PIC in Sweden is nearly five times greater than the
cost of IOC.
Results: Satisfactory opacification of the biliary
system was obtained in 90.1 and 96.8 percent of
patients who underwent PIC and IOC, respectively.
Preoperative infusion cholangiography required
support by IOC in 19.5 percent of patients. There
were no statistically significant differences between
the PIC and IOC groups with regard to the incidence
(7 percent in both groups) of or positive predictive
value (68 and 80 percent, respectively) for bile duct
stones, rate of retained stones (6 and 20 percent,
respectively), intraoperative (5.6 and 6.3 percent, re-
spectively) or postoperative (13.3 and 15.9 percent,
respectively) morbidity, or incidence of bile duct
anomalies (0.9 and 0.3 percent, respectively). Median
operative time was longer in .patients with (95
minutes) compared to those without (75 minutes)
IOC (p<0.001). More postoperative complications
occurred after bile duct exploration (26 of 75
patients) compared to cholecystectomy alone (114
of 917 patients, p<0.001). The 30-day mortality was
zero. Minor bile duct injuries occurred in two
patients (0.2 percent) at cholecystectomy, (one with
and one without bile duct exploration). In no patient
was the cholangiographic finding of a biliary
anomaly crucial for the safe execution of cholecys-
tectomy.
Conclusions: In our study, PIC and IOC were
comparable, but routine use of either method did
not promote the safety of cholecystectomy and thus
their routine use is not warranted. The shorter
operative time and preoperative identification of
common bile duct (CBD) stones provided by PIC
might favor this examination when applied selec-
tively in patients with increased risk of having CBD
stones. However, this potential advantage is offset
by the need for PIC to be supported by IOC in
approximately 20 percent of patients. Also, the cost
of PIC is greater than the cost of IOC, J. Am. Coll.
Surg., 1996, 182, 408-416.
Keywords: Infusion cholangiography, intraoperative cholan-
giography, cholangiography, cholecystectomy, bile duct
resection
PAPER DISCUSSION
In the era of open cholecystectomy, whether
intraoperative cholangiography (IOC) for gall-
stone disease should be performed routinely or
selectively has been controversial. Advocates of
its routine use argue that IOC detects asympto-
matic common bile duct (CBD) calculi, ductal
anomalies and tumours ofthebile duct [1-6]. The
incidence of a positive yield with IOC, however,
is low. Despite using the classical criteria of a
dilated CBD, multiple gallbladder stones, history
of pancreatitis and jaundice as indicators of high
risk for choledocholithiasis, the actual CBD stone
rate in about 5000 patients was only 5% [7]. In
another study involving 280 patients with no
criteria indicating possible choledocholithiasis
who underwent open cholecystectomy and were
randomised to IOC or no IOC, no patients from
either group had retained CBD calculi over a 12
month follow-up period. However, the IOC was
falsely positive in 3 patients (2.1%) and 2 were
subjected to unnecessary CBD exploration [8].
Although CBD exploration is safe, Doyle et al.
reported the mortality of patients with CBD
exploration was 2.4 times greater than that for
cholecystectomy alone [2].
HPB INTERNATIONAL 343
The routine use of preoperative infusion
cholangiography (PIC) as compared with rou-
tine IOC was studied prospectively by Ham-
merstrom and colleagues at elective open
cholecystectomy. PIC failed to opacify or ade-
quately opacify the bile ducts in 9.9% of patients.
Furthermore IOC was necessary in 19.5% of
patients who had had PIC performed [9]. Faced
with the financial stringency of a cost conscious
health system, the much higher cost of perform-
ing PIC (5 times the cost of IOC) cannot be
justified. The estimated hospital charge for each
IOC is US $641 [10]. In 1987, 600,000 cholecys-
tectomies were performed in the United States
[11]. Even if the number of cholecystectomies
performed were to remain static until 1996, the
cost of routine IOC alone in the United States
wouldbe a staggeringUS$384.6 millions for 1996!
Both intravenous cholangiography and ultra-
sonography have the advantage of providing
preoperative knowledge of the bile duct status.
Intravenous cholangiography can directly visua-
lize the duct but the technique takes longer than
ultrasonography to perform, uses radiation and
has a low risk of allergic reaction which makes it
less attractive than ultrasonography. Preopera-
tive ultrasonography and liver function tests are
widely used for assessing the bile duct for stones
but these tests have the limitation of a poor
positive predictive value of 14- 58% for stones
[12-17]. Bile duct stones can and do migrate
through the sphincter of Oddi thus making any
form of radiological and/or biochemical assess-
ment of the bile duct valid onlyif performed close
to the time to operation. Welbourn et al., in a
prospective study evaluating ultrasonography
and liver function tests for preoperative assess-
ment of stones within the bile duct, demonstrated
that if the ultrasonography and/or liver function
tests performed on the daybefore operation were
normal then the negative predictive value for the
absence of stones was at least 96% [18].
The use of intraoperative ultrasonography
(IOUS) during open biliary tract surgery in
screening for bile duct stones at the time of
cholecystectomy is a more attractive option than
IOC. In 666 IOUS and 401 IOC, IOUS was
technically unsuccessful in only 1.2% of cases
compared to 5.5% with IOC. The positive
predictive value of IOUS (94.8%) was signifi-
cantly better than that of IOC (71.7%) [19]. IOUS
has a 94% accuracy in predicting the presence of
bile duct stones if the size of gallstones present
were < 3 mm and the bile duct diameter was
_> 7 mm [20]. An added advantage of IOUS is it
takes less time to perform than IOC.
The advent of endoscopic retrograde chol-
angiopancreatography (ERCP) in 1970 and a
diathermy sphincterotome in 1974 made endo-
scopic extraction of CBD stones a reality. With a
success rate of 85-92% of clearance of CBD
stones [21], preoperative ERCP combined with
cholecystectomy was thought to be superior to
open cholecystectomy and CBD exploration.
However, this has not been substantiated in
randomized trials [22-24]. In 9-29% of cases,
the sheer size of the stone or the disproportion
between the diameter of the distal CBD and the
size of the stone precludes endoscopic removal
[22, 24, 25] and these patients will still come to
open CBD exploration.
Although the case for selective cholangiogra-
phy in open cholecystectomy has been well
made [8, 26], the birth and success of laparo-
scopic cholecystectomy has rekindled the con-
troversy about routine or selective use of
cholangiography in laparoscopic cholecystect-
omy. The experience gained from the era of open
cholecystectomy cannot be directly extrapolated
to laparoscopic cholecystectomy. There are
proponents [27] and opponents [28] of routine
cholangiography during laparoscopic cholecys-
tectomy. Equally the question of whether ERCP
should be performed before or after laparo-
scopic cholecystectomy in the presence of ductal
stones remains conjectural. A recent decision
analysis study by Erickson and Carlson con-
cluded that postoperative ERCP for ductal
stones discovered at laparoscopic cholecystect-
omy was more cost effective and produces less
344 HPB INTERNATIONAL
morbidity than preoperative ERCP and open
CBD exploration (no comparison was performed
on laparoscopic CBD exploration). When chole-
docholithiasis is likely, the result of selective
preoperative ERCP is comparable to postopera-
tive ERCP [29]. The issue has become even more
complicated because CBD stones can now be
dealt with by laparoscopic CBD exploration at
the time of the laparoscopic cholecystectomy.
Whether laparoscopic treatment of CBD stone
has any advantages over ERCP and endoscopic
stone retrieval remains unknown. It is only with
proper randomised studies that definitive an-
swers to all these questions can be provided in
this era of laparoscopic surgery.
References
[1] Cranley, B. and Logan, H. (1980). Exploration of the
common bile duct the relevance of the clinical
picture and the importance of peroperative cholangio-
graphy, Br. J. Surg., 67, 869-872.
[2] Doyle, P. J., Ward-McQuaid, J. N. and McEwen Smith,
A. (1982). The value of routine peroperative cholangio-
graphy a report of 4000 cholecystectomies. Br. J.
Surg., 69, 617-619.
[3] Faris, I., Thomson, J. P. S., Grundy, D. J. and LeQuesne
L. P. (1975). Operative cholangiography: A reappraisal
based on a review of 400 cholangiograms. Br. I. Surg.,
62, 966-972.
[4] Holliday, H. J., Farringer, J. L., Terry, R. B. and Pickens,
D. R. (1980). Operative cholangiography: Review of
7529 operations on the biliary tree in a community
hospital. Am. J. Surg., 139, 379-382.
[5] Hermann, R. E. (1990). Surgery for acute and chronic
cholecystitis. Surg. Clin. North Am., 70, 1263-1275.
[6] Shively, E. H., Wieman, T. J., Adams, A. L., Romines, R.
B. and Garrison, R. N. (1990). Operative cholangio-
graphy. Am. J. Surg., 159, 380-384.
[7] Strasberg, S. M. and Soper, N. J. (1995). Management of
choledocholithiasis in the laparoscopic era. Gastro-
enterology, 109, 320-322.
[8] Hauer-Jensen, M., Karesen, R., Nygaard, K., Solheim,
K. Amlie, E., Havig, O. and Viddal, K. O. (1986).
Consequences of routine peroperative cholangiogra-
phy during cholecystectomy for gallstone disease: A
prospective, randomized study. World, J. Surg., 10,
996 1002.
[9] Hammarstron, L. E., Holmin, T., Stridbeck, H. and Ihse,
I. (1996). Routine preoperative infusion cholangiogra-
phy versus intraoperative cholangiography at elective
cholecystectomy: A prospective study in 995 patients. J.
Am. Coll. Surg., 182, 408-416.
[10] Orlando, R. III, and Russell, J. C. (1996). Managing
gallbladder disease in a cost-effective manner. Surg.
Clin. North Am., 76, 117-128.
[11] Bogokowsky, H., Slutzki, S., Zaidenstein, L., Halpern
Z., Negri, M. and Abramsohn, R. (1987). Selective
operative cholangiography. Surg. Gynecol. Obstet., 164,
124-126.
[12] Neuhaus, H., Feussner, H., Ungeheuer, A., Hoffmann,
W., Siewert, J. R. and Classen, M. (1992). Prospective
evaluation of the use of endoscopic retrograde cholan-
giography prior to laparoscopic cholecystectomy.
Endoscopy, 24, 745-749.
[13] O'Rourke, N. A., Askew, A. R., Cowen, A. E., Roberts,
R. and Fielding, G. A. (1993). The role of ERCP and
endoscopic sphincterotomy in the era of laparoscopic
cholecystectomy. Aust. N. Z. J. Surg., 63, 3-7
[14] Leitman, I. M., Fisher, M. L., McKinley, M. J., Rothman,
R., Ward, R. J., Reiner, D. S. and Tortolani, A. J. (1993).
The evaluation and management of known or sus-
pected stones of the common bile duct in the era of
minimal access surgery. Surgery Gynecol. Obstet., 176,
527-533.
[15] Hawasli, A., Lloyd, L., Pozios, V. and Veneri, R. (1993).
The role of endoscopic retrograde cholangio-pancrea-
ticogram in laparoscopic cholecystectomy. Am. Surg.,
59, 285-289.
[16] Graham, S. M., Flowers, J. L., Scott, T. R., Bailey, R. W.,
Scovill, W. A., Zucker, K.A. and Imbembo, A. L. (1993).
Laparoscopic cholecystectomy and common bile duct
stones. The utility of planned perioperative endoscopic
retrograde cholangiography and sphincterotomy: Ex-
perience with 63 patients. Ann. Surg., 218, 61-67.
[17] Madhavan, K. K., Macintyre, I. M. C., Wilson, R. G.,
Saunders, J. H., Nixon, S. J. and Hamer-Hodges,
D. W. (1995). Role of intraoperative cholangiography
in laparoscopic cholecystectomy. Br. J. Surg., 82,
249-252.
[18] Welbourne, C. R. B., Haworth, J. M., Leaper, D. J. and
Thompson, M. H. (1995). Prospective evaluation of
ultrasonography and liver function tests for preopera-
tive assessment of the bile duct. Br. J. Surg., 82,
1371-1373.
[19] Machi, J. and Sigel, B. (1996). Operative ultrasound in
general surgery. Am. J. Surg., 172, 15-20.
[20] Grieg, J. D., John, T. G., Mahadevan, M. and Garden,
O. J. (1994). Laparoscopic ultrasonography in the
evaluation of the biliary tree during laparoscopic
cholecystectomy. Br. J. Surg., 81, 1202-1206.
[21] Gordon, R. L. and Shapiro, H. A. (1990). Nonoperative
management of bile duct stones. Surg. Clin. North Am.,
70, 1313-1328.
[22] Neoptolemos, J. P., Carr-Locke, D. I. and Fossard, D. P.
(1987). Prospective randomized study of preoperative
endoscopic sphincterotomy versus surgery alone for
common bile duct stones. BMJ, 294, 470-474.
[23] Stain, S. C., Cohen, H., Tsuishoysha, M. and Donovan,
A. J. (1991). Choledocholithiasis. Endoscopic sphincter-
otomy or common bit duct exploration. Ann. Surg., 213,
627-632.
[24] Stiegmann, G. V., Goff, J. S., Mansour, A., Pearlman,
N., Reveille, R. M. and Norton, L. (1992). Prechole-
cystectomy endoscopic cholangiography and stone
removal is not superior to cholecystectomy, cholangio-
graphy, and common duct exploration. Am. J. Surg.,
163, 227-230.
[25] Ponchon, T., Bory, R., Chavaillon, A. and Fouillet, Ph.,
(1989). Biliary lithiasis: Combined endoscopic and
surgical treatment, Endoscopy, 21, 15-18.
[26] Taylor, T. V. (1990). Editorial comment. Am. J. Surg.
159:385.
HPB INTERNATIONAL 345
[27] Soper, N. J. and Brunt, L. M. (1994). The case for routine
operative cholangiography during laparoscopic chole-
cystectomy. Surg. Clin. North Am., 74, 953-959.
[28] Clair, D. G. and Brooks, D. C. (1994). Laparoscopic
cholangiography: The case for a selective approach.
Surg. Clin. North Am., 74, 961-966.
[29] Erickson, R. A. and Carlson, B. (1995). The role of
endoscopic retrograde cholangiopancreatography in
patients with laparoscopic cholecystectomies Gastro-
enterology, 109, 252-263.
W. Y. Lau
Arthur K. C. Li
Department of Surgery
The Chinese University of Hong Kong
Prince of Wales Hospital
Shatin
Hong Kong