Evaluation of perioperative cholangiography in one thousand laparoscopic cholecystectomies.

Introduction: We analyzed a teaching institution's experience with intraoperative cholangiography (IOCG) and endoscopic retrograde cholangiopancreatography (ERCP) and established an algorithm for their timing and use.

Methods: The records of all patients undergoing LC during a five year period were reviewed. Patients with a history of jaundice or pancreatitis, abnormal bilirubin, alkaline phosphatase, serum glutamicoxaloacetic transaminase, or radiographic evidence suggestive of choledocholithiasis were considered "at risk" for common bile duct stones (CBDS). The remaining patients were considered to be at low "risk".

Results: LC was attempted on 1002 patients during the study period and successfully completed on 941 (94% of the time). The major complication rate was 3.1% and the common bile duct injury rate 0.1%. Eighty eight (9.5%) patients underwent ERCP, 67 in the preoperative period and 19 in the postoperative period. IOCG was attempted in 272 (24%) patients and completed in 234 for a success rate of 86%. Intraoperative cholangiography (IOCG) and preoperative endoscopic retrograde cholangiopancreatography (ERCP) were equivalent in the detection of CBDSs. Twelve of the 21 patients (57%) with IOCG positive for stones underwent successful laparoscopic clearance of the common duct, and did not require postop. ERCP. No patients were converted to an open procedure for common bile duct exploration. Because postoperative ERCP was 100% successful in clearing the common duct, reoperation for retained common bile duct stones was not necessary.

Conclusion: IOCG is an alternative procedure to ERCP for patients at risk with biochemical, radiological, or clinical evidence of choledocholithiasis. The incidence of CBDS in low-risk patients is 1.7%, a risk that does not warrant routine cholangiography. Preoperative ERCP is recommended in cases of cholangitis unresponsive to antibiotics, suspicion of carcinoma, and biliary pancreatitis unresponsive to supportive care. Although IOCG leads to a similar percentage of nontherapeutic studies as preoperative ERCP, it often allows for one procedure therapy.