Should intraoperative cholangiography be performed routinely during cholecystectomy?
I'm a routine intraoperative cholangiographer. It's a cheap and accurate test. There are no well-established, reliable criteria for performing it selectively. As far as I'm concerned, the indication for intraoperative cholangiography should be the cholecystectomy.
Every time I scrub with the residents I look at them and ask, "Is today going to be the day I whack the duct?" I haven't done it yet and I hope that it never happens. But I think there is pretty compelling evidence that one reason it hasn't happened is that when 1 do a cholecystectomy, I routinely perform intraoperative cholangiography.
In an Australian review of nearly 20,000 cholecystectomies--backed by similar findings in a review of 30,000 cholecystectomies in Washington state--there was a nearly twofold increase in common bile duct (CBD) injuries when intraoperative cholangiography was not done. And when acute cholecystitis was present, CBD injuries increased eight-fold in the absence of intraoperative cholangiography.
These iatrogenic CBD injuries are a serious matter. They necessitate surgical reconstruction of the duct, which is a sophisticated operation that entails a prolonged hospital stay. And as a recent study from the University of Washington, Seattle, has documented, CBD in jury during cholecystectomy nearly triples the risk of death.
The retrospective study scrutinized nearly 1.6 million cholecystectomies performed during 1992-1999 on Medicare patients. The incidence of CBD injury was 0.5%. During a mean 9.2 years of follow up, 80.5% of the patients who had experienced a CBD injury died, as did 44.8% of patients who did not have this injury. Patients with a CBD injury had an adjusted 2.79 fold increased mortality. If the surgeon who did the CBD repair was the same one who caused the injury, the risk of mortality was 11% greater than if another surgeon performed the reconstruction (JAMA 290:2168 73, 2003).
Medicare data also indicate that the rate of intraoperative cholangiography during cholecystectomy has been on the decline in the last decade. I understand why. Intraoperative cholangiography is time-consuming.
Moreover, reimbursement toe the procedure is lousy. An extra $50 is not much of an inducement. But I'm convinced that intraoperative cholangiography prevents ductal injury and reduces the severity of such injuries when they do occur. It probably reduces malpractice problems as well.
Dr. Michael Edye is in practice in laparoscopic surgery at New York University, New York.
I believe in selective intraoperative cholangiography. I perform it in patients I identify preoperatively as being at high risk for having a CBD stone based upon the presence of abnormal liver function tests, a dilated CBD upon ultrasound, and jaundice or pancreatitis.
I also perform the procedure in all patients with acute cholecystitis, since they have roughly a 10% chance of having a CBD stone. And I always obtain an intraoperative cholangiogram if I'm unable to clearly delineate the anatomy.
Cholangiography can reasonably be avoided if the patient's anatomy is well visualized and the risk of a CBD stone is low, based on normal liver function tests, a normal-sized CBD, and no jaundice or pancreatitis. A persuasive argument against routine cholangiography is that the test has a 2%-3% false-positive rate even in the best of hands. Those false-positive tests trigger intervention in the form of endoscopic retrograde cholangiopancreatography (ERCP), which is not a benign procedure. Many articles report complication rates of up to 5%, including bleeding, perforation, and pancreatitis.
A key question in this debate is, What is the incidence of problematic CBD stones in patients undergoing cholecystectomy? One of the best studies on this topic was recently reported by surgeons at Mercy University Hospital in Cork, Ireland. Of 962 consecutive patients who underwent laparoscopic cholecystectomy, intraoperative cholangiography showed that 4.6% had at least one filling defect.
In a brilliant stroke, the surgeons left the catheter clipped in the cystic duct so that they could perform repeat cholangiograms at 48 hours and 6 weeks. Of 46 patients with an abnormal intraoperative cholangiogram, 12 had a normal one 48 hours later, as did another 12 patients at 6 weeks. Only 2.2% of the total study population had persistent CBD stones 6 weeks after cholecystectomy; the stones were then removed by ERCP (Ann. Surg. 239:28-33, 2004).
Thus, most of the abnormal intraoperative cholangiograms either were false-positives or identified stones that soon passed spontaneously. And that means more than half of ERCPs prompted by abnormal intraoperative cholangiography would have been unnecessary.
Routine intraoperative cholangiography advocates claim it prevents surgical CBD injuries. I'm not convinced. The assertion is based on retrospective population-based studies showing lower rates of CBD injury by surgeons who routinely perform the procedure. That is not level-1 or even level-2 quality" evidence.
Dr. David W. Rattner, professor of surgery at Harvard Medical School, Boston, is chief of general and GI surgery at Massachusetts General Hospital.
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|Title Annotation:||Pro & Con|
|Author:||Edye, Michael; Rattner, David W.|
|Publication:||Family Practice News|
|Date:||Aug 1, 2004|
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