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

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.