Prospective comparison of routine and selective operative cholangiography

In a rural centre with limited resources and no endoscopic retrograde cholangiopancreatography facilities, a prospective cohort study was established to compare policies of routine and selective intraoperative cholangiography (IOC) in order to develop a local protocol.

Patients undergoing laparoscopic cholecystectomy from 1 February 1995 to 30 November 2002 were allocated to undergo routine or selective IOC according to birth date. Those with known common bile duct (CBD) stones were excluded. Selective IOC was performed on the basis of abnormal liver function tests or a dilated CBD on ultrasound. Study end points after 12 months follow-up were retained CBD stones, CBD injury, operating times and the effect of IOC on the management of patients with persistent biliary symptoms postoperatively.

Of the 148 patients in the routine group, 94 underwent IOC and CBD stones were shown in 12. Of the 155 in the selective group, IOC was performed in 34 of 45 eligible patients and stones were shown in five. Sixteen patients re-presented with recurrent biliary symptoms or jaundice postoperatively and eight had proven retained CBD stones, of whom only one had undergone (false-negative) IOC. There was no significant difference in mean operating time (56 vs 61 min; t-test P = 0.15). There was one CBD injury in each group, both incurred after successful IOC.

There was no difference between policies of routine or selective IOC in relation to operating times, retained CBD stone rates or CBD injury. However, the authors found management of patients with recurrent biliary symptoms easier if an IOC had been performed, and IOC was easier to perform when the staff were expecting it. Thus a policy of routine IOC has been adopted.