Choledochoscopy during biliary surgery for reducing the risk of overlooked stones

Although cholangiography is routinely performed during biliary surgery to ensure the removal of all stones, it is not always successful. Some investigators have claimed that intraoperative choledochoscopy is more effective in detecting all stones, although reports on the efficacy of this method have been contradictory. Furthermore, no study has systematically examined either of these procedures in terms of the actual incidence of overlooked stones. Thus, to evaluate the merits of intraoperative cholangiography as opposed to choledochoscopy, we studied the incidence of overlooked bile duct stones after surgery. We investigated 126 patients who had undergone surgery during which choledocholithotomy was performed within the past 10 years; 117 of these cases involved common bile duct stones and 22, intrahepatic stones. After the exclusion of 13 subjects whose stones were deliberately left for postoperative treatment due to severe complications, 126 patients were finally analyzed. Overlooked stones were found postoperatively in 13 (10%) of these 126 subjects, including 11 (14%) of 63 patients who had been inspected by intraoperative cholangiography alone and 2 (3%) of 63 who had undergone both choledochoscopy and cholangiography during surgery. Therefore, the incidence of overlooked stones proved to be significantly lower in those who had undergone choledochoscopy combined with cholangiography (P less than 0.01). Our results suggest the value of combining choledochoscopy with cholangiography during surgery for reducing the risk of overlooked bile duct stones.