A prospective evaluation of the diagnostic work-up before laparoscopic cholecystectomy

A prerequisite for successful laparoscopic cholecystectomy is the exclusion of potential risks such as cholangiolithiasis or anatomical malformations. As there is no general agreement regarding the appropriate preoperative diagnostic work-up, a comparative study of different diagnostic methods was carried out.

In 180 consecutive patients admitted to a community hospital for cholecystectomy due to symptomatic cholecystolithiasis, a prospective comparison was carried out of the diagnostic accuracy of patient history, physical examination, laboratory tests, upper gastrointestinal endoscopy, intravenous cholangiography, ultrasonography, and endoscopic retrograde cholangiopancreatography (ERCP).

Measurement of the diameter of the common bile duct was found to be a reliable method as a single noninvasive parameter for diagnosing cholangiolithiasis (sensitivity 100%, specificity 93%), with good predictive power (positive predictive value 0.7, negative predictive value 1.0). The best accuracy achieved noninvasively and without sonography was with a combination of positive patient history and gamma-glutamyl transferase findings (sensitivity 58%, specificity 84%, positive predictive value 0.37, negative predictive value 0.93). ERCP detected additional cholangiolithiasis in 19 of 139 patients (13.7%) and anatomical malformations in three patients. In all 19 patients, the bile ducts were cleared of stones endoscopically within 24 hours, prior to laparoscopic cholecystectomy. Among the 163 patients primarily assigned to laparoscopic cholecystectomy, the protocol diagnostic work-up, including ERCP, allocated three patients (1.8%) to open surgery. Conversion from laparoscopic cholecystectomy to open cholecystectomy occurred in a further two of 158 patients (1.3%).

These results show that routine ultrasonography prior to laparoscopic cholecystectomy can be recommended in order to determine the diameter of the common bile duct. In patients with a ductal diameter of more than 6 mm, ERCP should be performed. Laparoscopic cholecystectomy can be carried out within 24 hours after ERCP and papillotomy.