Indicated Cholangiography in Patients Operated on by Routine versus Selective Cholangiographers

Abstract

Intraoperative cholangiography (IOC) remains a subject of much debate among laparoscopic surgeons. When IOC is indicated, the surgeon's preference for routine cholangiography (RC) or selective cholangiography (SC) may have an impact on the outcome of IOC and cholecystectomy. Hereafter, we present our experience with cholangiography in patients with clear indications for IOC when operated on by surgeons favoring SC versus RC. Between January 1, 1999, and December 1, 2000, 389 patients underwent laparoscopic cholecystectomy at Loyola University Medical Center. One hundred fifty-one patients had indication for IOC (jaundice, pancreatitis, increased liver function tests (LFTs), abnormal anatomy, ductal dilatation, or ductal stones identified on preoperative ultrasound), and they constitute the sample for this study. The results of IOC and subsequent outcome of cholecystectomy were reviewed using the electronic medical database. Thirty-nine patients were operated on by 2 surgeons favoring RC and 112 by 12 favoring SC. Patient demographics were similar in both groups. Only 30 (27%) of the SC group had attempted IOC with 28 successful IOCs (25% of all patients). In contrast, 38 (97%) of the RC group had successful IOC, which was significantly higher than the SC group (P < 0.0001 by χ² test). Adverse events included conversions to open, postoperative endoscopic retrograde cholangiopancreatography, bile leak, repeat operative intervention, pancreatitis, elevated LFTs, intraabdominal and wound infection, prolonged emesis, and persistent abdominal pain. Two (5%) adverse events occurred in the RC group, which was significantly less than the 33 (30%) adverse events in the SC group (P = 0.002 by χ² test). Conversions to open were significantly less in the RC group, with no conversions in the RC group and 20 (18%) in the SC group (P = 0.005). There were no mortalities in this series. In a univariate analysis, age and gender did not correlate with increased risk of complications. In conclusion, surgeons who perform SC are less likely to attempt IOC even when IOC is indicated. More conversions to open and more adverse events occurred following cholecystectomy by those favoring SC. Our study further supports routine cholangiography during laparoscopic cholecystectomy.