Is There A Need Of Intraoperative Cholangiograms In Patients Of Cholelithiasis With And Without Clinical Indication Of Common Bile Duct Exploration While Performing Open Or Laparoscopic Cholecystectomy?

摘要

Background and Objectives: The study has been conducted with the aim to assess the need of intraoperative cholangiogram in patients of cholelithiasis with and without the clinical indication of common bile duct exploration.Design and Setting: Prospective study in patients of cholelithiasis with and without the clinical indication of common bile duct exploration admitted in the surgical wards. Patients and Methods : The study included 485 consecutive patients of cholelithiasis with and without the clinical indication of common bile duct exploration over a period of five years. All these patients were subjected to detailed history and clinical examination and investigations. An intraoperative cholangiogram was performed in all studied patients. Every alternate case was subjected to laparoscopic and open cholecystectomy with or without common bile duct exploration. Data collected was tabulated and the p-value measured.Results: In patients with indication of common bile duct exploration, intraoperative cholangiography could spare 60 out of 140 (42.86%) patients from unnecessary CBD exploration while in patients without indication of common bile duct exploration intraoperative cholangiography could pick stones in the common bile duct in 15 out of 345 (4.34%) patients only, with very significant p-value (p<0.005).Conclusion: Intraoperative cholangiography is applicable in selective cases only where the indications for its use exist to solve the dilemma of an operating surgeon in the form of preoperative status, abnormal biliary tract anatomy or a difficult cholecystectomy due to dense adhesions to get a clear road-map of the ductal system and also to minimize the rate of unnecessary pre- and post-operative endoscopic retrograde cholangio-pancreatography. Introduction Open or laparoscopic, safe cholecystectomy is a challenging job for the surgeon. Though preoperative diagnosis of calculous biliary tract diseases poses no problem, during surgery, biliary calculi are often missed, so that retained stones in the biliary channels are a persistent problem in the management of biliary tract calculi. The need for additional diagnostic methods to improve the results in gallbladder surgery has long been acknowledged to eliminate or minimize the possibility of overlooked stones in the biliary channels, the consequences of which are embarrassing to the surgeon and a source of discouragement to his patient. In 1936, Lahey concluded that previous to 1926 he had left a stone in the common bile duct in one out of every ten patients subjected to cholecystectomy1. In an effort to decrease this high incidence, he increased the choledochotomy to 44% (in a series of 200 cases) with a discovery of calculi in 18% of them. As the complications from choledochotomy may be considerable2, it is important both clinically and economically for the surgeon to try to reduce these to a minimum by proper scrutiny of the patients. Previously, choledochotomy was performed solely on the basis of traditional indications either because of clinical history, laboratory investigations or the operative findings, the main criteria being: 1. recent or recurrent jaundice, 2. history of acute or chronic pancreatitis, 3. history of intermittent chills or fever in patients with cholelithiasis, 4. preoperative radiological evidence of stones in the bile ducts, 5. laboratory investigations of elevated serum bilirubin, aspartate transaminase (AST), alkaline phosphatase (ALP) and gamma-glutamyl transpeptidase (GGT), 6. operative findings of cystic duct enlargement, a dilated CBD or palpable stones within the duct, 7. the presence of multiple small stones within the gallbladder, 8. turbid bile aspirated from the duct and 9. recurrent symptoms after biliary surgery. These traditional indications resulted in a high number of unnecessary choledochotomies, thus adding to the morbidity and even mortality in patients with biliary stone diseases. Also there is no provision for unsuspected comm