Does the Absence of Contrast Passage Into the Duodenum During Intraoperative Cholangiogram Truly Predict Choledocholithiasis?

Background and Aims

The absence of contrast passage to the duodenum is frequently encountered during an intraoperative cholangiogram (IOC), and patients with this finding are suspected of having choledocholithiasis. This study was conducted to determine the positive predictive value (PPV) of the absence of contrast passage during IOC and identify predictors, if any, that increase the pretest probability of choledocholithiasis in these patients.

Methods

All laparoscopic cholecystectomies with IOCs between September 1, 2019, and September 1, 2021, at a tertiary medical center were reviewed to identify those with abnormal cholangiograms due to only the lack of contrast passage to the duodenum. Patient demographic information, pre- and postoperative laboratory results, and radiographic studies were recorded. Postprocedural clinical outcomes including endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP) findings were tabulated to determine the presence of choledocholithiasis. Patient factors and outcomes were compared between a cohort that was found to have choledocholithiasis vs those who were not. Finally, multiple logistic regression was performed to identify predictors of choledocholithiasis.

Results

Of 320 IOCs, 31(9.7% of all abnormal IOCs) showed the lack of contrast passage in the duodenum as the only abnormality. The PPV of an IOC with the lack of contrast in the duodenum was 29%. Preoperative bilirubin levels, postoperative aspartate aminotransferase levels, and postoperative alanine transaminase levels were significant predictors of choledocholithiasis in this group of patients.

Conclusions

The lack of contrast passage to the duodenum as the sole finding of an abnormal IOC has poor PPV for choledocholithiasis. Thus, it is reasonable to consider using less invasive modalities such as EUS and/or magnetic resonance cholangiopancreatography before ERCP in these patients.