Routine intraoperative cholangiography during laparoscopic cholecystectomy

Objectives: The present study analyses the value of intraoperative cholangiography (IOC) performed in all patients during 22 years of surgical activity in three different Institutions and, as a result a continuous scientific concern on the matter, we developed a set of criteria that are analysed and discussed. Materials and methods: We studied the patients subjected to laparoscopic cholecystectomy in three hospitals between January 1995 and December 2017. A group of patients were analysed, IOC was performed in all cases. Results: we had a positive results of common bile duct stones (CBDS) unsuspected in more than 10%, a finding that changed surgical management of patient after IOC. This procedure required a median period of 10 minutes and there were no complications caused by IOC. Conclusions: Intraoperative cholangiography performed routinely represents an important tool in diagnosing unsuspected Common Bile Duct Stones (CBDS) during LC. This attitude has prevented further surgical treatment for all patients with asymptomatic biliary calculosis. *Correspondence to: Lacitignola Sebastiano, Contrada Sicarico 181/A, 70043 Monopoli , Italy, Tel: +39-330-840630; E-mail: lacitignola@libero.it Received: November 02, 2019; Accepted: November 24, 2019; Published: November 28, 2019 Introduction The asymptomatic stones of the common bile duct (CBD) represents, even today, a considerable challenge for the surgeon despite the progress made both in endoscopy and laparoscopy. Just over 10 years ago, 10% of patients with symptomatic calculosis and 15% of those with acute cholecystitis had stones in the common bile duct. With the laparoscopic procedure the patients had the advantage of a more immediate and faster approach to cholecystectomy with a consequent reduction of choledocholithiasis. Even when all procedures are feasible, there are some techniques preferred to others. If the patient had cholecystectomy it is unanimous opinion that the choledochal lithiasis must be treated endoscopically through endoscopic retrograde cholangiopancreatography (ERCP) with Endoscopic Sphincterotomy (ES) reserving surgery in case of failure (5-10%) [1]. If the gallbladder is “in situ” the treatment is controversial i.e. ERCP followed by laparoscopic cholecystectomy (LC). Another possibility is to perform the cholecystectomy and to remove the CBD stones through the laparoscopy or to abandon the stones with subsequent ERCP after LC. Many surgeons agree with these options in relation to their personal experience as well as the various protocols to be followed. Our personal tendency is to treat the CBDS in a single time using all the possible surgical strategies in our possession and this our attitude is also confirmed by the positive results obtained over the years. Materials and methods From January 1995 to December 2017 we were collected the data of 8918 patients undergoing LC for symptomatic lithiasis in three different Institutions. Routine Intraoperative Cholangiography (IOC) was successfully performed in 8806 patients (98.8%). In the remaining 112 patients (1.2%) the failure was due to the technical difficulties. The preoperative suspicion of CBDS was based on the patient’s clinical history, on the possible appearance of jaundice or pancreatitis considering the high blood values of bilirubin (> 1.0 mg/dl) , alkaline phosphate (>147 U/dl), amylase (>115 U/dl) or the ultrasound documentation of CBDS or his diameter greater than 7 mm. If none of these elements is present, we consider the IOC routine. The common bile stones were found in 1631 patients (18,5%) with a preoperative diagnosis of 1458 cases (89,3%) and 173 cases (10,6%) discovered during the LC due to perioperative cholangiography. The ERCP with ES was performed successfully in 1221 patients (83,7%) who had a preoperative diagnosis of CBDS. The remaining 237 patients (16,2%) added to those they had an intraoperative diagnosis of CBDS were treated surgically as shown in table 1. Operative cholangiography was attempted in all patients using a 4-Fr catheter and a choledochoscopy was performed using a 7-FR size fiberscope introduced through the cystic duct or choledochotomy to confirm the complete bile duct clearance. The patients had follow-up at 6-12-24 months and was not found a residual or recurrence stones. The postoperative complications reported two cases of bilioma after removal of the T-tube and these patients were treated with conservative therapy. No mortality was found.