Predictors of common bile duct stones prior to cholecystectomy: a meta-analysis.

This paper reports the experience of three general surgeons performing 304 laparoscopic cholecystectomies in three private hospitals between October 1989 and November 1990. Laparoscopic cholecystectomy boasts two major advantages over the conventional procedure: the remarkable reduction in postoperative pain and economic benefit, largely due to the patient's early return to work. Revealing a complication rate of 2% and no deaths, this study has shown that this procedure can offer patients these advantages with a medical risk no greater than that accompanying conventional cholecystectomy. Patient safety must be paramount, and it is the responsibility of the surgical community to ensure that all surgeons receive the highest quality training and that the technique is applied appropriately.

Appraisal of laparoscopic cholecystectomy.

BACKGROUND There is still some controversy over whether to use laparoscopic operative cholangiograms routinely (RLOC) or selectively (SLOC). Due to their high cost as well as other issues, in March 1997 we converted from RLOC to SLOC. The purpose of this study was to validate that decision. METHODS The results of 2043 laparoscopic cholecystectomies (LC) were compiled and analyzed. The results of RLOC in 1556 patients undergoing LC from March 1990 through February 1997 were compared to the results of SLOC in 16 patients undergoing LC from March 1989 through February 1990 and 471 patients undergoing LC from March 1997 through December 1998. The literature was reviewed and data were compiled. Reasons that are typically given for operative cholangiograms (OC) were collected and scrutinized. Finally, cost surveys for RLOC and related procedures were obtained. RESULTS Overall, laparoscopic operative cholangiogram (LOC) was attempted in 1661 patients and was successful in 1656 cases (99.7%). Bile duct stones (BDS) were evident in 166 patients. Laparoscopic bile duct exploration (LBDE) was attempted in all cases. None were referred for preoperative endoscopic retrograde cholangiopancreatography (ERCP). In the RLOC group, evidence of BDS was observed in 136 patients (9%). Forty-two were unsuspected (2.8%) and five were false positive (0.3%). In a collection of other RLOC studies, the average rate of unsuspected BDS was 2.9%, while the average rate of false positive cholangiograms was 1.6%. In the SLOC group, LOC was indicated in 139 of 487 patients (28.6%). None of the patients who did not have a LOC developed symptomatic residual BDS in < or = 11 years of follow-up. In a large collection of other SLOC studies, the rate of symptomatic residual BDS was 0.3%. A cost survey in February 1997 revealed that the average minimum global charge (MGC) for an OC was $1283.21; for a transcystic duct LBDE it was $1055.10, and for a transcholedochal LBDE it was $3263.61 [corrected]. The MGC for an ERCP with papillotomy was $4303.00. Thus, to avoid one patient with symptomatic residual BDS, 354 unnecessary procedures (333 RLOC, 18 LBDE, and three postoperative ERCP) costing $473,927.52 would be performed. There were no false negatives, bile duct injuries, or other complications attributable to RLOC or SLOC. CONCLUSIONS The increased morbidity and cost of RLOC to avoid symptomatic residual BDS is not justified. All other reasons given for RLOC are either flawed or indicate that the procedure can be safely employed selectively. SLOC is an effective method of verifying suspected BDS and is safer and less expensive than RLOC.

/pdf/erratum-to-evaluation-of-operative-cholangiography-in-2043-4wale2l141.pdf

Erratum to: Evaluation of operative cholangiography in 2043 patients undergoing laparoscopic cholecystectomy: a case for the selective operative cholangiogram

Background
There is still some controversy over whether to use laparoscopic operative cholangiograms routinely (RLOC) or selectively (SLOC). Due to their high cost as well as other issues, in March 1997 we converted from RLOC to SLOC. The purpose of this study was to validate that decision.

Evaluation of operative cholangiography in 2043 patients undergoing laparoscopic cholecystectomy

Background: Indicators for cholangiography were originally designed to select patients at risk for common bile duct (CBD) stones for intraoperative cholangiography. Objective: To refine these criteria to apply to the much more invasive procedure of preoperative endoscopic retrograde cholangiopancreatography (ERCP). Design: Retrospective review of selection criteria for ERCP in consecutive patients referred over 18 months following the introduction of laparoscopic cholecystectomy. Setting: Two ERCP units in adjacent teaching hospitals. Patients: Three hundred seventeen patients with gallstones and in situ gallbladders. Intervention: Common bile duct imaging at ERCP. Main Outcome Measures: Abnormalities justifying ERCP. Results: Abnormalities justifying ERCP were found in 66% of patients. This group differed significantly from those with normal ducts, with more being referred with abnormal results of all liver function tests ( P P P P P =.003) or elevated results of individual liver function tests ( P Conclusion: The use of such a model rather than individual criteria would improve the selection of patients for preoperative ERCP, optimizing its role in the laparoscopic era. (Arch Surg. 1996;131:89-94)

Selection criteria for preoperative endoscopic retrograde cholangiopancreatography in the laparoscopic era.

The routine use of intraoperative cholangiography has vastly improved the results of common duct exploration by reducing the number of negative explorations. The controversy surrounding the use of routine versus selective intraoperative cholangiography has centered on the incidence of unsuspected common-duct stones. A prospective study was designed to examine both preoperative clinical data and intraoperative anatomical information to determine criteria that would identify patients who would not require cholangiography. One hundred consecutive patients undergoing cholecystectomy were included in the study. When considering patients without preoperative clinical data suspicious for common duct stones three anatomical conditions were identified in which common duct stones would not be present: cystic duct less than 3 mm; smallest stone size greater than 6 mm; a single stone. Using intraoperative criteria as a basis for cholangiography, 44 per cent of patients without clinical suspicion of common duct stones would be spared an intraoperative cholangiogram. It is the authors' opinion that the addition of anatomic findings to preoperative clinical data can further reduce or eliminate the risk of unsuspected stones while sparing a large number of patients the risk and expense of routine intraoperative cholangiography and possible negative duct exploration.

Selective intraoperative cholangiography. A case for its use on an anatomic basis.

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Selective intraoperative cholangiography. A case for its use on an anatomic basis.