Radio! Oncol 19%: .10: 171-6.
Routine versus selective intraoperative cholangiography during
open cholecystectomy?
Nino Šikic', Gordana Pavan2, Ana Baškot2, Zvonimir Tutek', Ante Polovic2
'Deportment of Ceneml and Orthopaedic Surgery, 2Department of Radiology Diagnostics.
Ceneml Hospital Korlovcic, Cmatia
In tlie last 20 wars, 3653 patients suffering from hi!iaiy calculous disease have heen operated on in the Kar!owic County General Hospital, 511 (14 %) of them \vilh common hile duct exploration (CEDE). A lota/ of' 4366 se/eclive !iitraoperalive Cholangiographies was performed and, oil the hcisis of' llie ohtained results, CBDE was performed in 271 (53 %) cases. !mraoperative cholangiography (IOC) was indicated but not performed in 7l (14 %) cases hecause of medical, tecliiiicci! and other reasons, mainly suhjeclive. In 47 (9 %) palienls CBDE was performed without previous !OC hecause of clear clinical findings in 112 (24 %) cases, CBDE was performed on the hasis of the surgeons's clinical estimation, withoul lOC. Preoperative and inlraoperative criteria were used The preoperalive crileria (CR !) included ohstructive jaundice, hi!iary panceatritis and cholangitis in recem history as we/1 as posilive findings of 'intravenous hiligrapliy (!VB) or ultrasonic tomography (UST). The intraoperative crileria included an enlarged CBD, a wide cystic duel or lhe presence of snw/11im/tiple stones in llie gallbladder: Positive !OC findings occured in 287 (6)3,5 %) and negative in 141 (33 %) cases. Tlie findings in eiglil cases were insttfjicienl for analysis. Fa/se positive !OC findings occured in 24 (5,2 %) andfalse negative !OCfindings in 22 (5 %) cases ofa/1 436 !OC's. By using selective lOC we recorded 6)9 (1.7 %) missed stones and 6)3 (13 %) negative, unnecessary CBDE's. Only one complication in llie form of a CUD lesion was recorded In average, !OC exlended operative time for ahoiii 30 miiiiiles and increased llie operative cosi for 62 %.
Key words: cholecystectomy: intraoperative period: intraoperative cholangiography. retained stones. negative common bile duct exploration. cryteria
Introduction
In 1932. Miriai puhlished his first experiences of intraoperative cholangiography (IOC) used for detecting unsuspected common bile duel (CBD) slo-nes. This method was widely accepted a few decades later. The purpose or IOC was to detect as many unsuspected CBD stones as possible, and to reduce the percentage of unnecessary common bile duct exploration (CBDE).
Correspondence to: Dr Nino Sikic. Department of General •and Orthopaedic Surgery. General Hospital. 47000 Karlo-vac. A. Stainpara .1. Croatia
UDC: 616.366-003.217.7-089.87:616.36 l-073.75
The method decreased unnecessary morbidity and mortality due to CBDE and reoperations.12 In the 1960s, the method was accepled by a great number of surgeons. The increased cosl of the procedure. extended operative time. increased danger of possi-hle intraoperative infections. unnecessary exposure to ,x-ray radiation as well as the need for additional. expensive x-ray equipment were its disadvantages. Because of the above mentioned reasons, a group of surgeons preferred a selective use of IOC.
They reported almost identical results to those obtained by routine IOC.2'' The selective use of IOC reduces the total cost of the procedure as well as the ahove mentioned complications and problems. IOC detects other changes in the CBD as well
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as in the papilla Vateri. We use pre-operative and intraoperative criteria. Laparoscopic cholecystectomy tries to maintain all successfull intraoperative diagnostic methods confirmed in open cholecystectomy, including IOC. The most recent papers discuss the use of selective IOC during laparos-copic cholecystectomy.
Material and methods
From I 974 to I 994. 3653 patients with calculous biliary disease underwent open cholecystectomy. During the procedure. 5 I I patients underwent CBDE. Patients with malignant diseases of the biliary tract with or without stones were excluded. IOC was performed in 436 patients on the basis of the preope-rative or intraoperative criteria. The mean age of the patients was 56 (18-84). There were 3 I % male and 69 % female patients.
The preoperative criteria were determined as follows:
1.	Fi//ing defecls wu/ n//r«sonic echo in /he CBD were considered as: positive findings as well as a wide CBD with an internal diameter larger than 10 mm.
2.	A wide C/3D with the contrast slowly emptying into the duodenum during IV/3 was considered a positive criteria. too.
3.	./«iindice in recenl hislory-bilirubin (Bil) > 50 umol/L. alkaline phosphatase (AP) > 100 u/L three months prior to the procedure.
4.	Pcrncrecrli/is in hislorv-data related to biliary pancreatitis a year prior to the operation.
5.	Cho/angifis-biliary colics. fever and transitory jaundice six months prior to the operation.
The intraoperative criteria established on ihe basis of the intraoperative findings were as I'ollows:
1. En/arged C/3D with an external diameter larger lhan 12 111111. The size of the CBD was determined by means of a 12-111111 olive Bakes probe:
2 En/crrged cyslic duct (CD) wilh an external diameter larger than 4 mm:
3. Presence ri/ small slones in ihe g«///j/iidderv Small multiple stones were detected either by palpating the emptied gallbladder (needle bile aspiration) or by examining the content of the extracted gallbladder.
In addition to the above mentioned criteria, CBDE with no previous IOC was performed in patients with the following:
1.	P«//j«We s/ones in CBD:
2.	Presence progressive ohslmc/ive icleriis at the time of the operation (Bil > l 00 umol/L. AP > 150 u/L):
3.	En/firged CBD with an external diameter larger than 15 mm.
In some cases IOC was not performed despite the positive criteria. Technical and medical disadvantages were the main reasons, as well as the fact that, at the beginning, some surgeons in the Hospital refused to accept the procedure. IOC was performed through a square incision on the lateral side of the cystic duct. A polyethylene venous 4-6 F gauge catheter or a metal Storz cannula was inserted. During the examination all unnecessary metal instruments were removed from the operating field. A mobile »SIEMENS« C-arm image amplifier was covered with a special sterile cover. Before the contrast injection the bile tree was flushed with 20-40 ml of warm Normal Saline.
Possible air bubbles were aspirated. The contrast, Telebrix. Biligraphin. Biliscopin. Omnipaque. Ron-pacon was diluted to 30 % dilute solution, so that the contrast would not obscure possibble small stones. Diascopy was performed with l 0 ml of the contrast and the contrast flow was followed through the papilla Vateri. Two films 24 x 30 cm size and additional 20 ml contrast medium was used. While the films were being developed we completed cholecystectomy to shorten operative time. Alter the examination. the complete sterile operative kit was replaced. The duration of the examination was recorded on an anaesthesiological sheet. The additional costs were calculated on the basis of the cost of x-ray films, contrast medium. syringes. catheters and additional sterile material. The cost of anaesthesia and the medical radiology team's fee were taken into account while the cost of operating theatre and the surgical leam's fees were not determined and. therefore. were left out.
Results
Of 3653 patients undergoing cholecystectomy, 436 (12 %) underwent selective IOC. Of 5 11 CBDEs performed, 271 (53 %) were performed on the basis of positive selective IOC findings.
The number and percentage of the positive and negative IOC findings and the distribution of the false negative and false positive finding are given in Figure 1. In performing selective lOCs we were guided by preoperative and intra operative criteria.
Roufine versus se/ectíve intraoperative c/iolangiograp/iy during open c/w/ecysteclomy
173
= p-;i!,v OO ¿.2.20%
Figure l. Relations between positive and negative IOC Undings. False negative and false positive Undings is presenl too. Eight (18 %) insuflitient IOCs was insuffitient lor use.
More than 60% of the patients fulfilled more than one criterion. In Table I we emphasized only one criterion, the one that had bccn recorded in the files first. In 22 patients the first criterion was not clcarly indicated and in 9 patients IOC was performed on the basis of unknown preoperative criteria. The most common combination not given in
Table I was a wide CBD accompanied by jaundice and/or pancreatitis in history. A positive IVB or UST finding was the most common preoperative criterion used in ,37% (129/350). Over one third of the positive CBDE results was due to pancreatitis. The most common combination of the intraoperative criteria was a wide CD with small stones in the gallbladder. Nevertheless, the most common intraoperative criterion was a wide CBD - 74 % (58/78).
As the paper shows, IOC .should have been performed in 71 (14%) cases, but. because of the reasons mentioned earlier, it was not performed. The results in this group were very bad as shown in Table 2.
The procedure extended operative time lor approximately 30 minutes. In cases with a preoperative indication, operative time was extended lor a little more than 20 minutes and in the cases with an intraoperative indication, it was extended for more than 45 minutes.
The IOC cost can not be shown in figures in our circumstances, bul we have estimated that the cost of cholecystectomy with IOC is 62 % more expen-
Table l. Preoperative and intraoperative criteria distribution and results of IOC Criteria lor IOC.
CRITERIA FOR IOC	IOC	IOC pos (%)	IOC neg (%)	CBDE	CBDE
				pos (%)	neg (%)
Preoperative (CR l)	350	227 (65 %)	12.3 (.35 %)	208 (92 %)	19 (8%)
Positive IVB*	.55	34 (62 %)	21 (28 %)	31 91 %)	3 (9%)
Positive UST*	42	23 (55 %)	19 (45 %)	21 91 %)	2 (9%)
Positive IVB or UST*	32	26 (81 %)	6(19 %)	24(92%,)	2 (8%)
Jaundice	82	63 (77 %)	19 (23 %)	.59 (94 %)	4 (6%)
Pancreatitis	85	43 (.51 %)	42 (49 %)	40 (9.3 %)	3 (790)
Cholangitis	23	17 (74%)	6 (26 %)	16 (94 %)	1 (6%)
Miscellaneous	22	17 (77 %)	5 (23 %)	13 (76 %)	4 (24%)
Unknown	9	4(44%)	5 (56 %)	4(100%)	o
lntraoperative (CR II)	78	60 (77 %)	18(23	56 (93 %)	4 (7%)
Wide CBD > 12 111111	58	47 (81 %)	II (19 %)	44 (94 %)	3 (6%)
Wide CD > 4 111111	9	7(78%)	2 (22 %)	6 (86 %)	1 (14%)
Small stones in	II	6 (55 %)	5(4.5%)	6 (1 00 %)	o
Total*'''	428	287 (67 %)	141 (33 %)	264 (92 %)	23 (8%)
IOC - intraoperative cholangyography, CBDE - common bile duct exploration (choledochotomy). IVB - intravenous biligraphy. UST - ultrasonic tomography, CBD - common bile duct. CD - cystic duct.
* In preoperative calculous biliary desease diagnostics we used IVB till 1984, from 1984 to 1989. the combination ofIVB and UST and since 1989 we have been using UST in most cases. ** The quality ol'8 IOC's was not suitable for analyses.
Table 2. Retained stones and negative CBDE dala.
	Crit 1	Crit II	IOC was not	CBDE	Simple	Total
			necessary	without IOC	cholecystectom	
Cholecystectomy	350	78	477	71	3106	3653
Retained slones	29 (8 %)	4(5%,)	2 (4 %)	21 (30%)	13 (0,4%-)	69
Negative CBDE	19(5%)	4 5	3 (6 %)	29 (40 %)	8 (0,25 %)	63
	48 (1.3 %)	8(10%)	5(10%)	50 (70%)	21 (0.65%)	132
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Figure 2a. Prepapillary slone detected by IOC. CBDE was performed. thc slone was extracted and T - tube inserted.
sive than simple cholecystectomy using the points and their value given in the so called »Blue Book«.
Discussion
IOC reduces the number of retained stones as well as the percentage of unnecessary CBDEs. Selective IOC has proved its value in conventional cholecystectomy. Recently, its use has been taken into consideration in laparoscopic cholecystectomy.' " CBDE increases morbidity and mortality rate three of lour times when compared with simple cholecystectomy.Stirnemann14 reports that mortality in biliary reoperations is 8.8 % and in CBDE with cholecystectomy only 2,8 %. Lennert15 reports two deaths in negative CBDE, and Sheridan et al11 noted 39,3 % complications in the patients who had had negative, unnecessary CBDEs, including two deaths, too.
On the basis of the data given in Table 3 we can seen that an attempt to avoid retained stones can
Figure 2h, Papillary stenosis with suprastenotic dilatation of the complete biliary tree. Latero-lateral choledochoduo-denostomy was performed.
lead to an increased percentage of negative CBDE. In their comparative reports, Clavien and Strass-berg17 using routine IOC report an irrelevant percentage (0,2 %) of retained stones or no stones at all, but their reported negative CBDEs were 27 % and 39 % respectively. Sheridan et al11 reported 2 % retained stones and 22,3 % negative CBDEs respectively. Morgenstern and Berci1'' conclude that 1 % of retained stones at routine IOC is an optimal percentage. On the other hand, Gerber and Apt21 showed 500 consecutive cholecystectomies without any IOC. They recorded only one retained stone. Therefore, our results of 1.7 % of retained stones and 13 % of negative CBDE could be considered satisfactory. We have been using the IOC criteria for a long time of which we reported earlier.22 Gregg3 divided the indications of common duct stones into three groups: mm/ma/ - 4 % of positive findings, moderate - 21 positive findings and rao.v/mfl/ - 91 of positive findings. He has concluded that IOC should be performed in only 7-8 % of patients. Wilson et al5 divide cholecystectomies into two
Routine versus selective intraoperative cholangiography during open cholecystectomy7	175
Table 3. References of reported cases in avaliable literature.
Refer	Author	Country	Year	Cholecisec-tomy No.	IOC%	Residual stones %	Negative CBDF%
14	Strinemann	Swiss	1984	346	100	1.2	18,6
16	Morgenstern	USA	1992	1200	95	0.8	
	& Berci						
17	Clavien	■Swiss	1992	602	91	0,2	26.8
17	Strassberg	Canada	1992	650	89	o	39,3
19	Den Besten	lnternational	1986	1072	83	4.5	18,5
	& Berci						
20	Moreaux	France	1994	5000	83	1.56	0,5
2	■Shively	USA	1990	579	81		2 l.5
5	Wilson	Austral	1986	272	51	0.36	18
11	Sheridan	United	1987	1962	10	1.9	14
		Kingdom					
3	Gregg	USA	1986	1035	1.9	2,5	16,5
	Present	Croatia	1994	3653	12	1.7	13,3
	Report						
groups: ,,Would explore« and » Would not explore«. There were 49 % of positive findings in the First group and only 4 % of missed stones in the second group. Pace et al'' divide the IOC criteria into CR+ and CR-. They had 9.5.7 % of normal fin dings in the CR- group and 71 % of positive findings in the CR+ group. In this way, they avoided unnecessary CBDE in .5.5 % of patients. The greatest percentage of positive findings (63 %) occured in the group with an elevated serum Bilirubin level as the criterion, while in the group where the criterion was preoperative cholangitis there were even 82 % of IOC findings. Our results show that preoperative jaundice gave 77 % of positive IOC findings while preoperative pancreatitis gave positive results in only one third of patients and this coresponds with other reporls. The most common preoperative criteria are preoperative positive IVB or UST findings.2'- 24 In addition to the presence of CBD stones we take into account the interna! diameter of CBD too. In our report a wide CBD was criterion in 73 % of cases and filling defects in 70 % of IOCs and in 56 % of CBDEs positive Although different authors consider an 8-15 111111 CBD enlarged, we take a I O 111111 interna! diameler as a positive preoperative criterion, while a 12 111111 external diameter is taken as a positive intraoperative criterion. Intraoperative criteria were determined only in 20 % of cases. Fourty-seven (9 %) patients underwent CBD without previous IOC. Twenty-eighl (8.5 %) patients had palpable stones in the CBD. Gregg' palpated only 7 (13.7 %) stones in 51 patients with CBD stones. Stimemann14 reporls that slones can be palpated only in the middle third of the CBD, the palpation certainty being only 1O %. Our reporl shows
that in the group of 71 patients where IOC was clinically indicated bul not performed, 21 (30 %) retained stones and 29 (49 %) negative CBDEs were recorded. Different authors report different extensions of operative time. Thompson and Bennion report a 7-minute extension of operative time, Gregg a 23-minute. Shively a 1O-minute and Paulino-Netto a 27-minute extension of operative time.2'- 26
Our results show an average extension of operative time of 30 minutes. The majority of the authors take the age of patients as a positive criterion but we have not noticed any incidence of CBD stones related to the patients' age. The cost of the procedure varies from USD 125 to USD 400 in different aulhors. Taylor17 states that routine IOC in all cholecystectomies carried out in 1987 would have cost additional 90 million dollars. According to Skilling,'" the cost of one detected unsuspected CBD stone is USD 6,612. According lo Gregg/ 200 cho-langiograms and 12 CBDEs have to be carried out to prevent one recurrent slone, at a cost of at least USD 80,000. Pace'' reports thal 2135 routine IOCs must be performed to detect one unsuspected CBD slone. Our investigation has shown that each IOC increases the cost of simple cholecystectomy for 62 %. 11' we compare our results with those given in literature we can conclude thal we have chosen good criteria lor selective IOC. It is a method of choice of intraoperative diagnostics in classical open as well as in laparoscopic cholecystectomy. Il decreases the total cost of the procedure giving good results in detecting CBD stones during cholecystectomy. In this way, unncessary CBDEs, which increase morbidity and mortality rate, are avoided.
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S/k/r N er a/.
References
1.	Stark ME. Longthry CW Routine operative cholangiography with cholecystectomy. S»;g Gynecol Ohstet 1980; 151: 6557-8.
2.	Shively EH et al. Operative cholangiography. A/ii .1 S»,g 1990; 159: 380-5.
.3. Gregg RO. The case for selective cholangiography. A/ii .1 S»/g 1988; 155: 540-5.
4.	Taylor TV, Torrance B. Rimmer S. Hillier V and Lucas SB. Operative cholangiography: Is there statistical alternative; A/11.! Suig 198.3; 145: 640-.3.
5.	Wilson TG. Hall JC. Watts J. Mc K. ls operative cholangiography allways necessary? Br .1 Sun; 1986; 73: 6.37-40.
6.	Pace BW. Cosgrove J. Brener B. Margolis IB. lntraope-rative cholangiography revisited. Arcli Swg 1992; 127: 448-50.
7.	Lorimer JW, Fairfull-Smith RJ. lntraoperative cholangiography is nor essential to avoid duct injuries during laparoscopic cholecystectomy. Aiii J Suig 1995; 169: .344-7.
8.	Sackier JN. Berci G. Philips E, Caroll B, Shapiro S. Par-Partlow M. The role of cholangiography in laparoscopic cholecystectomy. Arch S»;g 1991; 126: 1021-6.
9.	Soper NJ, Dunnegan DL. Routine versus selective intraoperative cholangiography during laparoscopic cho-lecystectomy. Wor/d.! S/ug 1992; 16: 1 1.3.3-40.
10.	Crumplin MKH et al. Menagement of gallstones in a district general hospital. Br j"Suig I985:"72: 428-32.
11.	Sheridan WG. Williams HOL. Lewis MH. Morbidity and mortality of common bile duct exploration. Br .! S/ug 1987; 74: 1095-9.
12.	Trede M. Schaupp W. Ein Pladoayer fir die Chole-cystetomie-Gold-Standard der Gallensteintherapie. Chi-mug 1990; 61: .365-9.
1.3. McShery ChR. Cholecystectomy. The Gold-Standard. Aiii .1 Suig 1985; 158: 174-88.
14. Stirneman H. Gallengangrevision: Ja oder Nein; Chi-mug (1984); 55: 162-7.
15.	Lennert KA, Muller U. Wie ist das Risiko der operativen Behandlung der Choledocholithiasis. C/;/n;;g 1990; 61: .376-8.
16.	Morgenstern, Wong L, Berci G. Twelve hundred open cholecystectomies before the laparoscopic era: A standard for comparison. Arch Surg 1992; 127: 400-.3.
17.	Clavien PA, Sanabria JR, et al. Recent results of elective open cholecystectomy in a North American and a European center A;;;; Sur« 1992; 216: 618-26.
18.	Schriefers KH, Gok Y. Bernhard JCh-Wandel von. Diagnostic und lndicationen in der Gallenstein chirurgie. C///;u,g 1988; 59: 185-9.
19.	Den Besten L and Berci G. The current status of biliary tract surgery: An international study of 1072 consecutive patients. Wor/d.! Swg 1986; 10: 1 16-22.
20.	Moreaux J. Prospective study of open cholecystectomy for calculous biliary disease. Br .1 Surg 1994, 81: 116-9.
21.	Gerber A, Apt MK. The case against routine cholangiography. Am J Surg 1982; 14.3:"375-7.
22.	Pajic M. Stefanovic M. Tonkovic V. Vrijednost intraoperative kolangiografija Acra C///r lug 1982; 29: 1: 55-60.
2.3. Baskot A, Pavan G, Polovic A. Kriticki osvrt na vrijednost ullrazvuka u dijagnostici koledokolitijaze. Strucni sastanek Hrvatskog drustva radiologa, Karlovac 20. 10. 1995.
24.	Fuckar Gallbladder and biliary tree. In: Kurjak A, Fuckar Z. Gharbi HA eds. Ar/as o/ahdo;;;/;;al and .small pa;-.! .sonography. Zagreb: MB, 1990: 155-68.
25.	Thompson JE, Bennion RK. A simple, costeffective medhod for operative cholangiography. Am .1 Surg 1989; 158: 461-2.
26.	Paulino-Neto A. A rewiev of .391 selected open cholecystectomies for comparison with laparoscopic cholecystectomy. Arn./ Surf; 1993; 166: 71-3.
27.	Taylor TV. Editorial commenl. A;;; J Su;g 1990; 159: 385.
28.	Skillings, Villiams JS, Hinshaw JR. Costeffectivness of operative cholangiography. /\m ./ Swg 1979; 137: 26-31.