A PROSPECTIVE EVALUATION OF THE DIAGNOSTIC WORK-UP BEFORE LAPAROSCOPIC CHOLECYSTECTOMY

Background and Study Aims: A prerequisite for successful laparoscopic cholecystectomy is the exclusion of potential risks such as cholangiol ithiasis or anatomical malformations, As there is no general agreement regarding the appropriate preoperative diagnostic work-up, a comparat ive study of different diagnostic methods was tarried out. Patients an d Methods: In 180 consecutive patients admitted to a community hospita l for cholecystectomy due to symptomatic cholecystolithiasis, a prospe ctive comparison was carried out of the diagnostic accuracy of patient history, physical examination, laboratory tests, upper gastrointestin al endoscopy, intravenous cholangiography, ultrasonography, and endosc opic retrograde cholangiopancreatography (ERCP). Results: Measurement of the diameter of the common bile duct was found to be a reliable met hod as a single noninvasive parameter for diagnosing cholangiolithiasi s (sensitivity 100%, specificity 93%), with good predictive power (pos itive predictive value 0.7, negative predictive value 1.0). The best a ccuracy achieved noninvasively and without sonography aas with a combi nation of positive patient history and gamma-glutamyl transferase find ings (sensitivity 58%, specificity 84%, positive predictive value 0.37 , negative predictive value 0.93). ERCP detected additional cholangiol ithiasis in 19 of 139 patients (13.7%) and anatomical malformations in three patients. In all 13 patients, the bile duets were cleared of st ones endoscopically within 24 hours, prior to laparoscopic cholecystec tomy. Among the 163 patients primarily assigned to laparoscopic cholec ystectomy, the protocol diagnostic work-up, including ERCP, allocated three patients (1.8%) to open surgery, Conversion from laparoscopic ch olecystectomy to open cholecystectomy occurred in a further two of 158 patients (1.3 %). Conclusions: These results show that routine ultras onography prior to laparoscopic cholecystectomy can lie recommended in order to determine the diameter of the common bile duct, in patients with a ductal diameter of more than 6 mm, ERCP should be performed, La paroscopic cholecystectomy can be carried out within 24 hours after ER CP and papillotomy.