ROUTINE PREOPERATIVE INFUSION CHOLANGIOGRAPHY VERSUS INTRAOPERATIVE CHOLANGIOGRAPHY AT ELECTIVE CHOLECYSTECTOMY - A PROSPECTIVE-STUDY IN 995 PATIENTS

BACKGROUND: There has been a resurgence of interest in recent years in preoperative infusion cholangiography (PIG), The role of routine PIC compared to routine intraoperative cholangiography (IOC) has not been clearly defined. STUDY DESIGN: Tn our department between 1985 and 1991 , 1,042 of 1,576 consecutive patients with biliary calculous disease h ad elective cholecystectomy: 694 patients were prospectively scheduled for PIG, and 348 patients were randomly allocated to IOC. The patient s in the PIC and IOC groups were similar with regard to age, history o f biliopancreatic complications, and laboratory findings. The cost of PIC in Sweden is nearly five times greater than the cost of IOC. RESUL TS: Satisfactory opacification of the biliary system was obtained in 9 0.1 and 96.8 percent of patients who underwent PIC and IOC, respective ly. Preoperative infusion cholangiography required support by IOC in 1 9.5 percent of patients. There were no statistically significant diffe rences between the PIC and IOC groups with regard to the incidence (7 percent in both groups) of or positive predictive value (68 and 80 per cent, respectively) for bile duct stones, rate of retained stones (6 a nd 20 percent, respectively), intraoperative (5.6 and 6.3 percent, res pectively) or postoperative (13.3 and 15.9 percent, respectively) morb idity, or incidence of bile duct anomalies (0.9 and 0.3 percent, respe ctively). Median operative time was longer in patients with (95 minute s) compared to those without (75 minutes) IOC (p<0.001). More postoper ative complications occurred after bile duct exploration (26 of 75 pat ients) compared to cholecystectomy alone (114 of 987 patients, p<0.001 ). The 30-day mortality was zero. Minor bile duct injuries occurred in two patients (0.2 percent) at cholecystectomy, (one with and one with out bile duct exploration). In no patient was the cholangiographic fin ding of a biliary anomaly crucial for the safe execution of cholecyste ctomy. CONCLUSIONS: In our study, PIC and IOC were comparable, but rou tine use of either method did not promote the safety of cholecystectom y and thus their routine use is not warranted. The shorter operative t ime and preoperative identification of common bile duct (CBD) stones p rovided by PIC might favor this examination when applied selectively i n patients with increased risk of having CBD stones. However, this pot ential advantage is offset by the need for PIC to be supported by IOC in approximately 20 percent of patients. Also, the cost of PIC is grea ter than the cost of IOC.