CHANGES IN THE PRACTICE OF BILIARY SURGERY AND ERCP DURING THE INTRODUCTION OF LAPAROSCOPIC CHOLECYSTECTOMY TO AUSTRALIA - THEIR POSSIBLE SIGNIFICANCE

Two and a half years after the introduction of laparoscopic cholecyste ctomy to Australia in February 1990, estimates from Medicare statistic s suggest that by July 1992, 69% of cholecystectomies were being perfo rmed laparoscopically. There was a smaller decline in the numbers of o pen cholecystectomies performed, suggesting a 28% rise in the rate of cholecystectomy. This has been associated with a 66% decline in the us e of intra-operative cholangiography. Whereas 87% of cholecystectomies had an operative cholangiogram performed, now only 23% of all cholecy stectomies do. It is suggested that in approximately half the patients , no attempt is made to exclude common duct stones. With those patient s in whom an attempt is made, most surgeons rely on endoscopic retrogr ade cholangiopancreatography, as evidenced by a 43% increase in its us e, or, more recently, a small proportion of surgeons have been using i ntravenous cholangiography, as evidenced by a 26% increase in its use. Once diagnosed, these stones are no longer being treated by open expl oration of the bile duct, indicated by a 46% decrease in this procedur e, but are being heated by endoscopic sphincterotomy, which has shown a 242% increase in its use. From the published results of the outcome of these treatments, the added risk, nationally, of these additional p rocedures in managing uncomplicated bile duct stones is predicted to i ncrease mortality 1-3-fold and morbidity 10-15-fold. This risk can be reduced by the use of laparoscopic bile duct exploration. These techni ques are already well established and can be learnt quickly if practic e is achieved by performing routine intra-operative cholangiography. T he treatment of common duct calculi at the time of cholecystectomy sti ll seems to be the most efficient strategy of management, even in the laparoscopic era.