CHOLECYSTECTOMY WITHOUT OPERATIVE CHOLANGIOGRAPHY - IMPLICATIONS FOR COMMON BILE-DUCT INJURY AND RETAINED COMMON BILE-DUCT STONES

Objective This study evaluated the selective use of endoscopic retrogr ade cholangiopancreatography (ERCP) in the context of laparoscopic cho lecystectomy (LC) while minimizing the use of operative cholangiograph y. Summary Background Data There has been a long-standing debate betwe en routine and selective operative cholangiography that has resurfaced with LC. Methods Prospective data were collected on the first 1300 pa tients undergoing LC at McGill University. Preoperative indications fo r ERCP were recorded, radiologic findings were standardized, and techn ical points for a safe LC were emphasized. Results A total of 106 pati ents underwent 127 preoperative ERCPs. Fifty patients were found to ha ve choledocholithiasis (3.8%), and clearance of the common bile duct ( CBD) with endoscopic sphincterotomy was achieved in 45 patients. The o ther five patients underwent open cholecystectomy with common duct exp loration. Intraoperative cholangiography (IOC) was attempted in only 5 4 patients (4.2%), 6 of whom demonstrated choledocholithiasis. Forty-n ine postoperative ERCPs were performed in 33 patients and stones were detected in 17 (1.3%), with a median follow-up time of 22 months. Endo scopic duct clearance was successful in all of these. The incidence of CBD injury was 0.38%, and a policy of routine operative cholangiograp hy might only have led to earlier recognition of duct injury in one ca se. The rate of complication for all ERCPs was 9% and the associated m edian duration of the hospital stay was 4 days. The median duration of the hospital stay after open CBD exploration was 13 days. Conclusions LC can be performed safely without routine IOC. The selective use of preoperative and postoperative ERCP will clear the CBD of stones in 92 .5% of patients.