A COMPARISON OF LAPAROSCOPIC ULTRASOUND WITH DIGITAL FLUOROCHOLANGIOGRAPHY FOR DETECTING CHOLEDOCHOLITHIASIS DURING LAPAROSCOPIC CHOLECYSTECTOMY

Background: Laparoscopic ultrasound is an alternative to operative cho langiogram for evaluation of the common bile duct (CBD) during laparos copic cholecystectomy. It is a safe, fast, and reliable method for det ecting choledocholithiasis. Methods: We prospectively evaluated the se nsitivity and specificity of laparoscopic ultrasound (LUS) and digital fluorocholangiogram (DFCG) in a three-phase study of 360 consecutive patients. Results: In phase I, 140 patients undergoing laparoscopic ch olecystectomy had LUS performed first, followed by DFCG. Thirteen pati ents had CBD calculi identified on LUS. Four patients with confirmed ( two cases) or presumed (two cases) CBD calculi on DFCG were not identi fied on LUS. Thus, the specificity of LUS was 100%, whereas the sensit ivity was 76.5%. DFCG had four false positives, for a sensitivity of 1 00% with a specificity of 96.7%. LUS was performed, on average, in 6.6 min, whereas DFCG required 10.9 min to perform. In phase II, the infu sion of saline through a cystic duct catheter was performed in instanc es where the distal CBD could not be well seen. This maneuver distende d the intrapancreatic portion of the CBD, allowing better visualizatio n. Nine stones were identified on LUS in 78 patients, increasing the s ensitivity to 100%. One false positive DCFG was encountered, resulting in a sensitivity of 100% and a specificity of 98.6%. In phase III, we performed routine LUS and used DFCG only in select cases. The sensiti vity and specificity for LUS were 95.7% and 100%, respectively, wherea s DFCG had a sensitivity of 95.2% and a specificity of 100%, One patie nt in phase In. has returned 11 months post-op with a CBD stone. This was initially missed on LUS, DFCG, and postoperative ERCP. The sensiti vity and specificity in all 360 patients were 90% and 100% for LUS and 98.1% and 98.1% for DFCG, respectively. A total of five CBD stones we re missed by LUS, four early in the study (phase I). One missed on LUS in phase III was also missed by DFCG and ERCP. Conclusions: LUS is a reliable alternative to DFCG during laparoscopic cholecystectomy (LC). With experience, it is as sensitive as DFCG and more specific. It is more rapidly performed than cholangiography.