Prospective evaluation of selective intraoperative cholangiography in preventing retained stones

OBJECTIVE: to determine the effectiveness of selective intraoperative chola ngiography (IOC) during gallstone surgery in preventing retained bile duct stones. We reviewed the design and application of our procedure for decidin g when to use IOC. METHODS: this was a prospective, 4-year observational study with delayed co hort evaluation after a follow-up period of 2-6 years. We studied 672 conse cutive patients who underwent cholecystectomy at the General Surgery Unit o f the Motril Hospital in Motril (Granada province), Spain, because of sympt omatic cholelithiasis. The study period was from September 1991 (when we ad opted a protocol to select patients for IOC) to June 1995. Clinical, bioche mical and ultrasonographic data, operative findings, and clinical and early postoperative data were collected prospectively. Follow-up clinical evalua tion was done by personal, postal or telephone interview. Biochemical, sono graphic and (when available) endoscopic examinations were done for patients suspected of having residual bile duct stones. RESULTS: intraoperative cholangiography was not done during simple cholecys tectomy in 453 patients. In 335 of these patients this decision was correct , and only 1 case of suspected residual stone was found (0.3%). In the othe r 188 patients the decision to omit IOC was arbitrary (i.e., not based on t he protocol); among these patients we found 5 cases (2 suspected and 3 prov en) of residual stones (4.2%). The difference was significant according to Fisher's exact test (p = 0.005). CONCLUSIONS: in some patients who undergo cholecystectomy, IOC may be omitt ed without major risk of retained duct stones. Patients in whom IOC will no t be done must be selected strictly according to a well-designed protocol t o avoid increasing the risk perceptibly.