Patient evaluation and management with selective use of magnetic resonancecholangiography and endoscopic retrograde cholangiopancreatography before laparoscopic cholecystectomy

Objective To assess the utility of triage guidelines for patients with cholelithiasis and suspected choledocholithiasis, incorporating selective use of magnetic resonance cholangiography (MRC) and endoscopic retrograde cholangiopancrea tography (ERCP) before laparoscopic cholecystectomy (LC). Summary Background Data ERCP is the most frequently used modality for the diagnosis and resolution of choledocholithiasis before LC, MRC has recently emerged as an accurate, noninvasive modality for the detection of choledocholithiasis. However, use ful strategies for implementing this diagnostic modality for patient evalua tion before LC have not been investigated. Methods During a 18-month period, the authors prospectively evaluated all patients before LC using triage guidelines incorporating patient information obtaine d from clinical evaluation, serum chemistry analysis, and abdominal ultraso nography. Patients were then assigned to one of four groups based on the le vel of suspicion for choledocholithiasis (group I, extremely high; group 2, high; group 3, moderate; group 4, low). Group 1 patients underwent ERCP an d clearance of common bile duct stones; group 2 patients underwent MRC; gro up 3 patients underwent LC with intraoperative cholangiography; and group 4 patients underwent LC without intraoperative cholangiography. Results Choledocholithiasis was detected in 43 of 440 patients (9.8%), The occurren ce of choledocholithiasis among patients in the four groups were 92.6% (25/ 27), 32.4% (12/37), 3.8% (2/52), and 0.9% (3/324) for groups 1, 2, 3, and 4 , respectively (P < .001). MRC was used for 8.4% (37/440) of patients. Pati ent triage resulted in the identification of common bile duct stones during preoperative ERCP in 92.3% (36/39) of the patients. Unsuspected common bil e duct stones occurred in six patients (1.4%). Conclusions The probability of choledocholithiasis can be accurately assessed based on information obtained during the initial noninvasive evaluation. Stratificat ion of risks for choledocholithiasis facilitates patient: management: with the most appropriate diagnostic studies and interventions, thereby improvin g patient care and resource utilization.