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Intraoperative Cholangiography And Bile Duct Injury In Laparoscopic Cholecystectomy

J. M. Manson
Published 2009 · Medicine

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Large national and international audits of laparoscopic cholecystectomy and associated topics are always useful and informative. Therefore, I read with interest the contribution of Mj~tland et al. concerning laparoscopic cholecystectomy and the handling of bile duct injuries in Scandinavia between 1989 and 1995 [1]. One finding was that the rate of intraoperative cholangiography (IOC) differs significantly for the various countries, as does the rate of bile duct (BD) injury. The authors go on to argue that their data support the thesis that "BD injury is preventable by routine use of IOC." This logic is fundamentally flawed. The rate of bile duct injury in any country is influenced by a host of factors. The use of IOC may be one of them, or it may not; there is no way of knowing from these data. This argument would be somewhat more convincing if there was a direct correlation between the use of IOC and the BD injury rate but this is not the case. For example, although the rate of IOC in Finland was more than five times that in Norway, the frequency of BD injury was the same. This discrepancy in the data hardly suggests a strong association. It is unarguable that almost every large, properly conducted survey or investigation in this controversial area has failed to show that the use of IOC decreases the incidence or risk of BD injury. There are too many references to quote, but large studies from Scotland and the USA are typical examples [2, 3]. In your own journal last year, a carefully conducted prospective 3-year study of the complications of laparoscopic cholecystectomy in Switzerland in 10,174 patients was presented [4]. Yet again, no relationship was found between the performance of IOC and BD injury. Nevertheless, the authors continued to try to justify the use of IOC on the basis of earlier recognition of injury. But the really interesting finding was that the overall morbidity, reoperation rates, and mortality in BD injury were unaffected by the use of IOC. A study from Hungary published a few months earlier on 26,440 procedures produced exactly the same conclusion. Overwhelmingly, the available data suggest that IOC does not have a role in the prevention of bile duct injury. There are many, including myself, who feel that rigorous insistence on the performance of cholangiography is actually counterproductive in that it deflects attention away from the careful and painstaking dissection of Calot 's triangle, which is surely the only reliable way to avoid BD injury. It 's a little strange that we continue to hear so much about it.
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