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Cholangiography Is No Substitute
Published 2006 · Medicine
In rounding off 2005, the Journal presented its readership with ‘A survey of the current surgical treatment of gallstones in Queensland’ by Dr James Askew.1 Achieving a survey response rate of over 90% of general surgeons is to his credit. The title is however misleading – the survey is actually of surgeons’ attitudes regarding aspects of cholecystectomy rather than an analysis of what each surgeon has actually done over a given time frame. The most controversial statement in the article is ‘Recent studies have indicated that the use of OC (operative cholangiography) reduces the risk of bile duct injury’. Mirizzi and Quiroza introduced intraoperative cholangiography in 1931 to detect choledocholithiasis in order to avoid the need for relaparotomy for retained stones.2 Some 40 years later, this concept was clouded by the desire to protect against iatrogenic bile duct injury3 even though this occurred in no more than 0.125% of open cholecystectomies4 and a vigorous debate regarding routine cholangiography has continued since. Three population-based studies have shown not obtaining an OC is a risk factor for bile duct injury.5–7 However, none of these studies has been able to show a causal association and attempts to show a link between routine OC and a lower risk of injury have yielded conflicting results.8,9 There are now many series of laparoscopic cholecystectomy without routine cholangiography with a low rate of injury.8,10,11 In one recent series of over 2500 cholecystectomies, all of the 0.16% laparoscopic bile duct injuries were low and repaired over a T-tube, that is, there were no injuries at or above the hilum.8 Developing a posterior window, accurate dissection of the hepatocystic triangle without the use of diathermy and the willingness to convert to an open approach will minimize the incidence and severity of bile duct injuries. Cholangiography should be performed whenever the surgeon suspects a ductal stone or needs to exclude its presence (e.g. pancreatitis) but in our view, a surgeon faced with unclear anatomy should convert to an open procedure rather than carry out OC through what he believes to be the cystic duct. Clearly, inadvertent OC through the bile duct actually causes a bile duct injury. One way of outlining the biliary tree without risking its injury is to carry out the cholangiogram via the gallbladder using contrast12 or diluted methylene blue,13 both of which have their limitations. Cholangiography is not a substitute for thorough training and a good surgical technique. There are at least two practical points Dr Askew fails to address regarding cholangiography: interpretation of the images and false-positive rate of identifying calculi. Of the 64 patients with a laparoscopic bile duct injury referred to the Hepatobiliary Unit at the Princess Alexandra Hospital in Brisbane, 24 did have an intraoperative cholangiogram.4 Disappointingly, the injury was identified in only a third of these patients.4 This indicates that surgeons not infrequently misinterpret results of OC. Routine cholangiography identifies unsuspected asymptomatic bile duct stones and this has its own associated problems. After a thorough review of published reports, Dr Maddern has recently pointed out that in order to ‘‘identify one common bile duct stone that would go on to cause symptoms in a patient with no preoperative evidence of duct stones, 167 intraoperative cholangiograms would have to be performed during laparoscopic cholecystectomy, and 8 unnecessary bile duct explorations or endoscopic retrograde cholangiopancreatography would be needed’’.11 With articles such as Dr Askew’s, there is a risk that the wrong message is sent to trainees, surgeons, patients and the legal community.