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 Table of Contents  
Year : 2021  |  Volume : 5  |  Issue : 2  |  Page : 83-86

Which preoperative findings translate to a positive intraoperative cholangiogram?

Department of Surgery, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa

Date of Submission14-Dec-2020
Date of Acceptance01-May-2021
Date of Web Publication23-Jul-2021

Correspondence Address:
Dr. Mohamed Ali M. Elmusbahi
Department of Surgery, Health Sciences Faculty, University of Cape Town, Anzio Road, Observatory 7925, Cape Town
South Africa
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/LJMS.LJMS_107_20

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Background: The most common investigations used in the preoperative diagnosis of choledocholithiasis are ultrasound and liver function tests (LFTs). These modalities have a low sensitivity for detecting common bile duct stones among the intermediate-risk groups. Aim: The aim of the study is to identify preoperative findings which predict choledocholithiasis in intermediate-risk groups. Describe the implications of a positive intraoperative cholangiogram (IOC). Materials and Methods: A retrospective study of all consecutive laparoscopic cholecystectomies with IOC performed. Data were collected over the past 2 years between January 1, 2015, and December 31, 2016. Standard demographic variables, preoperative symptoms, LFTs, IOC findings, abdomen ultrasound, and postoperative symptoms were included in the study. Results: Of 237 laparoscopic cholecystectomies 23 cases were planned for IOC. The median age was 41 years. Seventeen cases were female. Indications were 12 biliary colic, eight gallstone pancreatitis, two cases of acute cholecystitis, and one case was for ascending cholangitis. Four cases had a positive IOC, and in this group, the median age was 44.5 years with one male. The mean common bile duct diameter was 6.5 mm. Two patients had biliary colic, one patient gallstone pancreatitis, and one acute cholecystitis. One patient had a history of jaundice, and all four cases had elevated gamma-glutamyl transferase (GGT) above 40 mmol/l, three cases had alkaline phosphatase (ALP) above 98 mmol/l. Postoperative, out of 23 cases, five cases had an endoscopic retrograde cholangiopancreaticogram, repeated ultrasound in three cases, persistence symptoms in four cases. Conclusions: GGT was the strongest predictor of choledocholithiasis. A normal GGT seems to be quite good at ruling out Cannabidiol stones. ALP was less accurate. Gallstone pancreatitis is not a good predictor, but it is importance to exclude choledocholithiasis before/during cholecystectomy. There is no relation between the IOC and persistent symptoms.

Keywords: Cholecystectomy, choledocholithiasis, intraoperative cholangiogram

How to cite this article:
M. Elmusbahi MA, Kloppers JC. Which preoperative findings translate to a positive intraoperative cholangiogram?. Libyan J Med Sci 2021;5:83-6

How to cite this URL:
M. Elmusbahi MA, Kloppers JC. Which preoperative findings translate to a positive intraoperative cholangiogram?. Libyan J Med Sci [serial online] 2021 [cited 2023 Mar 31];5:83-6. Available from: https://www.ljmsonline.com/text.asp?2021/5/2/83/322197

  Introduction Top

In the 30-year era of laparoscopic cholecystectomy, two questions have not clearly been answered in the intermediate-risk groups[1],[2] of choledocholithiasis. First, the most cost-effectiveness modality to identify cannabidiol (CBD) stones, and second if CBD stone found how to deal with it?[3]

Intraoperative cholangiogram (IOC) is one modality for detecting CBD stones, but in published literature, there is little benefit in performing IOC routinely.[4] Selective IOC is the most common strategy, but no data support its benefit or which tests should be selected for which indication.[5],[6] The indication for selective IOC would be abnormal liver enzymes and/or dilated biliary system on preoperative ultrasound. Accordingly, the patients would be categorized as an intermediate-risk group for choledocholithiasis.[7] Cases with mild gallstone pancreatitis would also fall into this group. Jaundice patients would be in a high-risk group and thus justify preoperative endoscopic retrograde cholangiopancreaticogram (ERCP), which reflects our current practice.

There is still an ongoing debate if IOC is cost-effective and reliability either as a routine or selective modality.[8],[9],[10],[11] In routine use, the systemic review of eight randomized trials showed no benefit in the prevention of a retained CBD stone.[4] IOC advantages are relatively low-cost and it does not require advanced laparoscopic skills, although you need the availability of mobile fluoroscopy. IOC has 59%–100% sensitivity and 93%–100% specificity to detect CBD stones.[12] The disadvantages of IOC are a longer operation time by 16 min, technical difficulty in acute inflammation, and anatomical variation such as a short cystic duct.[13] Furthermore, it could potentially lead to a CBD injury or false-positive results which can lead to unnecessary CBD explorations or invasive procedures (postoperative ERCP). Few studies are evaluating the sensitivity or specificity of preoperative tests in detecting CBD stone among intermediate-risk groups.[2],[5],[14],[15]

The other unresolved issue is the treatment algorithm when detecting a filling defect on IOC. Options are performing an immediate operative CBD exploration, postoperative ERCP, or clinical observation and imaging follow-up. Our current practice is to perform a postoperative ERCP. CBD exploration is reserved for failed endoscopic management.

As clearly seen in the literature, there are no universal guidelines for the use of IOC.[7],[16],[17],[18] There are two role-players in magnetic resonance cholangiopancreatography (MRCP) and endoscopic ultrasound for the preoperative imaging of the bile duct, but in a limited resource environment, this cannot be accessed routinely. Furthermore, an efficient, cost-effective approach that avoids unnecessary investigations and unnecessary risk for the patient. Our study would correlate if intermediate-risk groups warrant any further intervention of the CBD.

  Materials and Methods Top

A retrospective analysis of a prospectively maintained database for all patients who underwent a cholecystectomy with IOC at Groote Schuur Hospital in the Acute Care Surgery and Hepato-Pancreato-Biliary units between January 1, 2015, and December 31, 2016. Standard demographic variables including age and gender were documented as well as preoperative symptoms, indications of cholecystectomy (biliary colic, gallstone pancreatitis, ascending cholangitis, and acute cholecystitis) were mentioned, preoperative liver function tests (LFTs) (bilirubin, gamma-glutamyl transferase [GGT], alkaline phosphatase [ALP], aspartate aminotransferase [AST], and ALT), IOC findings, postoperative abdomen ultrasound (dilated CBD), MRCP, ERCP, and persistence symptoms were detailed. The data were collected from patient' hospital files, operation notes, images on glutathione pacs, and blood results on National Health Laboratory Service (NHLS) online tool.

Data were exported to Stata version 13.0 (Stata Corp., College Station, TX, USA) for analysis. For descriptive statistics, categorical values were summarized as frequencies and percentages. The Chi-square test (or Fisher's exact test) was used to compare categorical variables by the positivity of IOC. Continuous variables (all nonnormally distributed per Shapiro–Wilk test) were summarized using medians with interquartile range. The Kruskal–Wallis test was used to compare continuous variables by IOC positivity.

The required data collection and analysis of this study was approved by the Faculty of Health Sciences Human Research Ethics Committee (HREC) of the University of Cape Town (HREC 712/2018).

  Results Top

During the 2-year study period, a total of 237 laparoscopic cholecystectomies were performed. In this cohort, 23/237 (9.7%) patients fell into the intermediate-risk group requiring an IOC. 17/23 (73.4%) were female and the indications for the cholecystectomy were biliary colic (12/23; 52.2%), gallstone pancreatitis (8/23; 34.9%), acute cholecystitis presentation in two cases, and one case with ascending cholangitis. Twenty-one patients had elevated GGT >40 mmol/l, and seven patients had ALP <98 mmol/l, eight patients had an ALP >98 mmol/l and <200 mmol/l, eight patients had an ALP above 200 mmol/l, no patient had elevated serum bilirubin as this is considered a high-risk group patient which would be managed by preoperatively ERCP. The results are summarized in [Table 1].
Table 1: Characteristics of the study participants

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In this study (4/23 or 17.4%) of the intermediate-risk group had choledocholithiasis [Figure 1]. The four cases that had positive findings on IOC: The median age was 44.5 years (36–58), one case was a male (25%), CBD diameter on ultrasound was between 6 and 7 mm (median 6.5 mm). The indications for cholecystectomy in this subgroup were two cases with biliary colic, one case of acute cholecystitis, and one case of ascending cholangitis. One case had a history of jaundice. Preoperative LFTs, four cases had raised GGT >40 mmol/l, and one case had ALP <98, and three cases ALP was between 98 and 200 mmol/l. Two cases had AST >35 and three cases had ALT >35 mmol/l summarized in [Table 1] and [Table 2].
Figure 1: Indication for cholecystectomy in the patients requiring intraoperative cholangiogram

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Table 2: Correlates of a positive intraoperative cholangiogram

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Postoperatively, four cases who had a positive IOC had a postoperative ERCP for stones extraction. No case had a CBD exploration, out of 23 cases three had a repeat ultrasound, no one had an MRCP, four out of 23 had persistent symptoms postoperatively summarized in [Table 3].
Table 3: Postoperative characteristics of the study participants

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  Discussion Top

This study aimed to identify the most predictive test for CBD stones precholecystectomy, but another interesting finding in this study was 23 of 237 patients in the Groote Schuur practice fell into the intermediate group and four of these had proven choledocholithiasis. In the literature, the most commonly used are ultrasound, history of jaundice, biliary pancreatitis, CBD dilatation, and preoperative LFT's to estimate the risk of having CBD stones.[14],[15] We found that the four cases who had positive IOC's had elevated GGT of >40 mmol/l, which was not surprising as the 23 patients who were planned to have IOC, 21 had raised GGT levels. In our analysis, a raised ALP of >98 mmol/l was found in 75% which correlates with the literature of 79.5%[14] All our patient's bilirubin was within the normal range or slightly raised. As seen in universal guidelines significantly increased bilirubin is considered to be in the high-risk group for which an ERCP is indicated preoperatively. AST and ALT >35 mmol/l occurred in 50% and 75%, consequently, within our study analysis, the sensitivity is 63% and 71.6%.[2] In this study, gallstone pancreatitis did not predict the presence of CBD stones, however, it is beneficial to exclude CBD stones by IOC or preoperatively MRCP, as it may lead to critical consequences.[7]

There is very little data from Africa about IOC to compare with our clinical practice and outcomes. One study from Egypt[19] which attempted to define the role of IOC in laparoscopic cholecystectomy showed preoperative ALP elevated in 82% which is in keeping with our analysis of 75% above 98 mmol/l. However, the CBD was dilated in 48% wherein in our series it was 17% >8 mm. Interestingly, all four cases that had a positive filling defect had a normal CBD diameter. As in the literature,[20],[21] the CBD diameter on abdominal ultrasound has low sensitivity for prediction of CBD stones. They concluded that the value of IOC is high in comparison to the minimal complications. Moreover, it has higher diagnostic accuracy than MRCP; it saved another admission for the patient who underwent intraoperative evaluation.[19] There is no data from South Africa regarding IOC as it is not commonly used in South African institutions where they rely mainly on ERCP for managing CBD stones as a diagnostic and therapeutic procedure instead of IOC.[22]

The retrospective nature is a serious limitation of this study. Furthermore considering the shallow sample size (n = 23), the study has low power to detect differences. However, it suggests where differences could be rather than affirmatively showing these differences. For example, it suggests those with positive IOC's are more likely to be of higher age which is somehow significant. In the published guidelines the age above 55 years is categorized as a moderate predictor for choledocholithiasis, but one cannot be affirmative about this finding since the statistical power is low.

One of the recommendations from this study is the need to conduct ongoing prospective research. Establishing a gallstone registry might even contribute to the standardization of care. As we practice in limited-resource environments, institutions cannot routinely offer reliable, accurate tools for the identification of choledocholithiasis such as MRCP, intraoperative U/S, or even ERCP. Preoperative predicted modules such as LFT and IOC selectively as indicated are cost-effective and reduce the incidence of retained CBD stones postcholecystectomy.

  Conclusions Top

A normal GGT has good negative predictive value. In a limited resources facility, IOC is cost-effective to confirm or exclude choledocholithiasis with minimal complications.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Einstein DM, Lapin SA, Ralls PW, Halls JM. The insensitivity of sonography in the detection of choledocholithiasis. AJR Am J Roentgenol 1984;142:725-8.  Back to cited text no. 1
Yang MH, Chen TH, Wang SE, Tsai YF, Su CH, Wu CW, et al. Biochemical predictors for absence of common bile duct stones in patients undergoing laparoscopic cholecystectomy. Surg Endosc 2008;22:1620-4.  Back to cited text no. 2
Costi R, Gnocchi A, Di Mario F, Sarli L. Diagnosis and management of choledocholithiasis in the golden age of imaging, endoscopy and laparoscopy. World J Gastroenterol 2014;20:13382-401.  Back to cited text no. 3
Ford JA, Soop M, Du J, Loveday BP, Rodgers M. Systematic review of intraoperative cholangiography in cholecystectomy. Br J Surg. 2012;99:160-7.  Back to cited text no. 4
Giulea C, Enciu O, Bîrcâ T, Miron A. Selective intraoperative cholangiography in laparoscopic cholecystectomy. Chir 2016;111:26-32.  Back to cited text no. 5
Silva AA, Camara CA, Martins A Jr., Teles CJ, Terra JA Jr., Crema E. Intraoperative cholangiography during elective laparoscopic cholecystectomy: Selective or routine use? Acta Cir Bras 2013;28:740-3.  Back to cited text no. 6
ASGE Standards of Practice Committee, Buxbaum JL, Abbas Fehmi SM, Sultan S, Fishman DS, Qumseya BJ, et al. ASGE guideline on the role of endoscopy in the evaluation and management of choledocholithiasis. Gastrointest Endosc 2019;89:1075-105.e15.  Back to cited text no. 7
Kumar A, Kumar U, Munghate A, Bawa A. Role of routine intraoperative cholangiography during laparoscopic cholecystectomy. Surg Endosc 2015;29:2837-40.  Back to cited text no. 8
Ragulin-Coyne E, Witkowski ER, Chau Z, Ng SC, Santry HP, Callery MP, et al. Is routine intraoperative cholangiogram necessary in the twenty-first century? A national view. J Gastrointest Surg 2013;17:434-42.  Back to cited text no. 9
Sajid MS, Leaver C, Haider Z, Worthington T, Karanjia N, Singh KK. Routine on-table cholangiography during cholecystectomy: A systematic review. Ann R Coll Surg Engl 2012;94:375-80.  Back to cited text no. 10
Rystedt JM, Tingstedt B, Montgomery F, Montgomery AK. Routine intraoperative cholangiography during cholecystectomy is a cost-effective approach when analysing the cost of iatrogenic bile duct injuries. HPB (Oxford) 2017;19:881-8.  Back to cited text no. 11
Machi J, Tateishi T, Oishi AJ, Furumoto NL, Oishi RH, Uchida S, et al. Laparoscopic ultrasonography versus operative cholangiography during laparoscopic cholecystectomy: Review of the literature and a comparison with open intraoperative ultrasonography. J Am Coll Surg 1999;188:360-7.  Back to cited text no. 12
Mohandas S, John AK. Role of intra operative cholangiogram in current day practice. Int J Surg 2010;8:602-5.  Back to cited text no. 13
Barkun AN, Barkun JS, Fried GM, Ghitulescu G, Steinmetz O, Pham C, et al. Useful predictors of bile duct stones in patients undergoing laparoscopic cholecystectomy. McGill Gallstone Treatment Group. Ann Surg 1994;220:32-9.  Back to cited text no. 14
Prat F, Meduri B, Ducot B, Chiche R, Salimbeni-Bartolini R, Pelletier G. Prediction of common bile duct stones by noninvasive tests. Ann Surg 1999;229:362-8.  Back to cited text no. 15
Erickson RA, Carlson B. The role of endoscopic retrograde cholangiopancreatography in patients with laparoscopic cholecystectomies. Gastroenterology 1995;109:252-63.  Back to cited text no. 16
Ciulla A, Agnello G, Tomasello G, Castronovo G, Maiorana AM, Genova G. The intraoperative cholangiography during videolaparoscopic cholecystectomy. What is its role? Results of a non randomized study. Ann Ital Chir 2007;78:85-9.  Back to cited text no. 17
Kaltenthaler E, Vergel YB, Chilcott J, Thomas S, Blakeborough T, Walters SJ, et al. A systematic review and economic evaluation of magnetic resonance cholangiopancreatography compared with diagnostic endoscopic retrograde cholangiopancreatography. Health Technol Assess 2004;8:i1-89.  Back to cited text no. 18
Omar W, Karoicdlca AA, Omar W, Khalil A. role of intraoperative cholangiography during laparoscopic cholecystectomy. Al-azhar Assiut Med J 2015;13:2.  Back to cited text no. 19
Gurusamy KS, Giljaca V, Takwoingi Y, Higgie D, Poropat G, Štimac D, et al. Ultrasound versus liver function tests for diagnosis of common bile duct stones. Cochrane Database Syst Rev 2015;;2015:CD011548. doi:10.1002/14651858.CD011548.  Back to cited text no. 20
Laing FC, Jeffrey RB, Wing VW. Improved visualization of choledocholithiasis by sonography. AJR Am J Roentgenol 1984;143:949-52.  Back to cited text no. 21
Bornman PP. Common bile duct stones: ERCP or surgery? HPB Surg 1992;5:277-80.  Back to cited text no. 22


  [Figure 1]

  [Table 1], [Table 2], [Table 3]


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