Selective cholangiography in 600 patients undergoing cholecystectomy with 5-year follow-up for residual bile duct stones

Abstract

Background: The need for cholangiography to identify possible bile duct stones in all patients undergoing cholecystectomy is controversial.

Aims: To assess the results of a policy for selective pre-operative endoscopic retrograde cholangiography (ERC) in patients undergoing laparoscopic cholecystectomy and to determine the incidence of postoperative symptomatic bile duct stones.

Patients and methods: Between 1993 and 1998, 600 patients underwent laparoscopic cholecystectomy under one consultant surgeon. Patients were selected for pre-operative or postoperative ERC based on symptoms, liver function tests and/or abnormalities on ultrasonography. A general practitioner questionnaire was used to assess follow-up of patients with postoperative stones.

Results: Of 600 patients, 107 (18%) with a median age of 57 years and male:female ratio of 1:2.1 were selected to undergo pre-operative ERC; of these, 41 patients (38%) had bile duct stones. Postoperative ERC was performed in 30 patients (5%) and stones were identified in seven (23.3%). Three patients (0.5%) had stones removed within 15 days of operation and four (0.7%) between 2.6 months and 1.8 years. Median follow-up was 5.0 years (range, 2.5-7.5 years). The overall incidence of bile duct stones was 48 cases (8%). The stone rate was 11% in males and 7.3% in females. Stones were successfully extracted at ERC in 43 patients (89.6%).

Conclusions: A policy of selective pre-operative ERC is the most effective technique for identifying and removing bile duct stones and the incidence of symptomatic gallstones following laparoscopic cholecystectomy is very low. With an overall stone rate of 8%, routine peroperative cholangiography is unnecessary and, in a surgical unit providing an ERC service, laparoscopic exploration of the bile duct is not a technique required for the management of bile duct stones.