Comparison between Intraoperative Cholangiography and Choledochoscopy for ductal clearance in Laparoscopic CBD exploration – a prospective randomized study

Anubhav Vindal, MS, DNB, MRCSEd, MNAMS, Jagdish Chander, MS, Pawanindra Lal, MS, DNB, MNAMS, FRCSEd, FRCSGlas, FRCSEn, FACS, Balu Mahendra, MS. Division of Minimal Access Surgery, Department of Surgery, Maulana Azad Medical College (University of Delhi), New Delhi, India.

Introduction
Laparoscopic CBD exploration is an accepted treatment modality for single stage management of CBD stones in fit patients. A trans choledochal approach is preferred in patients with a dilated CBD and large impacted stones in whom ductal clearance remains problematic. There are very few studies comparing intraoperative cholangiography (IOC) with choledochoscopy to determine ductal clearance in patients undergoing transcholedochal laparoscopic CBD exploration. This series represents the first of those comparing the two from Asia.

Methods and Procedures
Between April 2009 and October 2012, 150 consecutive patients with CBD stones were enrolled in a prospective randomized study to undergo transcholedochal laparoscopic CBD exploration on an intent-to-treat basis. Patients with CBD diameter of less than 9 mm on preoperative imaging were excluded from the study. Out of the 132 eligible patients 65 patients underwent intraoperative cholangiography (Group A) and 67 patients underwent intraoperative choledochoscopy with a rigid ureteroscope (Group B) to determine CBD clearance.

Results
There were no significant differences between the two groups in the demographic profile and the preoperative biochemical findings. There was no conversion to open procedures and stone clearance was achieved in all the 132 cases. The mean CBD diameter was comparable between the two groups. The mean number of CBD stones removed in Group A was 5.09 while in group B it was 4.76 (p > 0.05). Mean operating time in Group A was 170 minutes while in group B it was 140 minutes (p< 0.001). No difference in complications was noted between the two groups. Nine patients in Group A (13.8%) showed non passage of contrast into the duodenum at IOC which resolved on administration of i.v. glucagon, suggesting a transient spasm of sphincter of Oddi. Although inconsequential, this added to an increase in operative time in this group. Two patients (3%) showed a false positive result with IOC due to an air bubble in the distal end of the CBD, which had to be resolved with choledochoscopy.

Conclusions
The present study showed that intraoperative choledochoscopy is a better option than IOC in determining ductal clearance after transcholedochal laparoscopic CBD exploration. It is less cumbersome and less time consuming than IOC, and avoids false positive results. We recommend intraoperative choledochoscopy as the standard procedure for determining the ductal clearance after laparoscopic transcholedochal CBD exploration in patients with CBD diameter more than 9 mm.

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