Evaluation of the Efficacy and Accuracy of Intraoperative Cholangiograms in Patients with Suspected Choledocholithiasis

Andrew J Cleland, BS¹, Carrie Ronstrom, BS¹, Reema Mallick, MD², Kevin Rank, MD³, Stuart Amateau, MD, PhD³, Mustafa Arain, MD³, Martin Freeman, MD³, James V Harmon, MD, PhD². ¹University of Minnesota Medical School, ²University of Minnesota, Department of Surgery, ³University of Minnesota, Department of Medicine

Introduction: We evaluated the efficiency and efficacy of performing intraoperative cholangiograms (IOC) to evaluate for choledocholithiasis during laparoscopic cholecystectomy (LC). We compared the preoperative data, operative data, and clinical outcomes in 24 patients who underwent IOCs to the findings in 84 patients who did not undergo IOC in a 108 patient cohort with a high likelihood of choledocholithiasis.

Methods and Procedures: This patient cohort consisted of 108 consecutive patients who underwent both LC and endoscopic retrograde cholangiopancreatography (ERCP) within a 30-day period at our teaching hospital between July 2010 and July 2014. All patients in this cohort had a high likelihood of choledocholithiasis based on laboratory imaging studies. The patients who underwent IOCs were further characterized based on the findings of the ICOs: positive or suspicious for stones (12), negative for stones (6), or IOC unable to be completed (6). Student T-tests and ANOVA statistical assays were performed to evaluate the statistical significance of the differences between the groups.

Results: Of all patients in this cohort, stones were found in 52%; and sludge was found in 78%. The presence of either stones or sludge were found in 95% of all patients in the cohort. The average operative time to perform LC for patients who did not undergo IOC was 101 ± 58 minutes; for patients who underwent LC/IOC the average operative time was144 ± 59 minutes, the difference was statistically significant (p = 0.0014). Clearly positive or suspicious findings were identified in half of the patients who underwent IOC. Clearly negative IOCs were recorded in 25% of the patients who underwent IOC. In 25% of patients in whom the IOC was attempted, it could not be completed. There were no significant differences in the average peak liver function values, pancreatic enzyme values, number or size of stones recovered, or clinical outcomes between the patient groups.

Conclusions: Even in patients with a high likelihood of choledocholithiasis, IOC was clearly positive or suspicious for stones in only half of the patients in whom the IOC procedure was either attempted or completed. The IOC was completed in only 75% of the patients in whom it was attempted. The average additional operative time to perform or attempt the IOC was 43 minutes. Intraoperative mentoring for surgeons performing IOC might improve the efficiency and success of this procedure at our teaching hospital. No complications were associated with performing the IOC procedures.