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Safety, quality and efficiency of intra-operative imaging for treatment decisions in patients with suspected choledocholithiasis without pre-operative magnetic resonance cholangiopancreatography

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Abstract

Introduction

Cholecystectomy is the accepted treatment for patients with symptomatic gallstones. In this study, we evaluate a simplified strategy for managing suspected synchronous choledocholithiasis by focussing on intra-operative imaging as the primary decision-making tool to target common bile duct (CBD) stone treatment.

Methods

All elective and emergency patients undergoing laparoscopic cholecystectomy (LC) for gallstones with any markers of synchronous choledocholithiasis were included. Patients unfit for surgery or who had pre-operative proof of choledocholithiasis were excluded. Intra-operative imaging was used for evaluation of the CBD. CBD stone treatment was with bile duct exploration (LCBDE) or endoscopic retrograde cholangiopancreatography (LC + ERCP). Outcomes were safety, effectiveness and efficiency.

Results

506 patients were included. 371 (73%) had laparoscopic ultrasound (LUS), 80 (16%) had on-table cholangiography (OTC) and 55 (11%) had both. 164 (32.4%) were found to have CBD stones. There was no increase in length of surgery for LC + LUS compared with average time for LC only in our unit (p = 0.17). 332 patients (65.6%) had clear ducts. Imaging was indeterminate in 10 (2%) patients. Overall morbidity was 10.5%. There was no mortality. 142 (86.6%) patients with stones on intra-operative imaging proceeded to LCBDE. 22 (13.4%) patients had ERCP. Sensitivity and specificity of intra-operative imaging were 93.3 and 99.1%, respectively. Success rate of LCBDE was 95.8%. Effectiveness was 97.8%.

Conclusions

Eliminating pre-operative bile duct imaging in favour of intra-operative imaging is safe and effective. When combined with intra-operative stone treatment, this method becomes a true ‘single-stage’ approach to managing suspected choledocholithiasis.

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Abbreviations

LC:

Laparoscopic cholecystectomy

CBD:

Common bile duct

LCBDE:

Laparoscopic common bile duct exploration

LUS:

Laparoscopic ultrasound

ERCP:

Endoscopic retrograde cholangiopancreatography

MRCP:

Magnetic retrograde cholangiopancreatography

EUS:

Endoscopic ultrasound

X-ray OTC:

X-ray on-table-cholangiogram

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Authors and Affiliations

  1. South Devon Upper GI Unit, Torbay Hospital, Torquay, UK

    A. E. S. Bush, P. Christopoulos, R. M. Jones, S. Sinha, G. Srinivas & S. N. Andrews

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  1. A. E. S. Bush
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  2. P. Christopoulos
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  3. R. M. Jones
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  4. S. Sinha
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  6. S. N. Andrews
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Correspondence to S. N. Andrews.

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A. E. S. Bush, P. Christopoulos, S. Sinha, G. Srinivas and S. Andrews declares that they have no conflict of interest to disclose.

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Bush, A.E.S., Christopoulos, P., Jones, R.M. et al. Safety, quality and efficiency of intra-operative imaging for treatment decisions in patients with suspected choledocholithiasis without pre-operative magnetic resonance cholangiopancreatography. Surg Endosc 36, 1206–1214 (2022). https://doi.org/10.1007/s00464-021-08389-y

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