Do all patients with abnormal intraoperative cholangiogram merit endoscopic retrograde cholangiopancreatography?

  • S. Varadarajulu
  • M. A. Eloubeidi
  • C. M. Wilcox
  • R. H. Hawes
  • P. B. Cotton



Endoscopic retrograde cholangiopancreatography (ERCP) is commonly used for postoperative evaluation of an abnormal intraoperative cholangiogram (IOC). Although a normal IOC is very suggestive of a disease-free common bile duct (CBD), abnormal studies are associated with high false-positive rates. This study aimed to identify a subset of patients with abnormal IOC who would benefit from a postoperative ERCP.


This prospective study investigated 51 patients with abnormal IOC at laparoscopic cholecystectomy who underwent postoperative ERCP at two tertiary referral centers over a 3-year period. Univariate and multivariate logistic regression analyses were performed to determine predictors of CBD stones at postoperative ERCP.


For all 51 patients, ERCP was successful. The ERCP showed CBD stones in 33 cases (64.7%), and normal results in 18 cases (35.2%). On univariate analysis, abnormal liver function tests (p < 0.0001) as well as IOC findings of a large CBD stone (p = 0.03), multiple stones (p = 0.01), and a dilated CBD (p = 0.07) predicted the presence of retained stones at postoperative ERCP. However, on multivariable analysis, only abnormal liver function tests correlated with the presence of CBD stones (p < 0.0001).


One-third of patients with an abnormal IOC have a normal postoperative ERCP. Elevated liver function tests can help to identify patients who merit further evaluation by ERCP. The use of less invasive methods such as endoscopic ultrasound or magnetic resonance cholangiopancreatography should be considered for patients with normal liver function tests to minimize unnecessary ERCPs.


Abnormal intraoperative cholangiogram CBD Common bile duct Endoscopic retrograde cholangiopancreatography ERCP IOC Predictors 


  1. 1.
    Ammori BJ, Birbas K, Davides D, Vezakis A, Larvin M, McMohan MJ (2000) Routine vs “on demand” postoperative ERCP for small bile duct calculi detected at intraoperative cholangiography: clinical evaluation and cost analysis. Surg Endosc 14: 1123–1126CrossRefPubMedGoogle Scholar
  2. 2.
    Arregui M, Davis CJ, Arkush AM, Nagan RF (1992) Laparoscopic cholecystectomy combined with endoscopic sphincterotomy and stone extraction or laparoscopic choledochoscopy and electrohydraulic lithotripsy for management of cholelithiasis with choledocholithiasis. Surg Endosc 6: 10–15CrossRefPubMedGoogle Scholar
  3. 3.
    Barkun JS, Fried GM, Barkun AN, Sigman HH, Hinchey EJ, Garzon J, (1993) Cholecystectomy without operative cholangiography: implications for common bile duct injury and retained common bile duct stones. Ann Surg 218: 371–379PubMedGoogle Scholar
  4. 4.
    Besten LD, Doty JE (1981) Choledocholithiasis. Surg Clin North Am 61: 893–907Google Scholar
  5. 5.
    Birkett D (1992) Technique of cholangiography and cystic-duct choledochoscopy at the time of laparoscopic cholecystectomy for laser lithotripsy. Surg Endosc 6: 252–254PubMedGoogle Scholar
  6. 6.
    Bose SM, Mazumdar A, Prakash S, Kocher R, Katariya S, Pathak CM (2001) Evaluation of the predictors of choledocholithisis: comprehensive analysis of clinical, biochemical, radiological, radionuclear, and intraoperative parameters. Surg Today 31: 117–122CrossRefPubMedGoogle Scholar
  7. 7.
    Cohen S, Bacon BR, Berlin JA, Fleischer D, Hecht GA, Loehrer PJ, Sr, McNair AE Jr, Mulholland M, Norton NJ, Rabeneck L, Ransohoff DF, Sonnenberg A, Vannier MW. (2002) National Institutes of Health State-of-the-Science Conference Statement: ERCP for diagnosis and therapy. Gastrointest Endosc 56: 802–809CrossRefGoogle Scholar
  8. 8.
    Cranley B, Logan H (1980) Exploration of the common bile duct: the relevance of the clinical picture and the importance of preoperative cholangiography. Br J Surg 67: 869–872PubMedGoogle Scholar
  9. 9.
    DePaula AL, Hashiba K, Bafutto M, Zago R, Grecco E (1993) Laparoscopic treatment of choledocholithiasis. Surg Laparosc Endosc 3: 157–160PubMedGoogle Scholar
  10. 10.
    Freeman ML (2002) Adverse outcomes of ERCP. Gastrointest Endosc 56(6 Suppl): S273–S282CrossRefPubMedGoogle Scholar
  11. 11.
    Frossard JL, Hadengue A, Amouyal G, Choury A, Marty O, Giostra E, Sivignon F, Sosa L, Amouyal P. (2000) Choledocholithiasis: a prospective study of spontaneous common bile duct stone migration. Gastrointest Endosc 51: 175–179CrossRefPubMedGoogle Scholar
  12. 12.
    Fulcher AS, Turner MA, Capps GW, Zfass AM, Baker KM (1998) Half-Fourier RARE MR cholangiopancreatography in 300 subjects. Radiology 207: 21–32PubMedGoogle Scholar
  13. 13.
    Hainsworth PJ, Rhodes M, Gompertz RH, Armstrong CP, Lennard TW (1994) Imaging of the common bile duct in patients undergoing laparoscopic cholecystectomy. Gut 7: 991–995Google Scholar
  14. 14.
    Hawasli A, Lloyd L, Cacucci B (2000) Management of choledocholithiasis in the era of laparoscopic surgery. Am Surg 66: 425–430PubMedGoogle Scholar
  15. 15.
    Hunter JG (1992) Laparoscopic transcystic common bile duct exploration. Am J Surg 163: 53–56CrossRefPubMedGoogle Scholar
  16. 16.
    Ijzermans JN, De Waard P, Merkelbach JW (1989) Cholangiography during cholecystectomy: a plea for selective use. Neth J Surg 41: 79–81PubMedGoogle Scholar
  17. 17.
    Johanson JF, Cooper G, Eisen GM, Freeman M, Goldstein JL, Jensen DM (2002) Quality assessment of ERCP: endoscopic retrograde cholangiopancreatography. Gastrointest Endosc 56:165–169CrossRefPubMedGoogle Scholar
  18. 18.
    Katz D, Nikfarjam M, Sfakiotaki A, Christophi C (2004) Selective endoscopic cholangiography for the detection of common bile duct stones in patients with cholelithiasis. Endoscopy 36: 1045–1049CrossRefPubMedGoogle Scholar
  19. 19.
    Kondylis PD, Simmons DR, Agarwal SK, Ciardiello KA, Reinhold RB (1997) Abnormal intraoperative cholangiography: treatment options and long-term follow-up. Arch Surg 132: 347–350PubMedGoogle Scholar
  20. 20.
    Korman J, Cosgrove J, Furman M, Nathan I, Cohen J (1996) The role of endoscopic retrograde cholangiopancreatography and cholangiography in the laparoscopic era. Ann Surg 223: 212–216CrossRefPubMedGoogle Scholar
  21. 21.
    Legorreta A, Brooks RJ, Staroscik RN, Xuan Y, Costantino GN, Zats S (1995) Increased ERCP rate following the introduction of laparoscopic cholecystectomy. J Laparaendosc Surg 5: 271–278Google Scholar
  22. 22.
    Levine SB, Lerner HJ, Leifer ED, Lindheim SR (1983) Intraoperative cholangiography: a review of indications and analysis of age-sex groups. Ann Surg 198: 692–697PubMedGoogle Scholar
  23. 23.
    Liberman MA, Phillips EH, Carroll BJ, Fallas MJ, Rosenthal R, Hiatt J (1996) Cost-effective management of complicated choledocholithiasis: laparoscopic transcystic duct exploration or endoscopic sphincterotomy. J Am Coll Surg 182: 488–494PubMedGoogle Scholar
  24. 24.
    Lilly MC, Arregui ME (2001) A balanced approach to choledocholithiasis. Surg Endosc 15: 467–472CrossRefPubMedGoogle Scholar
  25. 25.
    Loperfido S, Angelini G, Benedetti G, Chilovi F, Costan F, De Berardinis F, De Bernardin M, Ederele A, Fina P, Fratton A. (1998) Major early complications from diagnostic and therapeutic ERCP: a prospective multicenter study. Gastrointest Endosc 48: 1–10CrossRefPubMedGoogle Scholar
  26. 26.
    McMahon AJ, Russel IT, Baxter JN, Ross R, Anderson JR, Morran CG, Sunderland G, Galloway D, Ramsay G, O’Dwyer PJ. (1994) Laparoscopic versus mini laparotomy cholecystectomy: a randomized controlled trial. Lancet 343: 135–138CrossRefPubMedGoogle Scholar
  27. 27.
    Ng T, Amaral JF (1999) Timing of endoscopic retrograde cholangiopancreatography and laparoscopic cholecystectomy in the treatment of choledocholithisis. J Laparoendosc Adv Surg Tech A 9: 31–37PubMedGoogle Scholar
  28. 28.
    O’Doherty D, Neoptolemos J, Carr-Locke D (1986) Endoscopic sphincterotomy for retained common bile duct stones in patients with T-tube in situ in the early postoperative period. Br J Surg 73: 454–456PubMedGoogle Scholar
  29. 29.
    Onken JE, Brazer SR, Eisen GM, Williams DM, Bouras EP, DeLong ER, Long TT 3rd, Pancotto FS, Rhodes DL, Cotton PB. (1996) Predicting the presence of choledocholithiasis in patients with symptomatic cholelithiasis. Am J Gastroenterol 91: 762–767PubMedGoogle Scholar
  30. 30.
    Palazzo L, Girollet P-P, Salmeron M, Silvian C, Roseau G, Canard J-M, Chaussade S, Couturier D, Paolaggi JA. (1995) Value of endoscopic ultrasonography in the diagnosis of common bile duct stones: comparison with surgical exploration and ERCP. Gastrointest Endosc 42: 225–231CrossRefPubMedGoogle Scholar
  31. 31.
    Perret RS, Sloop GD, Borne JA (2000) Common bile duct measurements in an elderly population. J Ultrasound Med 19: 727–730PubMedGoogle Scholar
  32. 32.
    Rhodes M, Sussman L, Cohen L, Lewis MP (1998) Randomised trial of laparoscopic exploration of common bile duct versus postoperative endoscopic retrograde cholangiography for common bile duct stones. Lancet 351: 159–161CrossRefPubMedGoogle Scholar
  33. 33.
    Ryberg AA, Fitzgibbons RJ Jr, Tseng A, Maffi TR, Burr LJ, Doris PE (1997) Abnormal cholangiograms during laparoscopic cholecystectomy. Surg Endosc 11: 456–459CrossRefPubMedGoogle Scholar
  34. 34.
    Schmitt CM, Baillie J, Cotton PB (1995) ERCP following laparoscopic cholecystectomy: a safe and effective way to manage CBD stones and complications. HPB Surg 8: 187–192PubMedGoogle Scholar
  35. 35.
    Shapiro SJ, Gordon LA, Daykhovsky L, Grundfest W (1991) Laparoscopic exploration of the common bile duct: experience in 16 selected patients. J Laparoendosc Surg 1: 333–341PubMedGoogle Scholar
  36. 36.
    Soto JA, Barish MA, Alvarez O, Medina S (2000) Detection of choledocholithiasis with MR cholangiography: comparison of three-dimensional fast spin-echo and single- and multisection half-Fourier rapid acquisition with relaxation enhancement sequences. Radiology 215: 737–745PubMedGoogle Scholar
  37. 37.
    Stoker ME (1995) Common bile duct exploration in the era of laparoscopic surgery. Arch Surg 130: 265–268PubMedGoogle Scholar
  38. 38.
    Sugiyama M, Atomi Y (1997) Endoscopic ultrasonography for diagnosing choledocholithiasis: a prospective comparative study with ultrasonography and computed tomography. Gastrointest Endosc 45: 143–146CrossRefPubMedGoogle Scholar
  39. 39.
    Taylor TV, Armstrong CP (1987) Migration of gallstones. Br Med J (Clin Res Ed) 294: 1320–1322CrossRefGoogle Scholar
  40. 40.
    Tham TCK, Lichtenstein DR, Vandervoort J, Wong RCK, Brooks D, Van Dam J, Ruymann F, Farraye F, Carr-Locke DL. (1998) Role of endoscopic retrograde cholangiopancreatography for suspected choledocholithiasis in patients undergoing laparoscopic cholecystectomy. Gastrointest Endosc 47: 50–56CrossRefPubMedGoogle Scholar
  41. 41.
    Urbach DR, Khajanchee YS, Jobe BA, Standage BA, Hansen PD, Swanstrom LL (2001) Cost-effective management of common bile duct stones: a decision analysis of the use of endoscopic retrograde cholangiopancreatography (ERCP), intraoperative cholangiography, and laparoscopic bile duct exploration. Surg Endosc 15: 4–13CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, Inc. 2006

Authors and Affiliations

  • S. Varadarajulu
    • 1
  • M. A. Eloubeidi
    • 1
  • C. M. Wilcox
    • 1
  • R. H. Hawes
    • 2
  • P. B. Cotton
    • 2
  1. 1.Division of Gastroenterology-HepatologyUniversity of Alabama at BirminghamBirminghamUSA
  2. 2.Digestive Disease CenterMedical University of South CarolinaCharlestonUSA

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