- Email: [email protected]
Routine operative cholangiography: A critical appraisal
Routine Operative Cholangiography: A Critical Appraisal Rahmat Mazaheri Seif, MD, FACS, Roanoke, Virginia
Preexploratory operative cholangiograms have been a great asset in helping surgeons avoid unnecessary common bile duct explorations. Unfortunately, advocates of operative cholangiograms have gone too far by claiming they should be performed routinely during every cholecystectomy. Fortunately, the majority of practicing surgeons are against the routine use of this procedure and now may be the time for the silent majority to voice their opinion. The present report is based upon an experience with 180 operative cholangiograms performed during 856 consecutive cholecystectomies. Material and Methods
From 1970 through 1975,856 consecutive cholecystectomies were performed in Roanoke Memorial Hospital, Roanoke, Virginia. Cholecystectomy alone was performed on 572 patients and common bile ducts were explored in 88 (10 per cent) of the patients. On 214 (25 per cent) of the patients, associated procedures were performed along with gallbladder surgery (18 of these 214 patients also had common bile duct exploration). Values for serum bilirubin, serum glutamic oxalacetic transaminase, and alkaline phosphatase were determined preoperatively in the entire series. Common Bile Duct Explorations. The following criteria were considered likely indicators of common bile duct stones: (1) (2) (3) (4)
Abnormal liver function tests. History of past or present jaundice. History of pancreatitis. Presence of gallstones smaller than cystic duct diameter. (5) Abnormally appearing common bile duct or palpable common duct stones.
Two hundred twenty-two (26 per cent) of the patients presented one or more of these criteria. In 86 of these patients with positive criteria, neither cholangiograms nor common bile duct explorations were performed. In 85 patients preexploratory operative cholangiograms were done, and in 88 patients the common bile ducts were explored with or without such operative cholangiograms. Of the 88 From the Department of Surgery, Roanoke Memorial Hospital, Roanoke, Virginia. Reprint requests should be addressed to Rahmat M. Seif. MD, Suite 303. 707 South Jefferson Street, Roanoke, Virginia 24011.
566
patients with common bile duct exploration, 55 (63 per cent) were positive for stones-32 of 54 (60 per cent) undergoing exploration based on the usual criteria for expectancy of stones and 23 of 34 (70 per cent) undergoing exploration based on the usual criteria and positive cholangiograms. There were 11 patients who had positive preexploratory operative cholangiograms but no stones found at exploration. These 11 negative explorations due to false-positive cholangiograms comprised 33 per cent of our total of 33 negative common bile duct explorations. One comforting fact was that all these 11 patients were also positive by our criteria for expectancy of common bile duct stones. In 3 patients who were positive by our criteria, and therefore suspected to have common duct stones, common bile ducts were explored despite negative operative cholangiograms, and stones were recovered during exploration. Operative Cholangiograms. One hundred eighty preexploratory operative cholangiograms were performed in the entire series. (Table I.) Cholangiograms were performed in 85 patients who were positive for probable common bile duct stones by our criteria. Of these, 51 patients (60 per cent) had negative cholangiograms: 3 patients had false-negative results (stones were found after compelling clinical and operative indications led to common bile duct exploration) and 48 patients were saved from unnecessary exploration. Of the 34 (40 per cent) positive cholangiograms 11 were false-positive. In the other 95 patients, operative cholangiograms were performed merely as a routine measure despite absence of positive criteria for probable common bile duct stones. All 95 cholangiograms proved negative. Thus, 6 per cent of all cholangiograms were false-positive and 2 per cent were false negative. A subhepatic bile collection occurred in one patient after a preexploratory cholangiogram by a butterfly needle through the common bile duct. Comments
Mortality of common bile duct exploration is several times greater than mortality of cholecystectomy alone. In the present series it was 2.3 per cent (2 of 88) for common bile duct exploration, 0.18 per cent (1 of 572) for cholecystectomy alone, and 1.5 per cent (3 of 214) for cholecystectomy with associated procedures. (Eighteen of these 214 patients also had common bile duct explorations.) Yet, too many unnecessary common bile duct explorations are performed every year. Glenn [I], in a collected series of
rhe American
Journal of Surgery
Routine Operative Cholangiography
TABLE I
Results of 180 Consecutive Cholangiograms Patients with Patients without Positive Criteria for Positive Criteria for Common Bile Duct Common Bile Duct Stones Stones
Negative Cholangiograms False-Negative Positive Cholangiograms False-Positive Total
51 (60%) 3 34 (40%)
G (100%)
95 (100%)
0
Percentage of Common Bile Duct Explorations Avoided by Use of Operative Cholansrionrams
Authors Letton and Wilson [ 31 Thurston [ 41 Saltzstein, Evani, and Mann [5] Present studv
Number of Patients Positive by Criteria
Negative Common Duct by Operative Cholangiogram
69 33 79
76% 82% 50%
85
57%
95 (100%)
4,087 common bile duct explorations, reported a 54 per cent rate of negative explorations. Arnold [2] collected a series of approximately 4,209 common bile duct explorations, of which 50 per cent were negative explorations. These two large series reveal that almost one out of two common bile duct explorations in the United States is fruitlessly negative and, therefore, unnecessary. The reason for these negative explorations of common bile ducts is that surgeons usually suspect the presence of common bile duct stones whenever any of five previously mentioned criteria is present in their patients. If we disregard those criteria, with the exception of palpable common bile duct stone, as indications for common bile duct exploration and instead use them as criteria for operative cholangiography, we would screen out those 50 per cent of patients whose common bile ducts are free of stones and, therefore, spare them unnecessary common bile duct explorations. This claim is well illustrated in the literature [3-51. (Table II.) Patients with positive criteria for probable common bile duct stones usually comprise 25 per cent of patients with gallbladder disease. It is in this group of patients that a preexploratory operative cholangiography should be performed. Unfortunately, the advocates of operative cholangiography have gone too far by claiming that operative cholangiograms should be a routine procedure in all cholecystectomies. A poll taken by Jolly et al [6] among the members of the Ohio Chapter of American College of Surgeons revealed that only 18 per cent of the surgeons use operative cholangiograms routinely (in 90 per cent or more of the cases). Those who advocate the routine use of this procedure usually refer to the rate of unexpected stones which they have found in common bile ducts with the help of operative cholangiograms-which otherwise would have been missed. In the present series, in 95 patients who were negative for common bile duct stones with the usual criteria, operative cholangiography failed to reveal any unexpected common bile duct stone (0 per cent).
Volume134,November1977
TABLE II
Wayne et al [7], Nienhuis [8], and Kakos et al [9] all reported a rate of approximately 4 per cent unexpected common bile duct stone findings. Yet these authors failed to include abnormal liver function tests as criteria for expectancy of common duct stones. Jolly et al [6] report 24 cases of unexpected common bile duct stone findings in 380 patients who were otherwise negative by the criteria (6.3 per cent). But later in their report, they revealed that 19 of those 24 patients had small stones in their gallbladders. Needless to say, the presence of common bile duct stones in these 19 patients should not have been so unexpected. Therefore, their true rate of unexpected stone findings should be five out of 380 patients and thus, much lower than the rate reported. It is surprising that Saltzstein, Evani, and Mann [5] and Wiethoff and Clover [IO] report a rate of approximately 1.6 per cent unexpected stone findings, yet despite such a low rate, both groups advocate the routine use of operative cholangiograms. Schulenburg [II] in 908 cholangiograms reported only 1.2 per cent unexpected common bile duct stone findings. I believe the rate of unexpected common bile duct stone findings would be near 1 per cent (in the present series, 0 per cent) if the abnormal liver function tests are added to the usual criteria and if the criteria are strictly adhered to. Considering that 50 per cent of all common bile duct explorations are unnecessary, as previously mentioned, as well as the 1 per cent probability of unexpected stone findings, one could draw the following conclusions: (1) Whenever surgeons, based on positive criteria for expectancy of common bile duct stones, think that a common bile duct may contain stone, they are wrong in-50 per cent of the cases. It is in this group that preexploratory operative cholangiography could have its best effect, by helping to eliminate those unnecessary explorations. (2) However, whenever surgeons, based on the absence of the positive criteria, think that a common bile duct does not contain any stone, they are correct in 99 per cent of the cases. Advocates claim routine operative cholangiography could improve this 99 per
567
Seif
cent accuracy to 100 per cent. On the contrary, employing an operative cholangiogram routinely does not improve our 99 per cent rate of accuracy; rather, it decreases it because of the occurrence of falsepositive reports by routine operative cholangiography which are as high as 22 per cent [6], 11 per cent [4], and 6 per cent in the present series. These figures of false-positive reports indicate the frequency in which common bile ducts would be opened fruitlessly, thereby defeating our main purpose, which is to save common bile ducts from unnecessary exploration. Even if’one could ignore these false-positive reports, one could not justify the cost of routine operative cholangiograms in order to detect 1 per cent unexpected common bile duct stones. The cost for a cholangiogram in our community is approximately $180 per procedure: $50 for the surgeon; $50 for the radiologist; and $80 for operating room and anesthesia time (if the time spent is 15 minutes). Although surgeons usually tend to underestimate this time, still Wayne et al [7] report 15 minutes, Jolly et al [6] 19 minutes, and Thurston [4] 23 minutes for performance of operative cholangiograms. Approximately 600,000 cholecystectomies are performed in the United States every year. The total cost of routine operative cholangiograms may be more than $100 million a year. All that expense for 1 per cent unexpected common bile duct stone findings! Is it worth it? I realize the difficulty of estimating this cost, since it varies from community to community and from state to state. One also appreciates the cost of probable future reoperations for those 1 per cent missed common bile duct stones. However, we should also consider the additional cost of unnecessary common bile duct explorations due to false-positive operative cholangiograms. Even if we could disregard the intangible cost of occasional complications of this procedure, and the occasional maleffects of the 15 minute additional anesthesia time on some critically
566
ill patients, the financial considerations not justify the routine use of operative grams.
would still cholangio-
Summary
If abnormal liver function tests are added to the classic criteria for expectancy of common bile duct stone, the rate of unexpected common bile duct stone findings should be 1 per cent or less. This low rate does not justify the cost of routine operative cholangiography. However, a preexploratory operative cholangiogram should be performed prior to common bile duct exploration in order to avoid negative, and therefore unnecessary, common bile duct explorations.
References 1. Glenn F: Retained calculi within the biliary ductal sySt8R-bAnn Surg 179: 529, 1974. 2. Arnold DJ: 28,621 cholecystectomies in Ohio. Am J Surg 119: 714,197o. 3. Letton AH, Wilson JP: Routine cholangiography during biliary tract operations: technic and utility in 200 consecutive cases. Ann Surg 163: 937, 1966. 4. Thurston DG: Nonroutine operatfve cholanglography. Arch Swg 108: 512, 1974. 5. Saltzstein EC, Evani SV, Mann RW: Routine operative cholangiography. Arch Surg 107: 289, 1973. 6. Jolly PC, Baker JW, Schmidt HM, Walker JH. Holm JC: Operative cholangiography: a case for its routine use. Ann Surg 168: 551.1966. 7. Wayne R. Cegileski M, Bleicher J, Saporta J: Operative cholangiography in uncomplicated blllary tract sugery. Am J Sug 131: 324, 1976. 8. Nienhuis LI: Routine operative cholangiography: an evalutatlon. Ann Surg 154: 192, 1961. 9. Kakos GS, Tompkins RK, Turnipseed W, Zollinger RM: Operative cholangiogaphy during routfne cholecystectomy. A&I surg 104: 484, 1972. 10. Wiethoff CA, Clover JL: Operative cholangiography in a rural surgical practice. Arch Surg 109: 254, 1974. 11. Schulenburg CAR: Operative cholangiography: 100 cases. Surgery 65: 723, 1969.
The American Journal of Sur#ery
Preexploratory operative cholangiograms have been a great asset in helping surgeons avoid unnecessary common bile duct explorations. Unfortunately, advocates of operative cholangiograms have gone too far by claiming they should be performed routinely during every cholecystectomy. Fortunately, the majority of practicing surgeons are against the routine use of this procedure and now may be the time for the silent majority to voice their opinion. The present report is based upon an experience with 180 operative cholangiograms performed during 856 consecutive cholecystectomies. Material and Methods
From 1970 through 1975,856 consecutive cholecystectomies were performed in Roanoke Memorial Hospital, Roanoke, Virginia. Cholecystectomy alone was performed on 572 patients and common bile ducts were explored in 88 (10 per cent) of the patients. On 214 (25 per cent) of the patients, associated procedures were performed along with gallbladder surgery (18 of these 214 patients also had common bile duct exploration). Values for serum bilirubin, serum glutamic oxalacetic transaminase, and alkaline phosphatase were determined preoperatively in the entire series. Common Bile Duct Explorations. The following criteria were considered likely indicators of common bile duct stones: (1) (2) (3) (4)
Abnormal liver function tests. History of past or present jaundice. History of pancreatitis. Presence of gallstones smaller than cystic duct diameter. (5) Abnormally appearing common bile duct or palpable common duct stones.
Two hundred twenty-two (26 per cent) of the patients presented one or more of these criteria. In 86 of these patients with positive criteria, neither cholangiograms nor common bile duct explorations were performed. In 85 patients preexploratory operative cholangiograms were done, and in 88 patients the common bile ducts were explored with or without such operative cholangiograms. Of the 88 From the Department of Surgery, Roanoke Memorial Hospital, Roanoke, Virginia. Reprint requests should be addressed to Rahmat M. Seif. MD, Suite 303. 707 South Jefferson Street, Roanoke, Virginia 24011.
566
patients with common bile duct exploration, 55 (63 per cent) were positive for stones-32 of 54 (60 per cent) undergoing exploration based on the usual criteria for expectancy of stones and 23 of 34 (70 per cent) undergoing exploration based on the usual criteria and positive cholangiograms. There were 11 patients who had positive preexploratory operative cholangiograms but no stones found at exploration. These 11 negative explorations due to false-positive cholangiograms comprised 33 per cent of our total of 33 negative common bile duct explorations. One comforting fact was that all these 11 patients were also positive by our criteria for expectancy of common bile duct stones. In 3 patients who were positive by our criteria, and therefore suspected to have common duct stones, common bile ducts were explored despite negative operative cholangiograms, and stones were recovered during exploration. Operative Cholangiograms. One hundred eighty preexploratory operative cholangiograms were performed in the entire series. (Table I.) Cholangiograms were performed in 85 patients who were positive for probable common bile duct stones by our criteria. Of these, 51 patients (60 per cent) had negative cholangiograms: 3 patients had false-negative results (stones were found after compelling clinical and operative indications led to common bile duct exploration) and 48 patients were saved from unnecessary exploration. Of the 34 (40 per cent) positive cholangiograms 11 were false-positive. In the other 95 patients, operative cholangiograms were performed merely as a routine measure despite absence of positive criteria for probable common bile duct stones. All 95 cholangiograms proved negative. Thus, 6 per cent of all cholangiograms were false-positive and 2 per cent were false negative. A subhepatic bile collection occurred in one patient after a preexploratory cholangiogram by a butterfly needle through the common bile duct. Comments
Mortality of common bile duct exploration is several times greater than mortality of cholecystectomy alone. In the present series it was 2.3 per cent (2 of 88) for common bile duct exploration, 0.18 per cent (1 of 572) for cholecystectomy alone, and 1.5 per cent (3 of 214) for cholecystectomy with associated procedures. (Eighteen of these 214 patients also had common bile duct explorations.) Yet, too many unnecessary common bile duct explorations are performed every year. Glenn [I], in a collected series of
rhe American
Journal of Surgery
Routine Operative Cholangiography
TABLE I
Results of 180 Consecutive Cholangiograms Patients with Patients without Positive Criteria for Positive Criteria for Common Bile Duct Common Bile Duct Stones Stones
Negative Cholangiograms False-Negative Positive Cholangiograms False-Positive Total
51 (60%) 3 34 (40%)
G (100%)
95 (100%)
0
Percentage of Common Bile Duct Explorations Avoided by Use of Operative Cholansrionrams
Authors Letton and Wilson [ 31 Thurston [ 41 Saltzstein, Evani, and Mann [5] Present studv
Number of Patients Positive by Criteria
Negative Common Duct by Operative Cholangiogram
69 33 79
76% 82% 50%
85
57%
95 (100%)
4,087 common bile duct explorations, reported a 54 per cent rate of negative explorations. Arnold [2] collected a series of approximately 4,209 common bile duct explorations, of which 50 per cent were negative explorations. These two large series reveal that almost one out of two common bile duct explorations in the United States is fruitlessly negative and, therefore, unnecessary. The reason for these negative explorations of common bile ducts is that surgeons usually suspect the presence of common bile duct stones whenever any of five previously mentioned criteria is present in their patients. If we disregard those criteria, with the exception of palpable common bile duct stone, as indications for common bile duct exploration and instead use them as criteria for operative cholangiography, we would screen out those 50 per cent of patients whose common bile ducts are free of stones and, therefore, spare them unnecessary common bile duct explorations. This claim is well illustrated in the literature [3-51. (Table II.) Patients with positive criteria for probable common bile duct stones usually comprise 25 per cent of patients with gallbladder disease. It is in this group of patients that a preexploratory operative cholangiography should be performed. Unfortunately, the advocates of operative cholangiography have gone too far by claiming that operative cholangiograms should be a routine procedure in all cholecystectomies. A poll taken by Jolly et al [6] among the members of the Ohio Chapter of American College of Surgeons revealed that only 18 per cent of the surgeons use operative cholangiograms routinely (in 90 per cent or more of the cases). Those who advocate the routine use of this procedure usually refer to the rate of unexpected stones which they have found in common bile ducts with the help of operative cholangiograms-which otherwise would have been missed. In the present series, in 95 patients who were negative for common bile duct stones with the usual criteria, operative cholangiography failed to reveal any unexpected common bile duct stone (0 per cent).
Volume134,November1977
TABLE II
Wayne et al [7], Nienhuis [8], and Kakos et al [9] all reported a rate of approximately 4 per cent unexpected common bile duct stone findings. Yet these authors failed to include abnormal liver function tests as criteria for expectancy of common duct stones. Jolly et al [6] report 24 cases of unexpected common bile duct stone findings in 380 patients who were otherwise negative by the criteria (6.3 per cent). But later in their report, they revealed that 19 of those 24 patients had small stones in their gallbladders. Needless to say, the presence of common bile duct stones in these 19 patients should not have been so unexpected. Therefore, their true rate of unexpected stone findings should be five out of 380 patients and thus, much lower than the rate reported. It is surprising that Saltzstein, Evani, and Mann [5] and Wiethoff and Clover [IO] report a rate of approximately 1.6 per cent unexpected stone findings, yet despite such a low rate, both groups advocate the routine use of operative cholangiograms. Schulenburg [II] in 908 cholangiograms reported only 1.2 per cent unexpected common bile duct stone findings. I believe the rate of unexpected common bile duct stone findings would be near 1 per cent (in the present series, 0 per cent) if the abnormal liver function tests are added to the usual criteria and if the criteria are strictly adhered to. Considering that 50 per cent of all common bile duct explorations are unnecessary, as previously mentioned, as well as the 1 per cent probability of unexpected stone findings, one could draw the following conclusions: (1) Whenever surgeons, based on positive criteria for expectancy of common bile duct stones, think that a common bile duct may contain stone, they are wrong in-50 per cent of the cases. It is in this group that preexploratory operative cholangiography could have its best effect, by helping to eliminate those unnecessary explorations. (2) However, whenever surgeons, based on the absence of the positive criteria, think that a common bile duct does not contain any stone, they are correct in 99 per cent of the cases. Advocates claim routine operative cholangiography could improve this 99 per
567
Seif
cent accuracy to 100 per cent. On the contrary, employing an operative cholangiogram routinely does not improve our 99 per cent rate of accuracy; rather, it decreases it because of the occurrence of falsepositive reports by routine operative cholangiography which are as high as 22 per cent [6], 11 per cent [4], and 6 per cent in the present series. These figures of false-positive reports indicate the frequency in which common bile ducts would be opened fruitlessly, thereby defeating our main purpose, which is to save common bile ducts from unnecessary exploration. Even if’one could ignore these false-positive reports, one could not justify the cost of routine operative cholangiograms in order to detect 1 per cent unexpected common bile duct stones. The cost for a cholangiogram in our community is approximately $180 per procedure: $50 for the surgeon; $50 for the radiologist; and $80 for operating room and anesthesia time (if the time spent is 15 minutes). Although surgeons usually tend to underestimate this time, still Wayne et al [7] report 15 minutes, Jolly et al [6] 19 minutes, and Thurston [4] 23 minutes for performance of operative cholangiograms. Approximately 600,000 cholecystectomies are performed in the United States every year. The total cost of routine operative cholangiograms may be more than $100 million a year. All that expense for 1 per cent unexpected common bile duct stone findings! Is it worth it? I realize the difficulty of estimating this cost, since it varies from community to community and from state to state. One also appreciates the cost of probable future reoperations for those 1 per cent missed common bile duct stones. However, we should also consider the additional cost of unnecessary common bile duct explorations due to false-positive operative cholangiograms. Even if we could disregard the intangible cost of occasional complications of this procedure, and the occasional maleffects of the 15 minute additional anesthesia time on some critically
566
ill patients, the financial considerations not justify the routine use of operative grams.
would still cholangio-
Summary
If abnormal liver function tests are added to the classic criteria for expectancy of common bile duct stone, the rate of unexpected common bile duct stone findings should be 1 per cent or less. This low rate does not justify the cost of routine operative cholangiography. However, a preexploratory operative cholangiogram should be performed prior to common bile duct exploration in order to avoid negative, and therefore unnecessary, common bile duct explorations.
References 1. Glenn F: Retained calculi within the biliary ductal sySt8R-bAnn Surg 179: 529, 1974. 2. Arnold DJ: 28,621 cholecystectomies in Ohio. Am J Surg 119: 714,197o. 3. Letton AH, Wilson JP: Routine cholangiography during biliary tract operations: technic and utility in 200 consecutive cases. Ann Surg 163: 937, 1966. 4. Thurston DG: Nonroutine operatfve cholanglography. Arch Swg 108: 512, 1974. 5. Saltzstein EC, Evani SV, Mann RW: Routine operative cholangiography. Arch Surg 107: 289, 1973. 6. Jolly PC, Baker JW, Schmidt HM, Walker JH. Holm JC: Operative cholangiography: a case for its routine use. Ann Surg 168: 551.1966. 7. Wayne R. Cegileski M, Bleicher J, Saporta J: Operative cholangiography in uncomplicated blllary tract sugery. Am J Sug 131: 324, 1976. 8. Nienhuis LI: Routine operative cholangiography: an evalutatlon. Ann Surg 154: 192, 1961. 9. Kakos GS, Tompkins RK, Turnipseed W, Zollinger RM: Operative cholangiogaphy during routfne cholecystectomy. A&I surg 104: 484, 1972. 10. Wiethoff CA, Clover JL: Operative cholangiography in a rural surgical practice. Arch Surg 109: 254, 1974. 11. Schulenburg CAR: Operative cholangiography: 100 cases. Surgery 65: 723, 1969.
The American Journal of Sur#ery