The elective evaluation of patients with suspected choledocholithiasis undergoing laparoscopic cholecystectomy

TECHNOLOGICAL REVIEW The elective evaluation of patients with suspected choledocholithiasis undergoing laparoscopic cholecystectomy Frances Tse, MD, Jeffrey S. Barkun, MD, CM, MSc (clinical epidemiology), Alan N. Barkun, MD, CM, MSc (clinical epidemiology) Montreal, Canada

Common bile duct (CBD) stones occur in 10% to 15% of patients with symptomatic gallstones undergoing cholecystectomy.1-3 In general, CBD stones should be removed, because they may be associated with severe complications, such as pancreatitis and cholangitis.4 There are many possible management approaches, depending on the preferred diagnostic and therapeutic modality: ERCP, intra-operative cholangiogram (IOC), EUS, MRCP, intra-operative US (IOUS), intravenous cholangiography (IVC), and helical CT cholangiography (hCTC). Controversy persists because of the variety of approaches, the difficulty of comparing all strategies in all-encompassing prospective trials, the regional variation in expertise and availability of technologies. The purpose of this article is to review competing technologies and approaches for diagnosing CBD stones with regard to diagnostic performance characteristics, technical success, safety, and costeffectiveness. Patients with symptomatic cholelithiasis in whom choledocholithiasis is suspected before cholecystectomy, based on clinical or laboratory clues, are the primary focus of this review. The specific management of patients with cholangitis, gallstone pancreatitis, and bile duct stones after cholecystectomy will not be addressed. An algorithm for the management of suspected CBD stones is put forward based on evidence and the quality thereof. Future areas for investigation of the different diagnostic modalities for the detection of CBD stones are proposed. Current affiliations: Divisions of Gastroenterology and General Surgery, Montreal General Hospital and Royal Victoria Hospital Sites, McGill University Health Centre, Montreal, Quebec. Reprint requests: Dr. Alan N. Barkun, Division of Gastroenterology, Montreal General Hospital Site, McGill University Health Centre, 1650 Cedar Ave., Rm. D7.148, Montreal, Quebec, Canada, H3G 1A4. Copyright Ó 2004 by the American Society for Gastrointestinal Endoscopy 0016-5107/$30.00 PII: S0016-5107(04)01457-9 VOLUME 60, NO. 3, 2004

REVIEW METHODOLOGY A systematic search was performed for relevant articles published in the English language by using MEDLINE, PubMed, and the Cochrane Controlled Trials Register from 1966 to December 2003. The search strategy included the key terms: choledocholithiasis, cholecystectomy, cholangiography, endoscopic, intravenous, laparoscopic, intra-operative, ultrasonography, magnetic resonance imaging, computed tomography, surgery, complications, decision support techniques, costs and cost analysis, costbenefit analysis, sensitivity and specificity, comparative study, and prospective studies. Information was collected on study design, prevalence of CBD stones, type of imaging modalities used for diagnosis and/or management of CBD stones, technical success, diagnostic performance characteristics, side effects, and costs. Sensitivity, specificity, and positive predictive value (PPV) and negative predictive value (NPV) were abstracted. The grading of recommendations in this manuscript is based on the grading put forth by Ball et al. (http:// www.cebm.net/levels_of_evidence.asp). In this grading system, the level of recommendation is supported by evidence that is based on: 1a, a systematic review of available RCTs; 1b, an individual RCT; 2a, a systematic review of available cohort studies; 2b, an individual cohort study; 2c, outcomes research or ecological studies; 3a, a systematic review of available case-control studies; 3b, an individual casecontrol study; 4, case-series; 5, expert opinion.5,6 CURRENT TECHNOLOGY ERCP ERCP traditionally has been considered the standard of reference for the diagnosis of CBD stones. Frey et al.7 noted that ERCP had a sensitivity of 90%, a specificity of 98%, and an accuracy of 96% in the evaluation of CBD stones when IOC was used as the reference. ERCP is successful in clearing CBD stones in 85% to 90% of cases when standard procedures, such as endoscopic sphincterotomy (ES) and balloon or basket stone extraction, are used.8-13 For those patients who fail standard techniques, mechanical lithotripsy will increase the success rate to more than 90%.14-15 A major benefit of ERCP in the evaluation of CBD stones is that ERCP provides a means of diagnosis and therapeutic intervention in the same setting. However, large prospective case series have found overall complication rates of 5% to 10% and mortality rates of 0.02% to 0.5% after diagnostic and therapeutic ERCP.16-19 The most common complication is acute pancreatitis, occurring in 5% of cases, GASTROINTESTINAL ENDOSCOPY

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Laparoscopic cholecystectomy: elective evaluation of suspected choledocholithiasis

Table 1. Prospective studies of IOC with n > 50 that provided data on the success rates, sensitivity, and specificity of IOC during laparoscopic cholecystectomy in the diagnosis of CBD stones Investigator Greig et al.105 Ohtani et al.31 Rothlin et al.25 Machi et al.28 Barteau et al.24 Tranter et al.104 Flowers et al.32 Stiegmann et al.106 Siperstein et al.33 Thompson et al.27 Birth et al.35 Catheline et al.26 Weighted averages*

Study type Prospective, Prospective, Prospective, Prospective, Prospective, Prospective, Prospective, Prospective, Prospective, Prospective, Prospective, Prospective,

non-random non-random non-random non-random non-random non-random non-random non-random non-random non-random non-random non-random

N

Success (%)

Sensitivity (%)

Specificity (%)

54 65 100 100 125 135 165 209 300 360 518 600

89% 83% 100% 92% 100% 90% 91% 93% 94% 98% 92% 83% 91%: 95% CI[90, 92]

83% 80% 75% 88% 93% 86% 100% 59% 96% 95% 100% 78% 87%: 95% CI[86, 88]

95% 97% 99% 98% 96% 99% 98% 100% 100% 100% 98% 97% 98%: 95% CI[97, 99]

PPV (%)

NPV (%)

71% 98% 100% 78% 76% 100% 98% 100% 100% 100% 82% 79% 89%: 95% CI[88, 90]

98% 95% 95% 98% 99% 98% 100% 95% 99% 99% 100% 98% 98%: 95% CI[97, 99]

IOC, Intra-operative cholangiogram; CBD, common bile duct; PPV, positive predictive value; NPV, negative predictive value; CI, confidence interval. *Weighted averages were based on the total number of patients (n = 2731); 95% CI were calculated by using the normal approximation of the binomial distribution.

and being moderate to severe in about 1%16-20 Because of its attendant risks and the availability of safer noninvasive cholangiographic methods with comparable diagnostic abilities, the sole use of diagnostic ERCP should, and likely will in most instances, become extinct.4 Certainly, the routine use of pre-operative ERCP, with a substantial rate of negative examinations and the risk of complications, is unacceptable.17-23 IOC Intra-operative cholangiography is considered, along with ERCP, to be the reference standard against which all other imaging modalities of the biliary tree are evaluated. Intra-operative cholangiography is performed during cholecystectomy by contrast injection through a catheter introduced into the cystic duct, with successful cannulation rates of greater than 90%.11,12,24-35 Overall, IOC has a sensitivity of 87%: 95% CI[86, 88] and a specificity of 98%: 95% CI[97, 99] in the detection of CBD stones (Table 1).24-35 The complication rate related to IOC is less than 0.1%.32,36 There exists a long-standing debate between the use of routine and selective IOC. Supporters of routine IOC claim this practice ensures fewer retained stones, fewer postoperative ERCPs, and a reduction in the number of CBD injuries.37-41 The main disadvantages of routine IOC are an increase in operating time and false-positive findings (2%).36,42,43 Arguably, the most convincing data in the open cholecystectomy (OC) or laparoscopic cholecystectomy (LC) era alike would favor the selective use of IOC (level 1A).36,44,45 With respect to the prevention 438

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of bile duct injuries, the routine use of IOC remains controversial.37,46,47 Percutaneous transhepatic cholangiography In the last decade, percutaneous transhepatic cholangiography has been primarily used as an alternative to surgery in patients with failed ERCP who require biliary drainage.22,48-51 This imaging modality will not be reviewed here, because it is not considered to be a routine initial diagnostic or therapeutic approach in patients with CBD stones. MRCP MRCP is performed with high-resolution breathhold T2-weighed sequences that depict the biliary tract as a bright structure without the use of contrast material or ionizing radiation.52-55 The high-signal intensity of the biliary tract makes it well suited for the detection of CBD stones. Current techniques permit imaging of the entire biliary tract in a single breathhold of 20 seconds or less and provide high spatial resolution so that structures such as 4th-order intrahepatic bile ducts and small stones are readily detected in many cases.56-58 A recent authoritative meta-analysis59 of 67 published controlled trials shows that MRCP has excellent overall sensitivity (95%: 95% CI[75, 99]) and specificity (97%: 95% CI [86, 99]) for demonstrating the level and the presence of biliary obstruction. However, MRCP is less sensitive for detecting stones (91%: 95% CI[73, 97]) or differentiating malignant from benign obstruction (88%: 95% CI[70, 96]). Moreover, the sensitivity for detecting stones seems to decrease according to stone size: 67% to 100% for VOLUME 60, NO. 3, 2004

Laparoscopic cholecystectomy: elective evaluation of suspected choledocholithiasis

F Tse, J Barkun, A Barkun

Table 2. Studies of EUS with n > 50 that provided data on the sensitivity, specificity, and accuracy of EUS in the diagnosis of CBD stones* Investigator Buscarini et al.74 Palazzo et al.75 Sugiyama et al.76 Kohut et al.77 Shim et al.78 Prat et al.79 Canto et al.80 Amouyal et al.72 Norton et al.81 Weighted averagesy

Study type

N

Prevalence (%)

Prospective, non-random Retrospective, non-random Prospective, non-random Prospective, non-random Prospective, non-random Prospective, non-random Prospective, non-random Prospective, non-random Prospective, non-random

485 422 142 134 132 119 64 62 50

59% 36% 36% 68% 21% 66% 30% 52% 48%

Sensitivity (%)

Specificity (%)

Accuracy (%)

98% 95% 96% 93% 89% 93% 84% 97% 88% 95%: 95% CI[94, 96]

99% 98% 100% 93% 100% 97% 95% 100% 96% 98%: 95% CI[97, 99]

97% 96% 99% 94% 97% 95% 94% 98% 92% 96%: 95% CI[95, 97]

CBD, Common bile duct; CI, confidence interval. *ERCP, percutaneous transhepatic cholangiography, laparoscopic CBD exploration, or open CBD exploration used as reference standards. yWeighted averages were based on the total number of patients (n = 1610); 95% CI were calculated by using the normal approximation of the binomial distribution.

stones greater than 10 mm in size, 89% to 94% for stones measuring 6 to 10 mm, and 33% to 71% for bile duct stones less than 6 mm in size.60-63 Overall, there is level 2A evidence that MRCP is accurate for the detection of CBD stones; however, its ability to diagnose small stones in non-dilated ducts may be limited. The major advantage of MRCP is the noninvasive nature of the procedure. It does not require exposure to radiation or to contrast agents. Diagnostic images can be obtained in the vast majority of patients, including those who have complex bilio-enteric anastomoses.64 As well, MRCP can demonstrate the biliary tree above and below a complete obstruction.53 The major disadvantages of MRCP compared with ERCP are lower spatial resolution,65 unit availability, lack of an immediate therapy that can be provided for duct obstruction, claustrophobia, and the inability to evaluate patients with pacemakers or ferromagnetic implants. Causes of possible artifact include pneumobilia, normal vessels, flow artifacts, and duodenal diverticulum.66-68 A stone impacted at the ampulla may be missed.69 As well, a low insertion of the cystic duct may be mistaken for a dilated CBD,70 and clips in the abdomen from previous surgery may distort images.71 EUS EUS involves the endoscopic insertion of an US probe into the stomach and the second stage of the duodenum, allowing for sonographic images of the CBD to be obtained without the interference of subcutaneous fat and bowel gas.72,73 By using high frequencies (7, 5, and 12 MHz), the resolution of EUS is less than 1 mm. A stone in the CBD appears as a hyperechoic focus with associated acoustic shadowing. EUS is extremely accurate in diagnosing VOLUME 60, NO. 3, 2004

CBD stones, with a sensitivity of 95%: 95% CI[94, 96]), specificity of 98%: 95% CI[97, 99], and an accuracy of 96%: 95% CI[95, 97].72-81 Table 2 summarizes the major studies that provided data on the sensitivity, the specificity, and the accuracy of EUS in the diagnosis of CBD stones. These results are far superior to US (sensitivity 63%) and CT (sensitivity 71%)76 and were approximately equivalent to that of ERCP. EUS is especially more sensitive than US or CT in detecting small stones and those stones that are situated within a small caliber CBD.76 Napoleon et al.82 followed, for at least 1 year, 328 patients undergoing EUS for suspicion of CBD stones; 230 had normal EUS findings, and the negative predictive value of EUS for the diagnosis of CBD stones was 95%. A recent prospective, controlled study suggested that EUS may be more accurate than MRCP for detecting CBD stones.83 EUS and MRCP were performed in 43 patients suspected of having CBD stones. The sensitivity of EUS was 100%, the specificity was 95%, the PPV was 91%, the NPV was 100%, and the overall accuracy was 97%. The corresponding values for MRCP were 100%, 73%, 63%, 100%, and 82%, respectively. Further studies are needed to evaluate the diagnostic performance and, even more so, the clinical impact of EUS in comparison to MRCP. Nevertheless, EUS may be more accurate in certain situations, because it does not seem to be as dependent on stone size.76 On the basis of the discussed data, there is level 2A evidence supporting EUS as an accurate and a safe method for the detection of CBD stones. EUS is less invasive than ERCP84 and is able to detect small stones in non-dilated ducts.76,85 This technology does not expose the patient to radiation or GASTROINTESTINAL ENDOSCOPY

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Laparoscopic cholecystectomy: elective evaluation of suspected choledocholithiasis

Table 3. Studies of hCTC with n > 10 that provided data on the sensitivity, specificity, and accuracy of hCTC in the diagnosis of CBD stones* Investigator Kwon et al.95 Cabada et al.101 Soto et al.100 Van Beers et al.98 Stockberger et al.102 Maniatis et al.103 Weighted averagesy

Study type Prospective, Prospective, Prospective, Prospective, Prospective, Prospective,

non-random non-random non-random non-random non-random non-random

N

Prevalence (%)

440 101 51 19 18 33

11% 22% 51% 16% 39% 30%

Sensitivity (%)

Specificity (%)

Accuracy (%)

85% 96% 92% 66% 86% 90% 87%: 95% CI[84, 90]

97% 97% 92% 100% 100% 100% 97%: 95% CI[95, 98]

96% 97% 92% 96% 94% 97% 96%: 95% CI[94, 97]

hCTC, Helical CT cholangiography; CBD, common bile duct; CI, confidence interval. *ERCP, percutaneous transhepatic cholangiography, laparoscopic CBD exploration, or open CBD exploration used as reference standards. yWeighted averages were based on the total number of patients (n = 662); 95% CI were calculated by using the normal approximation of the binomial distribution.

to contrast material. Tissue sampling in the form of either biopsy specimens or biliary cytology also is possible. The drawbacks to EUS include the high operator dependency with a steep learning curve, equipment cost, unit availability, the inability to provide an immediate therapeutic solution to CBD stones when present, the need for conscious sedation, and a 2% failure rate.75 Visualization is limited to the nearest 8 to 10 cm depth from the probe, and imaging can be obscured by pneumobilia, surgical clips, calcifying pancreatitis, or a duodenal diverticulum.86 IVC Intravenous cholangiography uses contrast material injected into the blood stream that then is rapidly taken up by the liver and subsequently excreted into the biliary tree, providing a cholangiogram. Reported performance characteristics are highly variable, possibly because of differences in patient populations studied and/or to inconsistent reference standards. Published studies pertaining to IVC in patients undergoing LC reports sensitivities ranging from 68% to 100% and specificities of 66% to 99% for identifying CBD stones, when it is compared with ERCP, IOC, MRCP, and/or clinical follow-up (level 2A).87-91 Intravenous cholangiography is contraindicated in any patient with a known allergy to iodine or with renal impairment. Major reactions to the contrast material include hepatorenal toxicity, cardiopulmonary symptoms, hypotension, severe skin reactions, and anaphylaxis.92,93 The overall mortality rate is 1 in 3000 to 5000 examinations. Because of its potential risks and limited test characteristics, IVC cannot be widely recommended in the routine workup of CBD stones. hCTC Helical CT cholangiography involves the use of slip ring technology and the injection of intravenous 440

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contrast to acquire volumetric data for high-quality three-dimensional reconstructions of the biliary tree.53,94-97 It has the ability to opacify up to thirdorder intrahepatic ducts.98,99 Compared with direct imaging such as ERCP or IOC, hCTC achieved a sensitivity of 87%: 95% CI[84, 90], a specificity of 97%: 95% CI[95, 98], and an overall accuracy of 95%: 95% CI[94, 97] for the diagnosis of CBD stones.94-103 Table 3 summarizes the major studies that provided data on the sensitivity, the specificity, and the accuracy of hCTC in the diagnosis of CBD stones. Despite the relatively small number of patients in these series (n = 629), there is level 2A evidence to suggest that hCTC is more accurate than US and conventional CT in the diagnosis of CBD stones. However, hCTC may not be as good as direct methods imaging, such as ERCP or IOC, for CBD stones and has not been compared with EUS or MRCP, both of which do not expose the patient to ionizing radiation or contrast agents. The major advantages of hCTC over ERCP are its low level of invasiveness, operator independence, and low technical failure rate (1%), as well as provision of a three-dimensional understanding of the biliary tree. The major drawback of hCTC is a risk of adverse reaction to the iodinated contrast agents (1%), while its main limitation is in highgrade obstruction, because contrast is not eliminated well into the biliary tree.94,95 The artifacts produced by a patient’s movement or intolerance to apnea might also limit the diagnostic value of this test. IOUS Intra-operative US involves the use of linear-array transducers with frequencies of 7.5 to 10 MHz to image the ductal system. B-mode scanning and color Doppler capability are used to distinguish the bile ducts from vascular structures. Scanning is performed while the transducer is moved along the cystic VOLUME 60, NO. 3, 2004

Laparoscopic cholecystectomy: elective evaluation of suspected choledocholithiasis

F Tse, J Barkun, A Barkun

Table 4. Studies of IOUS during laparoscopic cholecystectomy with n > 50 that provided data on the sensitivity, specificity, PPV, and NPV of IOUS in the diagnosis of CBD stones Investigator Ohtani et al.31 Greig et al.105 Machi et al.28 Rothlin et al.25 Barteau et al.24 Tranter et al.104 Stiegmann et al.106 Siperstein et al.33 Thompson et al.27 Birth et al.35 Catheline et al.26 Weighted averages*

Study type Prospective, Prospective, Prospective, Prospective, Prospective, Prospective, Prospective, Prospective, Prospective, Prospective, Prospective,

non-random non-random non-random non-random non-random non-random non-random non-random non-random non-random non-random

N

Prevalence (%)

65 54 100 100 125 135 209 300 360 518 600

83% 13% 9% 4% 11% 36% 9% 9% 14% 5% 9%

Sensitivity (%)

Specificity (%)

80% 71% 89% 100% 71% 96% 90% 96% 90% 83% 80% 86%: 95% CI[85, 87]

98% 96% 100% 98% 100% 100% 100% 100% 100% 100% 99% 99%: 95% CI[98, 99]

PPV (%)

NPV (%)

80% 71% 100% 67% 100% 100% 100% 100% 100% 100% 89% 95%: 95% CI[94, 96]

98% 96% 99% 100% 96% 98% 99% 99% 98% 99% 99% 99%: 95% CI[98, 99]

IOUS, Intra-operative US; PPV, positive predictive value; NPV, negative predictive value; CI, confidence interval. *Weighted averages were based on the total number of patients (n = 2566); 95% CI were calculated by using the normal approximation of the binomial distribution.

duct and the hepatoduodenal ligament to the terminal end of the CBD. The intrahepatic ducts also can be visualized by placing the probe on the liver surface. Prospective controlled trials24-28,31-35,104-109 have shown IOUS to be equivalent to IOC in its ability to diagnose CBD stones accurately, with a sensitivity of 86%: 95% CI[85, 87] and a specificity of 99%: 95% CI[98, 99] (level 2A). The operating time also is shorter with IOUS (4.5-10.2 min) than with IOC (10.9-17.9 min).24-28,31,34,35,106,107,109 Table 4 summarizes the major studies of IOUS that have provided data on the sensitivity, the specificity, PPV, and NPV of IOUS in the diagnosis of CBD stones. The advantages of IOUS over IOC are a lack of adverse effects, unlimited repetition, lower costs, shorter examination times, and detection of coexisting intra-abdominal pathology. The disadvantages are technical difficulty, equipment availability, suboptimal visualization of the distal CBD, and operator dependency. Also, IOUS may be overly sensitive in detecting small stones and sludge, which are of questionable clinical significance.106,110,111 CONSIDERATIONS IN DETERMINING AN OPTIMAL APPROACH TO PATIENTS WITH SUSPECTED CBD STONES WHO ARE UNDERGOING LC Endoscopic vs. laparoscopic approach In the era of OC, IOC, followed, if needed, by open CBD exploration (OCBDE), was the strategy of choice for the management of CBD stones. Randomized trials failed to demonstrate a role for preoperative endoscopic management of patients with CBD stones who were scheduled for OC (level 1A).8-10 This was mainly because the morbidities of ERCP VOLUME 60, NO. 3, 2004

and OC were found to be cumulative. However, the recent widespread use of LC has prompted a reevaluation of the role of peri-operative ERCP. With the evolution of laparoscopic CBD exploration (LCBDE), successful clearance of the CBD can be achieved in 77% to 100% of cases by using LCBDE, with a complication rate of 12% and a mortality rate of 0% to 2%.11-13 Randomized controlled trials of LCBDE vs. pre-operative11,13 or post-operative ERCP12 have shown similar rates of duct clearance (75%-85%), with an advantage in duration of hospital stay for the LCBDE group (level 1A). However, the disparity in expertise and the highly variable availability of LCBDE remain a significant consideration, especially in light of comparable efficacy data from competent endoscopic management that is much more readily available. Predictors of CBD stones Although many of the indirect imaging tests discussed above (MRCP, EUS, and hCTC) appear promising, they are not always easily accessible, and there are few published studies with respect to their cost-effectiveness. The safest and least invasive initial biliary imaging test thus remains the transabdominal US, which is readily available.112 However, US exhibits only modest test performance at detecting CBD stones, with sensitivities in the range of 25% to 58% and specificities of 68% to 91% (level 2A).113-118 Proper selection of patients for further biliary imaging to exclude CBD stones is crucial to minimize patient morbidity and institutional cost. Clinical correlation with liver enzymes, as well as US findings, helps in establishing the pretest probability of CBD stones. A number of clinical algorithms80,119-130 have been proposed for risk GASTROINTESTINAL ENDOSCOPY

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Laparoscopic cholecystectomy: elective evaluation of suspected choledocholithiasis

stratification in patients with suspected CBD stones. Barkun et al.119 made use of patient age (>55), total bilirubin (>30 lmoles/L, or approximately 1.8 mg/ dL), and US findings (a dilated CBD, a CBD stone) to predict the probability of CBD stones in patients referred for ERCP. Depending on the presence or the absence of these parameters, the algorithm predicted probabilities of finding a bile duct stone at ERCP range from 18% (no predictor present, amidst a patient population that only included patients with some liver or pancreatic test abnormality), to 94% (all four predictors present).119 In the metaanalysis published by Abboud et al.,125 indicators with positive likelihood ratios of 10 or above were cholangitis, pre-operative jaundice, and US evidence of CBD stones. Positive likelihood ratios for dilated CBD on US, hyperbilirubinemia, and jaundice ranged from 4 to 7.125 Elevated levels of serum alkaline phosphatase, pancreatitis, cholecystitis, and hyperamylasemia exhibited positive likelihood ratios of less than 3.125 In a prospective study by Liu et al.,122 variables, including clinical evaluation (cholecystitis or pancreatitis), blood chemistries (alanine aminotransferase, aspartate aminotransferase, alkaline phosphatase, total bilirubin), and US findings (cholelithiasis, CBD size) were used to risk stratify patients undergoing LC into one of 4 groups (Group 1, extremely high; Group 2, high; Group 3, moderate; Group 4, low). Patients with cholelithiasis, a CBD of 5 mm or more, and liver enzyme elevation without clinical evidence of cholecystitis or biliary pancreatitis were assigned to Group 1 and underwent pre-operative ERCP. Patients with cholelithiasis, CBD diameter of 5 mm or more, and liver enzyme abnormalities in a context of clinical resolution, the presence of cholecystitis, or biliary pancreatitis were assigned to Group 2 and underwent MRCP. Patients with cholelithiasis, liver enzyme elevation, and a CBD less than 5 mm were assigned to Group 3 and underwent LC with IOC. Patients with cholelithiasis, a CBD less than 5 mm, and normal liver enzymes were assigned to Group 4 and underwent LC without IOC. This strategy resulted in the identification of CBD stones during pre-operative ERCP in 92.3% of the patients, and unsuspected CBD stones occurred in only 1.4% of patients. The ability of such algorithms80,119-124 to correctly classify patients into low likelihood (#10% probability), moderate likelihood (11%-55% probability), and high likelihood (>55% probability) of harboring CBDS were prospectively evaluated in a cohort of patients with suspected CBD stones.131 In this study, the algorithm devised by Barkun et al.119 was found to be the simplest, most inclusive, and accurate algorithm published to date in determining the likelihood of 442

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CBDS. On the basis of the mentioned data, there is level 1B evidence for the use of these clinical algorithms in stratifying patients with symptomatic cholelithiasis who would most likely benefit from further investigation to exclude CBD stones. Decision models, including cost-effectiveness studies Controversies surrounding the management of CBD stones in the LC era include the role of IOC,132 the need for and timing of ERCP,133-135 the role of newer biliary imaging technologies, and the optimal use of LCBDE.11-13,136 Given the large number of possible management strategies for patients with suspected CBD stones undergoing LC, it is extremely difficult to determine the optimal strategy with a single headto-head prospective trial.8,9,11-13,106 Many investigators have thus turned to decision modeling.29,137,138 Barkun et al.137 examined 5 clinical strategies in their decision analysis. The first 3 strategies used diagnostic IOC in patients at medium and high risk of having CBD stones and therapeutic modalities of OCBDE (Strategy A), LCBDE (Strategy B), or postoperative ERCP (Strategy C) if a stone was found. In the final two strategies (Strategies D and E), patients at high risk for CBD stones first underwent pre-operative ERCP, whereas patients at medium risk went to pre-operative ERCP (Strategy D) or to IOC (Strategy E). Patients at low risk for CBD stones proceeded directly to LC in all strategies. The global duration of hospital stay for 100 patients was used as the measure of effectiveness of each approach. Results were as follows: 650 days for IOC + OCBDE (Strategy A), 411 days for IOC + LCBDE (Strategy B), 397 days for ERCP in high- and medium-risk patients (Strategy D), 374 days for IOC + postoperative ERCP (Strategy C), and 355 days for ERCP in high and IOC in medium risk patients (Strategy E). When examining the performance of the strategies developed, two key clinical variables emerged that drive the conclusions of the model: (1) the pretest probability (i.e., population prevalence) of CBD stones, and (2) the level of expertise of the operator (endoscopist and/or laparoscopist). As the proportion of patients suspected of CBD stones increased, there was a predictable increase in total hospitalization in all strategies with no change in rank order. As the relative efficacy of laparoscopic or endoscopic stone removal increased, there was a predictable decrease in the global duration of hospital stay. Therefore, in this analysis, the strategy with the lowest global duration of hospital stay was one that used pre-operative ERCP in high-risk patients, IOC in intermediaterisk patients, and expectant management in lowVOLUME 60, NO. 3, 2004

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Figure 1. Results of a decision model: sensitivity analysis expressed as a function of hospital stay and stone clearance for endoscopic or laparoscopic approach to CBD stone.137 The point of intersection between a laparoscopic and an endoscopic approach to CBD stone suggests that endoscopic stone removal is favored if equal expertise is available with a stone clearance rate of 52% or greater.137

risk patients. The sensitivity analysis showed, given an equal stone clearance rate for endoscopic and laparoscopic approaches, that the endoscopic approach was favored when a clearance rate of 52% or greater could be achieved (Fig. 1). Published studies with respect to cost-effectiveness of the new biliary imaging modalities are limited. Sahai et al.29 evaluated 4 peri-LC strategies: ERCP, IOC, EUS, and expectant management in patients with suspected CBD stones in a decision analysis. Their results revealed that IOC, and the selective use of EUS was the least costly method, unless the pretest probability of CBD stones was less than 11%, in which case expectant management was favored, or greater than 55%, in which case, ERCP was favored. Neither IOC nor EUS appear likely to reduce overall costs unless their accuracy and success rates are greater than 90% and their procedural cost is less than 60% to 70% that of ERCP. If neither is available, ERCP is preferred when the risk of stones is greater than 22%. Urbach et al.30 evaluated 4 strategies for managing CBD stones around the time of LC: (1) routine pre-operative ERCP, (2) LC with IOC, followed by LCBDE, (3) LC with IOC, followed by postoperative ERCP, (4) LC without cholangiography. Laparoscopic CBD exploration was found to be the most cost-effective method. If expertise in LCBDE was unavailable, selective postoperative ERCP was preferred over routine pre-operative ERCP, unless the probability of CBD stones was extremely high (>80%).30 In summary, the most cost-effective approach to CBD stones must take into account the pretest probability of stones, as well as local availability and expertise (level 2B).139 Patients with the lowest VOLUME 60, NO. 3, 2004

Figure 2. A proposed algorithm for the management of patients with suspected choledocholithiasis before laparoscopic cholecystectomy.

risk of having CBD stones should proceed directly to LC with no cholangiography (level 2B). Pre-operative ERCP should be reserved for patients who are at high risk of having CBD stones (level 2B).4 For patients at intermediate risk of having CBD stones, the optimal approach seems to be IOC followed, if positive, by LCBDE or postoperative ERCP, depending on local expertise (level 2B). Alternatively, a strategy that involves pre-operative ERCP, EUS, or MRCP instead of IOC may be considered for patients at intermediate risk, depending on local availability, expertise, and cost issues (level 2B). A proposed algorithm for the management of patients with suspected CBD stones undergoing LC is shown in Figure 2 and presents many similarities to that recently proposed by the American Society for Gastrointestinal Endoscopy.139 The supporting evidence for all final recommendations is graded in Table 5. CONCLUSIONS AND FUTURE DIRECTIONS There has been a marked increase in the choice and the use of biliary imaging modalities in recent years. Yet, their respective roles are still somewhat unclear, as are their impacts on health economics. Real-life results may be different than what could be anticipated, based on test performance GASTROINTESTINAL ENDOSCOPY

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Table 5. Optimizing the approach to patients with suspected CBD stones undergoing laparoscopic cholecystectomy5,6 Clinical situation Routine use of IOC in patients undergoing OC or LC is not recommended Pre-operative ERCP is not recommended in the management of patients with known CBD stones before OC MRCP is accurate and safe in the detection of CBD stones EUS is accurate and safe in the detection of CBD stones IVC cannot be widely recommended in the routine work-up of patients with suspected CBD stones because of its potential risk and limited test characteristics hCTC cannot be widely recommended in the routine work-up of patients with suspected CBD stones because of its potential risk and limited test characteristics IOUS is accurate and safe in the detection of CBD stones Abdominal US is the most cost-effective initial imaging test in the work-up of patients with suspected CBD stones Predictive models are useful in stratifying the risk of patients bearing CBD stones Pre-operative ERCP should be reserved for patients undergoing LC with high risk of having CBD stones Patients with low probability of CBD stones should proceed to LC with no cholangiography The choice of IOC vs. pre-operative ERCP for patients with intermediate probability of CBD stones should be dictated by the availability of local expertise and cost EUS and MRCP may be used to evaluate patients with intermediate probability of CBD stones The choice of LCBDE vs. peri-operative ERCP for patients with CBD stones detected at the time of IOC should be dictated by the availability of local expertise and cost

Level of evidence

Grades of recommendation

1A 1A

A A

2A 2A 2A

B B B

2A

B

2A 2A

B B

1B 2B 2B 2B

A B B B

2B 1A

B A

CBD, Common bile duct; IOC, intra-operative cholangiogram; OC, open cholecystectomy; LC, laparoscopic cholecystectomy; IVC, intravenous cholangiography; hCTC, helical CT cholangiography; IOUS, intra-operative US; LCBDE, laparoscopic CBD exploration.

characteristics or decision modeling. Clinicians may be reluctant to direct clinical actions based solely on noninvasive biliary images, consequently ERCP often will be requested to confirm the findings, thereby adding to clinical costs and patient inconvenience. For example, coincident with the marked increase in the number of MRCPs performed for biliary obstruction at the Hopital Erasme in Brussels from 1995 to 1997, there was only a minor reduction in the total number of ERCPs (about 1 diagnostic or therapeutic ERCP less for every 4 additional MRCPs).140 Preliminary data from a prospective randomized trial141 from our group, comparing ERCP with MRCP, whose study population was, in the majority, composed of patients with suspected choledocholithiasis, suggested a high rate of subsequent ERCPs in the MRCP arm (51%), with no differences between the groups in terms of rate of subsequent complications or overall duration of hospital stay. In a recent prospective cohort study142 comparing the incremental cost-effectiveness of initial MRCP and initial EUS with initial ERCP in patients with suspected biliary disease, initial EUS and initial MRCP were found to be less costly than initial ERCP, but provider expertise, biliary disease prevalence, and procedural costs influenced incremental cost-effectiveness. More true outcome trials, therefore, are needed to better assess the impact on clinical decision making or patient outcomes of these new diagnostic methods. 444

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