Br. J. Surg. Vol. 63 (1976)438-439
A comparison of operative cholangiographic techniques G . A . EVANS A N D D. H . R . JENKINS* SUMMARY
The accuracy and postoperative morbidity of cannulation of the cystic duct in routine operative cholangiography were compared with those of needle puncture of the common bile duct. The results are comparable and a case is made .for the simpler procedure of needle puncture of the common duct. THEtechnique of pre-exploratory operative cholangiography was first described by Mirizzi in 1932. Several methods have since been devised for introducing radio-opaque media into the biliary tree, none being entirely free from technical difficulties (Havard, 1970). Cannulation of the cystic duct is the most commonly used technique (Le Quesne and Whiteside, 1960; Dudley, 1968; Havard, 1970; Hatfield, 1973). This does not produce an increase in the morbidity or mortality of the surgical procedure (Bardenheiger et al., 1969; Kakof et al., 1972). Direct puncture of the common bile duct with a needle is normally reserved for cases in which cannulation of the cystic duct is not possible, and it is claimed that leakage of bile subsequently occurs from the puncture site (Hatfield, 1973). It has also been shown that leakage of bile is a cause of major complications and mortality following biliary surgery (McVicar et al., 1967). However, there has been no satisfactory study of cholangiographic techniques to establish whether puncture of the common bile duct does result in an increased incidence of complications. A study was therefore undertaken to assess the accuracy and postoperative morbidity associated with these two methods of operative cholangiography . Table I : AGE AND SEX OF PATIENTS STUDIED Cholangiographic technique Sex ratio (M : F) Average age (vr)
Cannulation 1 1 :40 46.4
Needle uuncture 12 : 39 49.4
Patients and methods Two groups of 51 patients each undergoing elective cholecystectomy were examined. In the first group operative cholangiography was performed by cystic duct cannulation with a size-5 ureteric catheter followed by two radiographs after the injection of 5 and 10 ml of 45 per cent Hypaque. The second group underwent direct puncture of the common bile duct with a 22-gauge angled needle. Radiographs were taken following the introduction of 20ml of 30 per cent Urografin. The two groups were strictly comparable for age, sex and the benign nature of the underlying condition (Table I ) .
438
All the patients underwent cholecystectomy. In addition, choledochotomy was performed on a further group of patients, 19 following cystic duct cannulation, and 25 following direct puncture of t h e common bile duct (Table ZZ). Table 11: OPERATIONS PERFORMED Cholangiographic technique Operation Cannulation Needle puncture Cholecystectomy 51 51 Cholecystectomy+ 19 25 choledochotomy Table 111: POSTOPERATIVE COMPLICATlONS Cholecystectomy Cholecystectomy and alone Choledochotomy Complications
Needle Needle Cannulation puncture Cannulation puncture (19 cases) (25 cases) (51 cases) (51 cases) 3 3 1 2
Wound Infection Excess bile drainage Pulmonary infection Deep vein thrombosis Pulmonary embolism Coronary
1
1
1
-
I
5
3
2
2
2
-
-
-
-
-
-
-
1
-
-
Results There were no significant differences in the incidence of initial postoperative complications following the two methods of cholangiography, and the distribution of the various types of complications was similar (Table 111). Pulmonary and wound infections were commonest, with prolonged drainage of bile, observed by Redivac drainage which was routinely used, occurring once in each group. A clinical diagnosis of deep vein thrombosis was made twice in each group, and in addition there was one death due to a coronary thrombosis, which was confirmed at autopsy, on the fifth postoperative day in the needle puncture group. The average postoperative hospitalization was 10.3 days in the needle puncture group, compared with 11.6 days in the cannulation group. Comparison of cholecystectomy alone and cholecystectomy with choledochotomy showed no significant difference in the incidence or distribution of complications (Table IZI).
* Department of Surgery, Cardiff Hospitals Group. Present addresses: G. A. Evans, at the Robert Jones and Agnes Hunt Orthopaedic Hospital, Oswestry. D. H. R. Jenkins, Department of Orthopaedics, Royal Infirmary, Cardiff.
Operative cholangiographic techniques The accuracy of the cholangiographic techniques indicated a slight advantage in direct needle puncture. Six of the cholangiograms performed by cannulation had technical shortcomings, one case being abandoned owing to inability to cannulate the cystic duct. The other difficulties were due to poor quality radiographs (2), the presence of air bubbles (2) and the passage of the cannula into the duodenum (I). Two of the cases performed by common bile duct puncture had technical shortcomings due to poor quality radiographs. In addition, there was one negative choledochotomy in each group following the demonstration of a radiographic filling defect in the common bile duct. Followup at 1 year showed no cases in which stones have subsequently been demonstrated in the biliary tree following normal operative cholangiography, and there were no late complications which could be attributed to either cholangiographic technique.
Discussion Leakage of bile has been incriminated as a cause of major complications and mortality following biliary surgery (McVicar et al., 1967), but it would appear from the p~esentstudy that the quantity of bile which may leak from a puncture site in the common bile duct is insufficient to produce such effects. Various methods of preventing this potential leakage have been described, such as transfixion of the puncture site with a suture (Mirizzi, 1937), or introducing the needle through the duct wall at a very oblique angle (Seiro and Kettunen, 1965). In the present study the needle was introduced obliquely through the duct wall, and not only were the complications associated with both cholangiographic techniques similar in incidence, but they were no greater than one would expect after cholecystectomy without cholangiography (Kakof et al., 1972). Cannulation of the cystic duct allows radiographs to be taken with increasing volumes of radio-opaque dye in the biliary tree, and it is claimed that the technique increases the accuracy of cholangiography (Le Quesne and Whiteside, 1960; Hatfield, 1973). The technique of fractionated injections has also been used successfully following needle puncture of the common bile duct (Partington and Sachs, 1948; Seiro and Kettunen, 1965), and claims have been made, because of its speed and the smaller likelihood of error involved, that needle cholangiography should be regarded as superior to other methods (Seiro and Kettunen, 1965). In the present study a single bolus of radiographic dye was in.jected into the common bile duct. Despite this, the injection technique showed intraductal calculi in a higher proportion of patients than in the cystic duct cannulation group, with no increase in the false
positive yield. In addition, there has been no instance of intraductal calculi being found subsequently in either group following normal operative cholangiography. Our assessments have been based on the technique of Havard (1970), i.e. the absence of severe postoperative pain and jaundice, and negative investigations and operations, when performed. As a consequence of these results we do not advocate a wholesale change of cholangiographic technique, but wish to point out that when difficulties arise during cannulation of the cystic duct, direct needle puncture of the common bile duct will produce good quality radiographs and yield as much diagnostic information, with no increase in the operative morbidity.
Acknowledgements We wish to thank Mr R. J. Williams and Mr G. Davies of the East Glamorgan Hospital, for their support, and permission to analyse the case records of patients under their care. References BARDENHEIGER J. A., KAMINSKI D. L., WILLMAN V. L. and HAMLON B. R. (1969) Ten year experience with
direct cholangiography. Am. J. Surg. 118, 900905. DUDLEY H. A. F. (1968) Surgery of the biliary tree. Br. J . Hosp. Med. 1, 27-3 I . HATFIELD G. J. (1973) Surgical anatomy of the biliary tract. Ann. R. Coll. Surg. Engl. 52, 381-391. HAVARD G. (1970) Operative cholangiography. Br. J. Surg. 57, 797-807. KAKOF G. s., TOMPKINS R . K., TURNIPSEED w. and ZOLLINGER R. M. (1972) Operative cholangiography during routine cholecystectomy. Arch. Surg. 104, 484-488. LE QUESNE L. P. and WHITESIDE c. G . (1960) Discussion on cholangiography. Proc. R . Sac. Med. 53, 852-858. MCVICAR F. T., MCNAIR T. J., WILKEN B. J. and BRUCE J. (1967) Death following gallbladder surgery. J. R . Coll. Surg. Edinb. 12, 139-148. MIRIZZI P. L. (1932) La colangiografia durante las operaciones de las vias biliares. Bol. Trab. SOC. Cir. Buenos Aires 16, 1 133. MIRIZZI P. L. (1937) Operative cholangiography. Surg. Gynecol. Obstet. 65, 702-710. PARTINGTON P. F. and SACHS M. D. (1948) Routine use of operative cholangiography. Surg. Gynecol. Obstet. 87, 299-307. SEIRO V. and KETTUNEN K. (1965) Operative needle cholangiography in gallstone surgery. Acta Chir. Scand. 129, 96-103.
439
A comparison of operative cholangiographic techniques G . A . EVANS A N D D. H . R . JENKINS* SUMMARY
The accuracy and postoperative morbidity of cannulation of the cystic duct in routine operative cholangiography were compared with those of needle puncture of the common bile duct. The results are comparable and a case is made .for the simpler procedure of needle puncture of the common duct. THEtechnique of pre-exploratory operative cholangiography was first described by Mirizzi in 1932. Several methods have since been devised for introducing radio-opaque media into the biliary tree, none being entirely free from technical difficulties (Havard, 1970). Cannulation of the cystic duct is the most commonly used technique (Le Quesne and Whiteside, 1960; Dudley, 1968; Havard, 1970; Hatfield, 1973). This does not produce an increase in the morbidity or mortality of the surgical procedure (Bardenheiger et al., 1969; Kakof et al., 1972). Direct puncture of the common bile duct with a needle is normally reserved for cases in which cannulation of the cystic duct is not possible, and it is claimed that leakage of bile subsequently occurs from the puncture site (Hatfield, 1973). It has also been shown that leakage of bile is a cause of major complications and mortality following biliary surgery (McVicar et al., 1967). However, there has been no satisfactory study of cholangiographic techniques to establish whether puncture of the common bile duct does result in an increased incidence of complications. A study was therefore undertaken to assess the accuracy and postoperative morbidity associated with these two methods of operative cholangiography . Table I : AGE AND SEX OF PATIENTS STUDIED Cholangiographic technique Sex ratio (M : F) Average age (vr)
Cannulation 1 1 :40 46.4
Needle uuncture 12 : 39 49.4
Patients and methods Two groups of 51 patients each undergoing elective cholecystectomy were examined. In the first group operative cholangiography was performed by cystic duct cannulation with a size-5 ureteric catheter followed by two radiographs after the injection of 5 and 10 ml of 45 per cent Hypaque. The second group underwent direct puncture of the common bile duct with a 22-gauge angled needle. Radiographs were taken following the introduction of 20ml of 30 per cent Urografin. The two groups were strictly comparable for age, sex and the benign nature of the underlying condition (Table I ) .
438
All the patients underwent cholecystectomy. In addition, choledochotomy was performed on a further group of patients, 19 following cystic duct cannulation, and 25 following direct puncture of t h e common bile duct (Table ZZ). Table 11: OPERATIONS PERFORMED Cholangiographic technique Operation Cannulation Needle puncture Cholecystectomy 51 51 Cholecystectomy+ 19 25 choledochotomy Table 111: POSTOPERATIVE COMPLICATlONS Cholecystectomy Cholecystectomy and alone Choledochotomy Complications
Needle Needle Cannulation puncture Cannulation puncture (19 cases) (25 cases) (51 cases) (51 cases) 3 3 1 2
Wound Infection Excess bile drainage Pulmonary infection Deep vein thrombosis Pulmonary embolism Coronary
1
1
1
-
I
5
3
2
2
2
-
-
-
-
-
-
-
1
-
-
Results There were no significant differences in the incidence of initial postoperative complications following the two methods of cholangiography, and the distribution of the various types of complications was similar (Table 111). Pulmonary and wound infections were commonest, with prolonged drainage of bile, observed by Redivac drainage which was routinely used, occurring once in each group. A clinical diagnosis of deep vein thrombosis was made twice in each group, and in addition there was one death due to a coronary thrombosis, which was confirmed at autopsy, on the fifth postoperative day in the needle puncture group. The average postoperative hospitalization was 10.3 days in the needle puncture group, compared with 11.6 days in the cannulation group. Comparison of cholecystectomy alone and cholecystectomy with choledochotomy showed no significant difference in the incidence or distribution of complications (Table IZI).
* Department of Surgery, Cardiff Hospitals Group. Present addresses: G. A. Evans, at the Robert Jones and Agnes Hunt Orthopaedic Hospital, Oswestry. D. H. R. Jenkins, Department of Orthopaedics, Royal Infirmary, Cardiff.
Operative cholangiographic techniques The accuracy of the cholangiographic techniques indicated a slight advantage in direct needle puncture. Six of the cholangiograms performed by cannulation had technical shortcomings, one case being abandoned owing to inability to cannulate the cystic duct. The other difficulties were due to poor quality radiographs (2), the presence of air bubbles (2) and the passage of the cannula into the duodenum (I). Two of the cases performed by common bile duct puncture had technical shortcomings due to poor quality radiographs. In addition, there was one negative choledochotomy in each group following the demonstration of a radiographic filling defect in the common bile duct. Followup at 1 year showed no cases in which stones have subsequently been demonstrated in the biliary tree following normal operative cholangiography, and there were no late complications which could be attributed to either cholangiographic technique.
Discussion Leakage of bile has been incriminated as a cause of major complications and mortality following biliary surgery (McVicar et al., 1967), but it would appear from the p~esentstudy that the quantity of bile which may leak from a puncture site in the common bile duct is insufficient to produce such effects. Various methods of preventing this potential leakage have been described, such as transfixion of the puncture site with a suture (Mirizzi, 1937), or introducing the needle through the duct wall at a very oblique angle (Seiro and Kettunen, 1965). In the present study the needle was introduced obliquely through the duct wall, and not only were the complications associated with both cholangiographic techniques similar in incidence, but they were no greater than one would expect after cholecystectomy without cholangiography (Kakof et al., 1972). Cannulation of the cystic duct allows radiographs to be taken with increasing volumes of radio-opaque dye in the biliary tree, and it is claimed that the technique increases the accuracy of cholangiography (Le Quesne and Whiteside, 1960; Hatfield, 1973). The technique of fractionated injections has also been used successfully following needle puncture of the common bile duct (Partington and Sachs, 1948; Seiro and Kettunen, 1965), and claims have been made, because of its speed and the smaller likelihood of error involved, that needle cholangiography should be regarded as superior to other methods (Seiro and Kettunen, 1965). In the present study a single bolus of radiographic dye was in.jected into the common bile duct. Despite this, the injection technique showed intraductal calculi in a higher proportion of patients than in the cystic duct cannulation group, with no increase in the false
positive yield. In addition, there has been no instance of intraductal calculi being found subsequently in either group following normal operative cholangiography. Our assessments have been based on the technique of Havard (1970), i.e. the absence of severe postoperative pain and jaundice, and negative investigations and operations, when performed. As a consequence of these results we do not advocate a wholesale change of cholangiographic technique, but wish to point out that when difficulties arise during cannulation of the cystic duct, direct needle puncture of the common bile duct will produce good quality radiographs and yield as much diagnostic information, with no increase in the operative morbidity.
Acknowledgements We wish to thank Mr R. J. Williams and Mr G. Davies of the East Glamorgan Hospital, for their support, and permission to analyse the case records of patients under their care. References BARDENHEIGER J. A., KAMINSKI D. L., WILLMAN V. L. and HAMLON B. R. (1969) Ten year experience with
direct cholangiography. Am. J. Surg. 118, 900905. DUDLEY H. A. F. (1968) Surgery of the biliary tree. Br. J . Hosp. Med. 1, 27-3 I . HATFIELD G. J. (1973) Surgical anatomy of the biliary tract. Ann. R. Coll. Surg. Engl. 52, 381-391. HAVARD G. (1970) Operative cholangiography. Br. J. Surg. 57, 797-807. KAKOF G. s., TOMPKINS R . K., TURNIPSEED w. and ZOLLINGER R. M. (1972) Operative cholangiography during routine cholecystectomy. Arch. Surg. 104, 484-488. LE QUESNE L. P. and WHITESIDE c. G . (1960) Discussion on cholangiography. Proc. R . Sac. Med. 53, 852-858. MCVICAR F. T., MCNAIR T. J., WILKEN B. J. and BRUCE J. (1967) Death following gallbladder surgery. J. R . Coll. Surg. Edinb. 12, 139-148. MIRIZZI P. L. (1932) La colangiografia durante las operaciones de las vias biliares. Bol. Trab. SOC. Cir. Buenos Aires 16, 1 133. MIRIZZI P. L. (1937) Operative cholangiography. Surg. Gynecol. Obstet. 65, 702-710. PARTINGTON P. F. and SACHS M. D. (1948) Routine use of operative cholangiography. Surg. Gynecol. Obstet. 87, 299-307. SEIRO V. and KETTUNEN K. (1965) Operative needle cholangiography in gallstone surgery. Acta Chir. Scand. 129, 96-103.
439
