REVIEWS
Operative Cholangiography in Uncomplicated
Biliary Tract
Surgery Review of 354 Cholangiography Common Duct Pathology
Studies in Patients without Indication of
Robert Wayne, MD,* Omaha, Nebraska Mieczyslaw Cegielski, MD, FACS, Omaha, Nebraska Jerome Bleicher, MD, Omaha, Nebraska Jose Saporta, MD, Omaha, Nebraska
A review of the substantial studies on operative cholangiography in uncomplicated biliary tract surgery reveals a spectrum of opinion about its value. The incidence of unsuspected stones in patients without the usual indications for common duct exploration ranges from 1.2 to 14.0 per cent. (Table I.) However, the limited number of uncomplicated cases in each of these studies is small [1,2]. The excellent studies of Schulenberg [3] and Jolly et al [4] each required indirect extrapolation to determine the number of patients with uncomplicated biliary tract disease in their series. Ferguson and Estes [5] and Hermann and Hoerr [6] each quote a percentage of unsuspected stones without giving documented size to their population. The present report reviews the seven year (1965 to 1972) experience of a private surgical group using routine operative cholangiography to determine
From the Department of Surgery, Creighton University School of Medicine, Omaha, Nebraska. * Present address and reprint requests: Robert Wayne, MD, Assistant Chief of Surgery, USPHS Hospital, Seattle, Washington 98114.
324
the role operative cholangiography played in revealing unsuspected pathologic features of the extrahepatic biliary tract. In this multispecialty group, all cholecystectomies were performed by three surgeons and the technic of cholangiography was standardized. Results This series is limited to individuals who had nonfunctioning gallbladders or cholelithiasis without clinical pathologic features of the common duct or operative indications for common duct exploration. There were 264 females and 90 males, a 3:l ratio that agrees with the ratio usually quoted in the literature for gallbladder disease [7]. Average age was fifty-one years, ranging from twentysix to eighty-four years. Operative cholangiography was employed in 354 consecutive cases. (Table II.) Of this group, 317 (89 per cent) had studies interpreted to be within normal limits, that is, there were no filling defects, dye passed freely into the duodenum, and the common duct radiographically measured 12 mm or less in diameter on x-ray ex-
The American Journal of Surgery
Operative Cholangiography
TABLE I
Review of Literature of Uncomplicated Cholecystectomies with Operative Cholangiography
Author
Institution
lsaacs and Davis [I] Mehn [2] Jolly et al [4] Schulenburg [3] Hermann and Hoerr [6] Ferguson and Estes [5] Present report
Johns Hopkins University Northwestern University Mason Clinic, Seattle University of Pretoria, South Africa Cleveland Clinic George Washington University Creighton University
amination. Twenty patients (5.7 per cent) had technically inadequate studies due to obesity, inadequately trained technicians, or difficulty with equipment. Of the seventeen patients (4.8 per cent) with abnormal cholangiograms, all underwent common duct exploration. Three (0.85 per cent) of these had negative exploration (false-positive), one (0.28 per cent) had cholangiocarcinoma, and thirteen (3.7 per cent) had stones discovered, for a total of 3.9 per cent patients with duct disease unsuspected before x-ray films. Since a large part of the patients in this study were drawn from a rather stable urban population, 90 per cent follow-up was obtained, indicating or suggesting that patients with symptoms of retained common duct stones would most likely be seen by us again. The number of missed stones (false-negative) that may have gone elsewhere cannot be determined, but to our knowledge there were none in this series.
TABLE
II
Per Cent of Unsuspected Stones
Number of Unsuspected Stones
Total Uncomplicated Choiecystectomies
8.0% 10.0% 14.0% 1.2%
7 13 24
87 113 182
11
908
5.0%
10.0%
... ...
... ...
3.7%
13
354
Results of Operative Cholangiography in Uncomplicated Biliary Tract Surgery (354 cases)
Cholangiogram Normal Positive Unsuspected stones Cholangiocarcinoma False-positive (negative common duct exploration) Technically inadequate
Total
Number of Patients
Per Cent of Total
317
89.50
13 1 3
3.67 0.28 0.85
20 354
5.70 100
Technic
10 cc SYRINGE
Our method of cholangiography is as follows (Figure 1). The abdomen is entered through a right subcostal incision. After thorough abdominal exploration, the cystic duct and artery are initially isolated. The cystic artery is transected between ligatures and the cystic duct is tied at its junction with the gallbladder neck. This prevents reflux of dye into the gallbladder and the escape of small stones into the cystic and/or common duct. The gallbladder is then dissected from the undersurface of the liver so that the cystic duct can be pulled taut. A 20 gauge needle bent at an angle of 120° attached to a 10 cc syringe is utilized. This needle is then passed 1 to 1.5 cm into the cystic duct just beyond the tie. During a 1 minute period, 10 ml of 30 per cent Hypaque@ (contrast material) is injected directly into the cystic duct. Two exposures are obtained and evaluated by the radi-
m&Mine131, brch
1976
20 2Oga.bentneedle
Common epaticDuct
PA Ld
Common
BileDuct
Figure 1. Technic of needfe cf?olangfography. A 20 gauge needfe bent at an angle of 120’ attached to 8 10 cc syringe Is utlllzed.
325
Wayne et al
Figure 2. A needle operative choiangiogram that was posttive for an unsuspected common duct stone.
ologist and the surgeon. Figure 2 demonstrates a needle operative cholangiogram that was positive for an unsuspected stone. When cholangiograms are of doubtful value or poor quality, the procedure is repeated. When satisfactory studies are obtained, a second tie is placed around the cystic duct, 0.5 cm from its junction with the common duct and the puncture site is amputated with the specimen. A scout film helps decrease the incidence of inadequate studies by advising the operator of possibly misinterpreted opaque substances that were present before the dye study. Comments
The value of operative cholangiography assumes a less disputed role when the usual clinical or operative indications of common duct exploration are present: jaundice, pancreatitis, a palpable stone, or dilated common duct (greater than 12 mm). When these indications are absent in the presence of uncomplicated biliary tract disease, operative chol-
326
angiograms can be of added value. In addition to the increased mortality and morbidity of the second biliary tract procedure for a missed common duct stone, the formidable task of the surgeon reoperating on the extrahepatic biliary tract must be appreciated. As the surgeon, radiology technician, and operating room personnel become more familiar with this procedure, (1) operating time is rapidly reduced to a minimum, (2) the radiologist improves in his interpretation of these studies, (3) the incidence of false-positive and false-negative results diminishes and (5) the surgeon’s confidence in the procedure increases. Jolly et a1[4] in their detailed study of operative cholangiography noted that this procedure added only 19 minutes to their operating time. The duration of needle cholangiography in our hands is now less than fifteen minutes. To properly utilize the time, immediately after the films are taken, routine appendectomy can be performed, the gallbladder fossa closed, the drain inserted, and the peritoneal cavity irrigated. The problem of false-positive cholangiograms is significant. In this series there were three such instances (0.85 per cent). Since common duct exploration can add mortality and morbidity to biliary tract surgery and unnecessary explorations must be avoided, review of these three cases and their cholangiograms with a radiologist was valuable. Two patients had filling defects considered to be air bubbles in retrospect. The third case revealed absence of dye flowing into the duodenum, eventually interpreted as ampullary spasm. Saving thirteen patients from possible reoperation still does not seem to negate these unnecessary explorations. Each of the thirteen patients with positive cholangiograms had one or more stones recovered. Furthermore, the discovery of cholangiocarcinoma was an unexpected bonus in one patient. We can only speculate that routine liver function tests combined with operative cholangiography may yield an even lower incidence of missed stones. Obtaining liver function tests on these patients would have been a worthwhile asset to the study. However, only in recent years has the rapid and inexpensive autoanalyzer been available to this clinic. In particular, routine preoperative values such as bilirubin, alkaline phosphatase, and serum glutamic oxaloacetic transaminase would have been useful. Some very well documented recent studies show a good correlation between the incidence of elevation of these tests and biliary tract disease thought to be ’ uncomplicated but later proved to have unsuspected stones [8].
The Amwlcan Jwmal
of Surgery
Operative Cholangiography
The major reported complications of this procedure, pancreatitis and bile peritonitis, were absent in our series. The incidence of clinically unsuspected stones in this study was 3.7 per cent (13 of 354 patients). There were no mortalities. A study by Glenn [9] showed the incidence of recurrent or missed common duct stones during a ten year period after uncomplicated cholecystectomy to be approximately 4 per cent. This figure is close to those shown in the studies reviewed in Table I and our study of stones discovered during “routine” operative cholangiography. More recently Glenn [IO] has observed about operative cholangiograpby: “Many clinics have advocated its routine use, and indeed this is ideal.” This opinion continues to be supported [11-131.
The literature of the past ten years is replete with articles on “routine” cholangiography, with particular reference to the overlooked or “unsuspected” stone. Many series do not differentiate between T-tube cholangiograms performed after common duct exploration and those performed on patients with and without the usual clinical or operative indications for common duct exploration. We present a pure operative cholangiographic study of 354 patients with apparent uncomplicated biliary tract disease; a significant incidence of
vohnno 191, Much 1976
unsuspected pathologic features are Can a convenient and innocuous routine operative cholangiography ignored, even in the most routine of
demonstrated. procedure like continue to be cases?
References 1. fsaacs JP, Davis ML: Technique and evaluation of operative cholangiography. Surg Gynecol O&ret 111: 103, 1960. 2. Mehn WH: Operating room cholangiography. Surg Gynecol Obstet 34: 151, 1954. 3. Schulenberg CAR: Operative cholangiography: 1000 cases. Surgery 65: 723, 1969. 4. Jolly PC, Baker JW, Schmidt HM. Walker JH, Holm JC: Operative cholangiography: a case for its routine use. Ann Surg 166: 551, 1966. 5. Ferguson WH, Estes JT: Value of routine operative cholangiograms. Am J Gasfroenterol46: 311, 1967. 6. Hermann RE, Hoerr SO: The value of the routine use of operative cholangiography. Surg Gymcot Obstet 12 1: 10 15, 1965. 7. Nardi GL, Zuidema GD: Surgery: A Concise Goal to Clinical Practice. Boston, Little, Brown, 1965, p 383. 8. Mullen JL, Rosato FE, Rosato EF. Miller WT, Sullivan M: The diagnosis of choledocholithiasis. Surg Gynecol Obstet 133: 774,197l. 9. Glenn F: Common duct exploration for stones. Surg Gynecol Obstet 95: 431, 1952. 10. Glenn F: Postcholecystectomy choledocholithiasis. Surg Gynecol Obstet 134: 149, 1971. 11. Kakos GS, Tompkins RK, Turnipseed W, Zollinger RM: Operative cholangiography during routine cholecystectomy. Arch Surg 104: 484, 1972. 12. Saltzstein EC, Evani SV, Mann RW: Routine operative cholangiography: analysis of 500 consecutive cholecystectomies. Arch Surg 107: 289, 1973. 13. Houston HE: Surgical pros and cons. Surg Gynecor Obstet 139: 89, 1974.
327
Operative Cholangiography in Uncomplicated
Biliary Tract
Surgery Review of 354 Cholangiography Common Duct Pathology
Studies in Patients without Indication of
Robert Wayne, MD,* Omaha, Nebraska Mieczyslaw Cegielski, MD, FACS, Omaha, Nebraska Jerome Bleicher, MD, Omaha, Nebraska Jose Saporta, MD, Omaha, Nebraska
A review of the substantial studies on operative cholangiography in uncomplicated biliary tract surgery reveals a spectrum of opinion about its value. The incidence of unsuspected stones in patients without the usual indications for common duct exploration ranges from 1.2 to 14.0 per cent. (Table I.) However, the limited number of uncomplicated cases in each of these studies is small [1,2]. The excellent studies of Schulenberg [3] and Jolly et al [4] each required indirect extrapolation to determine the number of patients with uncomplicated biliary tract disease in their series. Ferguson and Estes [5] and Hermann and Hoerr [6] each quote a percentage of unsuspected stones without giving documented size to their population. The present report reviews the seven year (1965 to 1972) experience of a private surgical group using routine operative cholangiography to determine
From the Department of Surgery, Creighton University School of Medicine, Omaha, Nebraska. * Present address and reprint requests: Robert Wayne, MD, Assistant Chief of Surgery, USPHS Hospital, Seattle, Washington 98114.
324
the role operative cholangiography played in revealing unsuspected pathologic features of the extrahepatic biliary tract. In this multispecialty group, all cholecystectomies were performed by three surgeons and the technic of cholangiography was standardized. Results This series is limited to individuals who had nonfunctioning gallbladders or cholelithiasis without clinical pathologic features of the common duct or operative indications for common duct exploration. There were 264 females and 90 males, a 3:l ratio that agrees with the ratio usually quoted in the literature for gallbladder disease [7]. Average age was fifty-one years, ranging from twentysix to eighty-four years. Operative cholangiography was employed in 354 consecutive cases. (Table II.) Of this group, 317 (89 per cent) had studies interpreted to be within normal limits, that is, there were no filling defects, dye passed freely into the duodenum, and the common duct radiographically measured 12 mm or less in diameter on x-ray ex-
The American Journal of Surgery
Operative Cholangiography
TABLE I
Review of Literature of Uncomplicated Cholecystectomies with Operative Cholangiography
Author
Institution
lsaacs and Davis [I] Mehn [2] Jolly et al [4] Schulenburg [3] Hermann and Hoerr [6] Ferguson and Estes [5] Present report
Johns Hopkins University Northwestern University Mason Clinic, Seattle University of Pretoria, South Africa Cleveland Clinic George Washington University Creighton University
amination. Twenty patients (5.7 per cent) had technically inadequate studies due to obesity, inadequately trained technicians, or difficulty with equipment. Of the seventeen patients (4.8 per cent) with abnormal cholangiograms, all underwent common duct exploration. Three (0.85 per cent) of these had negative exploration (false-positive), one (0.28 per cent) had cholangiocarcinoma, and thirteen (3.7 per cent) had stones discovered, for a total of 3.9 per cent patients with duct disease unsuspected before x-ray films. Since a large part of the patients in this study were drawn from a rather stable urban population, 90 per cent follow-up was obtained, indicating or suggesting that patients with symptoms of retained common duct stones would most likely be seen by us again. The number of missed stones (false-negative) that may have gone elsewhere cannot be determined, but to our knowledge there were none in this series.
TABLE
II
Per Cent of Unsuspected Stones
Number of Unsuspected Stones
Total Uncomplicated Choiecystectomies
8.0% 10.0% 14.0% 1.2%
7 13 24
87 113 182
11
908
5.0%
10.0%
... ...
... ...
3.7%
13
354
Results of Operative Cholangiography in Uncomplicated Biliary Tract Surgery (354 cases)
Cholangiogram Normal Positive Unsuspected stones Cholangiocarcinoma False-positive (negative common duct exploration) Technically inadequate
Total
Number of Patients
Per Cent of Total
317
89.50
13 1 3
3.67 0.28 0.85
20 354
5.70 100
Technic
10 cc SYRINGE
Our method of cholangiography is as follows (Figure 1). The abdomen is entered through a right subcostal incision. After thorough abdominal exploration, the cystic duct and artery are initially isolated. The cystic artery is transected between ligatures and the cystic duct is tied at its junction with the gallbladder neck. This prevents reflux of dye into the gallbladder and the escape of small stones into the cystic and/or common duct. The gallbladder is then dissected from the undersurface of the liver so that the cystic duct can be pulled taut. A 20 gauge needle bent at an angle of 120° attached to a 10 cc syringe is utilized. This needle is then passed 1 to 1.5 cm into the cystic duct just beyond the tie. During a 1 minute period, 10 ml of 30 per cent Hypaque@ (contrast material) is injected directly into the cystic duct. Two exposures are obtained and evaluated by the radi-
m&Mine131, brch
1976
20 2Oga.bentneedle
Common epaticDuct
PA Ld
Common
BileDuct
Figure 1. Technic of needfe cf?olangfography. A 20 gauge needfe bent at an angle of 120’ attached to 8 10 cc syringe Is utlllzed.
325
Wayne et al
Figure 2. A needle operative choiangiogram that was posttive for an unsuspected common duct stone.
ologist and the surgeon. Figure 2 demonstrates a needle operative cholangiogram that was positive for an unsuspected stone. When cholangiograms are of doubtful value or poor quality, the procedure is repeated. When satisfactory studies are obtained, a second tie is placed around the cystic duct, 0.5 cm from its junction with the common duct and the puncture site is amputated with the specimen. A scout film helps decrease the incidence of inadequate studies by advising the operator of possibly misinterpreted opaque substances that were present before the dye study. Comments
The value of operative cholangiography assumes a less disputed role when the usual clinical or operative indications of common duct exploration are present: jaundice, pancreatitis, a palpable stone, or dilated common duct (greater than 12 mm). When these indications are absent in the presence of uncomplicated biliary tract disease, operative chol-
326
angiograms can be of added value. In addition to the increased mortality and morbidity of the second biliary tract procedure for a missed common duct stone, the formidable task of the surgeon reoperating on the extrahepatic biliary tract must be appreciated. As the surgeon, radiology technician, and operating room personnel become more familiar with this procedure, (1) operating time is rapidly reduced to a minimum, (2) the radiologist improves in his interpretation of these studies, (3) the incidence of false-positive and false-negative results diminishes and (5) the surgeon’s confidence in the procedure increases. Jolly et a1[4] in their detailed study of operative cholangiography noted that this procedure added only 19 minutes to their operating time. The duration of needle cholangiography in our hands is now less than fifteen minutes. To properly utilize the time, immediately after the films are taken, routine appendectomy can be performed, the gallbladder fossa closed, the drain inserted, and the peritoneal cavity irrigated. The problem of false-positive cholangiograms is significant. In this series there were three such instances (0.85 per cent). Since common duct exploration can add mortality and morbidity to biliary tract surgery and unnecessary explorations must be avoided, review of these three cases and their cholangiograms with a radiologist was valuable. Two patients had filling defects considered to be air bubbles in retrospect. The third case revealed absence of dye flowing into the duodenum, eventually interpreted as ampullary spasm. Saving thirteen patients from possible reoperation still does not seem to negate these unnecessary explorations. Each of the thirteen patients with positive cholangiograms had one or more stones recovered. Furthermore, the discovery of cholangiocarcinoma was an unexpected bonus in one patient. We can only speculate that routine liver function tests combined with operative cholangiography may yield an even lower incidence of missed stones. Obtaining liver function tests on these patients would have been a worthwhile asset to the study. However, only in recent years has the rapid and inexpensive autoanalyzer been available to this clinic. In particular, routine preoperative values such as bilirubin, alkaline phosphatase, and serum glutamic oxaloacetic transaminase would have been useful. Some very well documented recent studies show a good correlation between the incidence of elevation of these tests and biliary tract disease thought to be ’ uncomplicated but later proved to have unsuspected stones [8].
The Amwlcan Jwmal
of Surgery
Operative Cholangiography
The major reported complications of this procedure, pancreatitis and bile peritonitis, were absent in our series. The incidence of clinically unsuspected stones in this study was 3.7 per cent (13 of 354 patients). There were no mortalities. A study by Glenn [9] showed the incidence of recurrent or missed common duct stones during a ten year period after uncomplicated cholecystectomy to be approximately 4 per cent. This figure is close to those shown in the studies reviewed in Table I and our study of stones discovered during “routine” operative cholangiography. More recently Glenn [IO] has observed about operative cholangiograpby: “Many clinics have advocated its routine use, and indeed this is ideal.” This opinion continues to be supported [11-131.
The literature of the past ten years is replete with articles on “routine” cholangiography, with particular reference to the overlooked or “unsuspected” stone. Many series do not differentiate between T-tube cholangiograms performed after common duct exploration and those performed on patients with and without the usual clinical or operative indications for common duct exploration. We present a pure operative cholangiographic study of 354 patients with apparent uncomplicated biliary tract disease; a significant incidence of
vohnno 191, Much 1976
unsuspected pathologic features are Can a convenient and innocuous routine operative cholangiography ignored, even in the most routine of
demonstrated. procedure like continue to be cases?
References 1. fsaacs JP, Davis ML: Technique and evaluation of operative cholangiography. Surg Gynecol O&ret 111: 103, 1960. 2. Mehn WH: Operating room cholangiography. Surg Gynecol Obstet 34: 151, 1954. 3. Schulenberg CAR: Operative cholangiography: 1000 cases. Surgery 65: 723, 1969. 4. Jolly PC, Baker JW, Schmidt HM. Walker JH, Holm JC: Operative cholangiography: a case for its routine use. Ann Surg 166: 551, 1966. 5. Ferguson WH, Estes JT: Value of routine operative cholangiograms. Am J Gasfroenterol46: 311, 1967. 6. Hermann RE, Hoerr SO: The value of the routine use of operative cholangiography. Surg Gymcot Obstet 12 1: 10 15, 1965. 7. Nardi GL, Zuidema GD: Surgery: A Concise Goal to Clinical Practice. Boston, Little, Brown, 1965, p 383. 8. Mullen JL, Rosato FE, Rosato EF. Miller WT, Sullivan M: The diagnosis of choledocholithiasis. Surg Gynecol Obstet 133: 774,197l. 9. Glenn F: Common duct exploration for stones. Surg Gynecol Obstet 95: 431, 1952. 10. Glenn F: Postcholecystectomy choledocholithiasis. Surg Gynecol Obstet 134: 149, 1971. 11. Kakos GS, Tompkins RK, Turnipseed W, Zollinger RM: Operative cholangiography during routine cholecystectomy. Arch Surg 104: 484, 1972. 12. Saltzstein EC, Evani SV, Mann RW: Routine operative cholangiography: analysis of 500 consecutive cholecystectomies. Arch Surg 107: 289, 1973. 13. Houston HE: Surgical pros and cons. Surg Gynecor Obstet 139: 89, 1974.
327
