Failure of operative cholangiography to prevent retained common duct stones

Optimal technique for intraoperative cholangiography (IOC) and are the technique and the findings optimally recorded at our institution?

BACKGROUND

Limited evidence exists describing the optimum protocol for intraoperative cholangiography (IOC) during laparoscopic cholecystectomy (LC). Images saved during surgery often fail to highlight the necessary anatomical landmarks and documentation is variable. Our aim was to identify the key characteristics of an optimal IOC and evaluate current practice at our institution.

METHODS

A literature search identified quality indicators for performing IOC and documenting key findings. A standardised proforma for scoring IOC was developed. Retrospective analysis was conducted of consecutive IOCs performed during elective LC. Visual documentation of seven anatomical landmarks on the captured IOC images and textual reporting in the operation note were assessed.

RESULTS

One hundred IOCs were evaluated. Only 32 (34%) of captured images had all 7 landmarks present. All cases failed to document all seven landmarks. There was a significant difference between landmarks that could be identified on the captured images and their documentation.

CONCLUSIONS

This study suggests that IOC image capture of the key seven landmarks and their textual reporting in this cohort is sub-optimal. We believe IOC technique, minimal data set for reporting and image capture should be standardised to allow better communication of findings and facilitate meaningful comparative research relating to the subject.

ERCP experience in patients with choledochoduodenostomy: diagnostic findings and therapeutic management

BACKGROUND

Endoscopic retrograde cholangiopancreatography (ERCP), besides reducing the need for surgery in a wide spectrum of biliary disease, is increasingly be used for the treatment of biliary complications of surgery. In this paper, we review our experience with postoperative ERCPs required after biliary surgery with a special focus on side-to-side choledochoduodenostomy (CD).

METHODS

The records of 70 patients with a history of CD who underwent ERCP from May 2000 to February 2006 were analyzed.

RESULTS

There were 70 patients, 32 (45.7%) women and 38 (35.6%) men, with a mean age of 56 (range, 21-80) years. Indications for ERCP were cholangitis in 46 (65.7%), abnormal liver function tests with abdominal pain and abnormal USG in 22 (31.4%), and abnormal liver function tests and abnormal USG in 2 (2.9%). Overall 133 ERCP were performed. Anastomotic stenosis was found in 14 (20%), benign biliary stricture above the anastomosis in 13 (18.6%), sump syndrome in 11 (15.7%), common bile duct stone in 8 (11.4%), malignancy in 4 (5.7%), hepatolithiasis in 1 (1.4%), and secondary sclerosing cholangitis in 1 (1.4%). ERCP was normal in 18 (25.8%). Patients were managed by stone extraction in 8 (11%), stent insertion in 22 (36%), balloon dilatation in 15 (21%), nasobiliary drainage in 11 (16%), and bougie dilatation in 2 (3%) patients.

CONCLUSIONS

We have reported one of the largest groups of patients with CD in the literature and showed that ERCP is a very important diagnostic and therapeutic tool for the management of biliary problems after CD.

Management of choledocholithiasis in the time of laparoscopic cholecystectomy

BACKGROUND

The best way to detect and manage common duct stones in conjunction with laparoscopic cholecystectomy is not agreed upon at the present time.

PATIENTS AND METHODS

Our experience with choledocholithiasis in a consecutive series of 1,123 cholecystectomies (94% by laparoscopy) has been reviewed. Suspected duct stones were investigated preoperatively or postoperatively by endoscopic retrograde cholangiography (ERC), and if necessary, duct clearance was attempted by endoscopic sphincterotomy (ES). No attempt was made to identify choledocholithiasis intraoperatively.

RESULTS

Endoscopic retrograde cholangiography was performed in 11% of patients, and 32% of these required ES. The complication rate of ERC and ES was 8%, without mortality. Two patients required a second operation for missed choledocholithiasis, for a reoperation rate of 0.2%.

CONCLUSION

We believe that primary or secondary open surgery is only occasionally necessary for the management of choledocholithiasis. Preoperative ERC and ES for suspected duct stones, with the same strategy employed as a salvage for stones presenting after cholecystectomy, was safe and efficient.

Biliary Laser Lithotripsy

Laser lithotripsy is an excellent method of fragmenting those biliary stones that cannot be removed easily by less technically advanced methods such as basket extraction. The energy can be delivered through fine flexible fibers, around 200 to 320 microns in diameter, that can be passed through the channels of a variety of small endoscopes. Currently, the optimal laser seems to a pulsed system because of the conversion of light to acoustic energy with minimal heating of the surrounding tissues, thus avoiding the chance of tissue injury and perforation. The best wavelength seems to be 504 nm, because at this wavelength, there is maximum absorption of laser energy by pigment stones, resulting in fragmentation using low-energy pulses. With further research, optimal wavelengths and pulse durations may emerge.

Operative choledochoscopy in patients with acute cholangitis: a prospective, randomized study

A prospective, randomized evaluation of operative choledochoscopy was carried out during emergency surgery in patients with acute cholangitis or acute suppurative cholangitis when conservative management had failed. After common bile duct exploration, 79 patients were randomized to have choledochoscopy and 78 patients to the control group. Laboratory and clinical parameters showed that choledochoscopy did not increase the incidence of septicaemia, acute pancreatitis, persistent cholangitis, postoperative wound sepsis, intraperitoneal sepsis and hospital mortality. The incidence of retained common bile duct stones detected by T tube cholangiography performed in the second postoperative week was significantly reduced (P less than 0.01) after choledochoscopy. Choledochoscopy detected stones missed by conventional common bile duct exploration in ten patients. It is concluded that choledochoscopy is a safe and effective technique in patients with acute cholangitis and acute suppurative cholangitis.

Percutaneous post-operative choledochofiberscopic lithotripsy for residual biliary stones

A total of 5,116 post-operative percutaneous choledochofiberscopy (POC) sessions were performed on 739 patients with residual bile duct stones between 1980 and 1988. These residual stones were detected and removed by choledochoscopy. The success rate of non-surgical stone removal using POC was 100% for residual common duct stones and required 414 treatment sessions in this group of 168 patients. The success rate was 92.2% (525/569) for patients with residual intrahepatic stones; in this group a total of 4,694 treatment sessions were needed. Two patients with residual cystic duct stones were also successfully treated with POC. The distribution of residual intrahepatic stones was as follows: 166 (29.2%) in the right hepatic duct, 255 (44.8%) in the left hepatic duct and 148 (26.0%) in both hepatic ducts. Complications after POC were minimal and subsided after conservative treatment except in 2 patients. One patient had hemobilia and another a large subphrenic abscess, which required surgical drainage. Choledochofiberscopic electrohydraulic shock-wave lithotripsy was effective treatment for large stones and was well tolerated. Residual stones in Oriental gallstone disease are not preventable, and we believe that POC should be the first choice for these patients. Many of the problems associated with residual stones can be overcome by this method and good results achieved.

Choledochoscopic stone removal through a T-tube tract: experience in 75 consecutive patients

Retained biliary stones remain a common clinical problem in patients after surgery. Since 1984, the authors have used choledochoscopy in the treatment of suspected retained biliary stones in 75 patients. These procedures were performed in the radiology department with use of local anesthesia supplemented by an intravenously administered sedative and analgesic. A 15-F flexible fiberoptic choledochoscope was used. Fifty-one of the 75 patients were treated as outpatients. Treatment was successful in 74 of 75 patients; in one patient, intrahepatic stones were not completely removed. Electrohydraulic lithotripsy was used to fragment calculi in 11 patients (15%). Biopsies were performed in four patients (5%). Five minor complications occurred; three required overnight admission. Choledochoscopic-assisted removal of retained biliary calculi is a highly effective and safe procedure. Advantages over standard fluoroscopic stone removal include the ability to directly visualize and fragment adherent or impacted stones and visualize noncalculous filling defects, such as air bubbles, mucus, and biliary tumors.

Prediction of choledocholithiasis using a pocket microcomputer

A computerized method, using a small pocket computer, has been used to predict the presence of choledocholithiasis in a prospective series of 239 patients undergoing cholecystectomy. From an initial data base of 424 patients 36 factors were evaluated and the most important 2 of these were determined by multivariate analysis for use in the prospective analysis. Satisfactory operative cholangiograms were a prerequisite to evaluation of the statistical method and were obtained in 90.4 per cent of cases. Using the computerized method a common bile duct stone would have been overlooked in only 1 patient but 17 unnecessary explorations would have been carried out. The overall accuracy of the computerized method was 92.5 per cent. When the method was applied to a further study of 97 patients from a separate centre the overall accuracy was 85.6 per cent. If the method was used to aid selective use of operative cholangiography, cholangiograms would be performed in 20 per cent and stones would be overlooked in less than 1 per cent.

Morbidity and mortality of common bile duct exploration

This retrospective study reviews the complications which occurred in 257 patients who had supraduodenal exploration of the common bile duct in one hospital during a 15-year period. One hundred and eighteen patients (46 per cent) developed complications: septic and cardiorespiratory complications were most common, occurring in 19.5 per cent and 16.7 per cent of patients respectively. Postoperative retained stones were detected in 37 patients (14 per cent), causing complications in 54 per cent. Peroperative postexploratory cholangiography did not significantly reduce the incidence of this problem. None of the 12 patients who had postexploratory choledochoscopy had retained stones. Five patients (1.9 per cent) died, three of whom had duct procedures in addition to supraduodenal exploration and two of whom had retained stones. It is concluded that common bile duct exploration has a high associated morbidity, particularly due to sepsis and retained stones.

A scientific evaluation of operative choledochoscopy in acute cholangitis

A prospective study to determine the safety and effectiveness of choledochoscopy in acute cholangitis and acute suppurative cholangitis due to common bile duct stones was conducted on 70 patients. Common bile duct pressures determined on the first 20 patients showed that choledochoscopy was unlikely to cause cholangiovenous reflux. Laboratory and clinical parameters revealed that choledochoscopy did not cause septicemia, worsen cholangitis, or provoke acute pancreatitis. There was no iatrogenic injury during choledochoscopy, and the choledochoscopic views were minimally affected by cholangitis. Choledochoscopy detected overlooked stones after conventional methods of exploration of common bile ducts in 14.3% of patients and it helped to remove impacted stones in 2.9% of patients. As a result, the incidence of retained stones after choledochoscopy was 1.4%. Time spent in choledochoscopy was short, and the total postoperative septic complication rate was only 10%. There was no operative mortality. It is concluded that choledochoscopy is safe and effective in cholangitis.

Medical care of the surgical patient with gastrointestinal disease

Common perioperative gastrointestinal disorders of surgical patients are presented. Recommendations for appropriate medical evaluation and management are described.

Is operative cholangiography always necessary?

To determine whether operative cholangiography could be performed on a selective basis, 272 consecutive patients undergoing cholecystectomy and routine operative cholangiography were studied prospectively. Appropriate clinical, biochemical and operative data were recorded and the surgeon was asked to estimate the likelihood of common bile duct stones. These factors were correlated with the subsequent cholangiographic and operative findings. From this information, four criteria were selected as indications for performing an operative cholangiogram: an abnormal common bile duct, a wide cystic duct, or elevated levels of alkaline phosphatase or bilirubin documented in the previous six months. Operative cholangiograms would have been indicated by the presence of one or more of these criteria in only 139 of the 272 patients in the study (51 per cent). Only one unsuspected stone would have been missed. It is concluded that a policy of selective cholangiography could have been safely adopted in this series of patients.

Incidence and associated mortality of retained common bile duct stones

A hundred consecutive patients who underwent cholecystectomy and exploration of the common bile duct were studied. The traditional indications for exploration resulted in a yield of 55 percent positive explorations. There were nine patients with retained stones, three of whom died. The high mortality rate of patients with retained stones stresses the importance of systematic and thorough exploration of the biliary tree during initial operation. Choledochoscopy, when combined with cholangiography, may decrease the incidence of retained stones.

Operative cholangiography--techniques and inadequacies

The effectiveness of three methods of operative cholangiography in outlining biliary anatomy was assessed in 60 patients undergoing routine cholecystectomy for gallbladder calculi. X-rays were scored according to bile duct visualization and an overall score calculated. There were no statistically significant differences between the three groups. However, ductal opacification was inadequate in a majority of patients. It is suggested that closer cooperation with the radiologist and more emphasis on technique are required if cholangiography is used to identify unsuspected calculi.

Incidence of complications with operative choledochoscopy

A 5 year retrospective study of the use of cholangioscopy in 153 difficult biliary cases including stones, strictures, tumors, and anomalies has been reported. In the 88 patients (58 percent) who underwent both operative cholangiography and cholangioscopy, the cholangioscope revealed 11 lesions (13 percent) missed by cholangiography. In this series, eight retained stones (5.2 percent) were detected on postoperative T-tube cholangiography; of this group, two patients had previous biliary surgery, two had an associated neoplasm, and four had incomplete cholangioscopy for various reasons. Postoperative complications included transient bile drainage (8 percent), pancreatitis (8 percent), persistent jaundice (7 percent), cholangitis (5 percent), and abscess (5 percent). Comparison of an operative cholangiography-only group with a cholangioscopy-only group revealed no significant difference in the incidence of postoperative complications. Cholangioscopy did not increase postoperative complications in this study. It frequently detected lesions missed by cholangiography and helped define the nature of the lesions. The incidence of retained stones may be reduced by use of the cholangioscope in difficult biliary cases. Its routine use in common bile duct exploration is recommended.

Critical factors in the image clarity of operative cholangiography

To evaluate image clarity in operative cholangiography with changing radiographic variables, in vitro experiments were performed in which 1-mm radiographically nonopaque biliary calculi in tubes were examined. Variables changed in these studies were tube caliber (6, 13 and 20 mm), contrast concentration (15, 30, and 60%), X-ray exposures (1, 2, 4, 8, 16, 32, 64, and 128 mAs) and location of calculi (central or peripheral). Sensitivity for the detection of calculi and the clarity of contrast radiographic images depended upon these variables. Reduced contrast concentration or increased radiographic exposure were needed for large caliber tubes. Central small calculi required more exposure than peripheral calculi. Practical inferences from these studies can be summarized as guidelines for performing operative cholangiography: (1) Surgeons should become aware of exposure settings used on the radiographic equipment in the operating room. In particular, the milliampere-seconds-setting is an important variable. (2) Normal size and slightly enlarged ducts should be injected with 30% radiographic contrast. (3) Ducts which are 20 mm or more in diameter should be injected with 15% contrast. (4) Variable radiographic exposures may be necessary to demonstrate centrally and peripherally located calculi, especially for small calculi in large ducts.

Use of fiberoptic choledochoscope in common bile duct and intrahepatic duct exploration

This report summarizes our experience with 339 consecutive flexible fiberoptic choledochoscopic examinations performed in the course of 598 common bile duct explorations for biliary tract stones. Routine choledochoscopy added 5 to 10 minutes to the operation and caused no complications. In 81 of the patients, additional stones were discovered with choledochofiberscopy after completion of routine bile duct exploration. Postoperative cholangiography demonstrated a retained stone in 57 patients (two in the common bile duct and 55 in the intrahepatic ducts). Forty-two patients with stones retained in the intrahepatic ducts were diagnosed during operation with the fiberoptic choledochoscope, but those stones were very difficult for us to remove. The accuracy of postexploratory choledochoscopy in diagnosis of stones in the common bile duct and intrahepatic ducts was 99.0% and 90.5%, respectively. Choledochofiberscopy is useful in exploration of the common bile duct and a safe procedure in the diagnosis of biliary tract stones during operation.

Operative cholangiography: is there a statistical alternative?

Data from 424 patients who underwent cholecystectomy were analysed on a computer by both univariate and multivariate methods to determine the factors that identify patients with stones in the common bile duct. The presence of common bile duct stones was associated with increased age (p = 0.003), increased numbers of gallbladder stones (p less than 0.0001), a diagnosis of acute cholecystitis (p = 0.06), and a history of jaundice (chi-square = 22.2; p less than 0.001). A dilated common bile duct was the most significant indicator of the presence of stones (chi-square = 155.5; p less than 0.0001), and a dilated cystic duct was second (chi-square = 47; p less than 0.001). Using multivariate analysis, 89.5 percent of patients were correctly classified as having bile duct stones without the use of cholangiographic data (chi-square = 246.5; p less than 0.0001). Common bile duct diameter and the number of gallbladder stones emerged as the most important variables; additional historical factors, including the presence of jaundice and pancreatitis did not add to their predictive value. If multivariate analysis was used without cholangiographic data, bile duct stones would be missed in 3 percent of patients and unnecessary explorations would be carried out in 7.5 percent.

Peroperative cholangiography: routine or selective?

The detection and removal of common bile duct stones remains a major challenge for the general surgeon. Peroperative cholangiography offers the most reliable method of detection and its routine use is now well accepted. This study of 262 cholecystectomies reassesses the value of this procedure and investigates the recent claim that cholangiography should be performed selectively rather than routinely. With routine cholangiography a positive exploration rate of 66% was achieved and retained stones occurred in 5% of patients with choledocholithiasis. Suggestions are made for ways in which the positive exploration rate could have been greatly improved. Had selective cholangiography been employed 47% of patients would have had the examination, the positive exploration rate would have been 70%, but the retained stone rate might have been 10%. In the light of this there appears little to commend selective cholangiography and we should continue to advise its routine use.

Endoscopic retrograde cholangiopancreatography

The ERCP report in the patient's chart was compared with findings on common duct exploration or cystic duct cholangiography in 72 patients and found to have a sensitivity of 90.4 percent, a specificity of 98 percent, and an accuracy of 95.8 percent. Factors having the potential to influence the accuracy of ERCP were errors in interpretation by the surgeon and the radiologist and the operative technique of cholecystectomy. Also, the interval between the performance of the procedure and operation was particularly important in the patient with multiple small gallstones or small common duct stones. Small gallstones may spontaneously pass from the gallbladder to the common duct, or small common duct stones may spontaneously pass into the duodenum; therefore, the longer the interval between ERCP and operation, the greater the likelihood of a discrepancy. At operation, gallstones may be squeezed into the common duct during manipulation of the gallbladder unless the cystic duct is obstructed before manipulation of the gallbladder. We found ERCP sufficiently accurate to make cystic duct cholangiography unnecessary in most patients with cholelithiasis having a preoperative ERCP examination.

Experience with the flexible fiberoptic choledochoscope

Despite significant effort on the part of surgeons, the incidence of retained calculi after common duct exploration still remains unacceptably high. It seems likely that the best way to reduce the incidence of retained calculi would be a more complete exploration of the common duct at the time of the initial operation. We report our experience with a flexible fiber optic endoscope used intraoperatively in 52 patients and postoperatively in one case to visualize the intrahepatic and extrahepatic bile ducts. In addition to visualization of stones, the choledochoscope has a channel through which various instruments can be passed to facilitate stone removal. Flexible choledochoscopy has been performed 53 times in 52 patients between July 1978 and November 1980. In one patient, the choledochoscope was used to explore the bile ducts via the T-tube tract after operation. In 52 patients, the scope was used intraoperatively: a) two patients demonstrated bile duct tumors, b) in 14, stones were not found on exploration. Of these, one had stenosis at the papilla of Vater and one had external compression of the duct by a pancreatic pseudocyst. All of these findings were confirmed by choledochoscopy, c) in 26 patients choledochoscopy confirmed complete surgical removal of all stones, d) in six patients, multiple stones were removed using routine common duct exploration but additional stones were seen with the choledochoscope, e) in three patients no stones were retrieved on routine duct exploration but were seen using the choledochoscope. In groups (d) and (e) the scope facilitated removal of the remaining stones. In eight cases stones were either grasped or crushed using the accessories of the choledochoscope. In one patient calculi were missed both by routine surgical exploration and choledochoscopy. No septic complications were seen in any of these patients.

Impact of choledochoscopy on the management of choledocholithiasis. Experience with 499 common duct explorations at the Massachusetts General Hospital

This report summarizes the experience with 144 choledochoscopic examinations performed in the course of 499 common bile duct explorations for stones. Routine choledochoscopy added 15--20 minutes to the operation and caused no complications. In 24% of the patients, additional stones were discovered with the choledochoscope after completion of routine bile duct exploration. In spite of this, the incidence of retained stones found postoperatively remained 4%, with or without choledochoscopy. The factors contributing to the failure of choledochoscopy, thus far, to prevent all retained stones are identified as inexperience of surgeons learning to perform biliary endoscopy, failure to scan the biliary tree systematically and thoroughly (including the left hepatic duct), and failure to reach the duodenum with the choledochoscope, meaning failure to see the lower segment of the common duct and ampullary orifice. With a modicum of experience and attention to detail, it should be possible to reduce considerably further the number of retained stones.

Dissolution of retained duct stones by perfusion with monooctanoin via a Teflon catheter introduced endoscopically

Retained bile duct stones in patients who have undergone prior cholecystectomy are removed by operation or endoscopic sphincterotomy. We achieved dissolution of cholesterol duct stones by perfusion with monooctanoin, a commercially available mixture of medium chain glycerides. Sixteen patients were treated in whom endoscopic sphincterotomy was impossible or unsuccessful. In 12 patients, 16 stones were dissolved within 6 to 25 days (mean, 15.6 days). In all successfully treated patients elevated serum liver enzymes became normal during therapy.

Dissolution of common bile duct stones

Retained common duct stones can now be treated by a number of non-operative techniques, including dissolution by cholesterol solvents, simple irrigation, stone extraction via the T tube tract and by endoscopic sphincterotomy. This paper reviews the various solvents available for stone dissolution and its physicochemical basis. When a retained stone is found simple irrigation with saline will be successful in about 50 per cent of patients. If this fails, stone extraction via the T tube tract or by endoscopic sphincterotomy are now the methods of choice, with a 90--95 per cent chance of success. Stone dissolution by cholic acid is slow and is only successful in about 60 per cent of patients but can be of value when stone extraction is unavailable or unsuccessful.

Choledochoscopy as a complementary procedure to operative cholangiography in biliary surgery

Six years' experience with the use of the flexible choledochoscope for biliary is reported. One hundred forty-nine patients underwent common bile duct exploration with choledochoscopy as a complementary procedure. Choledochoscopy immediately showed the absence of stones in 37 patients in whom stones were suspected but the results of preexploratory operative cholangiography were negative or equivocal. The remaining 112 patients underwent choledocholithotomy with choledochoscopy. Only two patients (1.3 percent) returned with unsuspected residual stones. Choledochoscopy used as a complementary procedure to operative cholangiography can easily and more accurately clarify suspicious findings in the operative cholangiogram. It avoids the use of blind instrumental exploration of the bile ducts. Impacted stones can be extracted easily under direct vision with the choledochoscope. We believe that the use of choledochoscopy contributed to our low incidence of retained stones.

Operative cholangiography: evaluation of its routine use in 569 cholecystectomies

From 1974 till 1979, 569 cholecystectomies with routine operative cholangiography were performed in the university surgical unit, Kwong Wah Hospital, Hong Kong, for non-malignant disease of the gallbladder. Gallstones were present in 522 cases. Acalculous cholecystitis occurred in 47 cases. At least one of the clinical or operative indications to explore the common bile duct was present in 312 of the patients. However, in this group of patients in whom routine operative cholangiography was done, exploration of the common bile duct was performed in only 147, thus avoiding unnecessary exploration of the duct in 165 cases (52.8%). In the remaining 257 patients in whom there was no indication to explore the common bile duct, operative cholangiography revealed unexpected stones in the common bile duct in 14 (5.5%). After choledochotomy, post exploratory operative T-tube cholangiography was performed to rule out overlooked stones, which were present in six cases (6/161, i.e., 3.7%). Postoperative T-tube cholangiography performed on the 12th to the 14th postoperative day showed retained stones in 17 cases, giving an incidence of known retained stones of 11% (17/161) of cholecystectomies with exploration of the common bile ducts, or 3% (17/569) in the whole series of cholecystectomies.

Operative choledochoscopy: experience with a rigid choledochoscope

The use of a choledochoscope after exploration of the common bile ducts should minimize the occurrence of retained common bile duct stones. Experience gained at 50 endoscopies with a rigid choledochoscope is reviewed. In 7 cases stones or debris were found remaining in the bile duct. In one case an unsuspected neoplasm was demonstrated and in another a suspected neoplastic stricture was confirmed. In the remaining 41 cases choledochoscopy showed the ducts to be free of stones. Postoperative cholangiography demonstrated a retained stone in 2 cases. There were 2 deaths in the series. The experience of other authors with rigid and flexible scopes is reviewed.

The missing stone

A case of missed stone at cholecystectomy and choledochotomy is described. The theoretical and practical aspects of postoperative cholangiography are discussed. Optimal contrast dilution and radiographic factors are suggested.

Intraoperative common duct pressure and flow measurements

Operative cholangiography is still the most accurate and available method for assessing the presence or absence of stones in the common duct. However, 30 to 40 percent of stones will still be overlooked with cholangiography. To reduce the incidence of overlooked common duct stones we recommended that pressure and flow measurements be obtained before cholangiography. When pressures are high or high normal and flows low, the duct should be explored even in the presence of a normal cholangiogram. Under these circumstances, the incidence of false-positive pressure flow studies is less than 5 percent even in inexperienced hands.

The value of choledochoscopy in exploration of the common bile duct

Direct visualization of the biliary tree using choledochoscopy has been recommended as a technique to improve the accuracy of common duct exploration. In several series the incidence of retained biliary calculi has been dramatically reduced using choledochoscopy, and some authors have reported the findings of other unsuspected benign and malignant lesions as well. During an eight-year period 288 patients underwent exploration of the common bile duct specifically for calculous disease. Operative rigid choledochoscopy was performed in 140 patients in this group, with 79 found to have choledocholithiasis; seven retained stones occurred in this group for an incidence of 8.9%. Routine common duct exploration in the other 148 patients revealed 67 to have choledocholithiasis; six retained stones occurred in this group for an incidence of 9.0%. Though there was no difference in the incidence of retained stones with or without choledochoscopy, 20 patients were found to have stones missed during routine exploration once the rigid choledochoscope was inserted. In addition to the obvious value of the choledochoscope in identifying and removing common duct stones, it was also found to be an aid in removing stones in the intra-hepatic ducts and in clarifying atypical anatomy. Other causes of biliary obstruction such as a liver fluke, benign polyp, benign strictures, and ductal carcinomas were identified by use of biopsy forceps inserted through the choledochoscope. It is recommended that routine choledochoscopy be performed during common duct explorations and that surgical training programs insure that residents learn the technique of operative choledochoscopy.

Experimental and clinical evaluation of cholangiography with xeroradiography

Conventional screen film radiography is compared with xeroradiography in an experimental model for cholangiography. The wider exposure latitude of the xerographic technique confers certain diagnostic advantages. However, the actual clinical application presents practical difficulties, which, combined with low sensitivity, are of such a nature that the method can hardly be considered suitable at the present time. If certain improvements can be made, xeroradiography could become a superior method for radiography of the bile ducts.

Operative choledochoscopy

We have reported the results of 121 examinations with the rigid choledochoscope performed by 13 different surgeons between 1969 and 1977. Pre-exploratory choledochoscopy was performed in 48 patients with a diagnostic accuracy of 94 per cent. Post-exploratory choledochoscopy was used in 73 patients to define whether the common bile duct had been adequately cleared of stones. Fifty-one patients were correctly assessed as having a clear duct and unsuspected residual calculi were demonstrated by choledochoscopy in 13 patients. However, choledochoscopy failed to identify 9 patients with retained stones. The accuracy of post-exploratory choledochoscopy alone was 87 per cent and the accuracy of post-exploratory cholangiography was 82 per cent, but when choledochoscopy was combined with post-exploratory cholangiography there were no errors. We conclude that the addition of choledochoscopy to conventional radiological techniques is likely to reduce the incidence of residual calculi after choledochotomy.

Unsuccessful postoperative extraction of retained common duct stones: an analysis

An analysis of unsuccessful extractions of retained biliary calculi using basket catheters reveals more than half the failures are related to the selection, placement, and size of the T tube. A new T tube has been developed which will improve postoperative access to the common duct and facilitate removal of retained calculi.

Operative fluoroscopy and cholangiography. The use of modern radiologic technics during surgery

Operative cholangiography as currently performed in many hospitals in the United States may be a cumbersome procedure yielding less than optimal information. For maximal accuracy and diagnostic yield, operative radiographic examination of the biliary tract should include fluoroscopic observation and aimed spot films. The advantages gained by using modern radiologic equipment and technics are increased image clarity, increased capability for functional assessment of a dynamic system, increased efficiency, and decreased radiation hazard. In a series of 100 patients undergoing operative cholangiography by our technic, only one retained stone was demonstrated by postoperative studies. Five anomalies of the ductal system were easily identified and possible injury to the anomalous ducts averted. Considering the morbidity and mortality attendant upon inadequate or inappropriate biliary tract operations, investment in the sophisticated equipment necessary for optimal operative radiography is small indeed.

Acute cholecystitis treated by early and delayed surgery. A controlled clinical trial

100 patients with acute cholecystitis (AC) diagnosed by clinical, laboratory, and roentgenological examinations were randomly divided into 2 groups; early surgery (ES), operated within 7 days after the onset of acute symptoms, and delayed (DS), operated 2--3 months after the acute episode. Patients with elevated serum bilirubin and/or amylase were included in the trial. Two patients died during conservative treatment, and in 4 cases medical treatment was interrupted because of peritonitis, and in 3 cases because of increasing jaundice. Recurrence of AC was found in 24% of the patients in the DS group. There was no mortality in the ES group, but 2 patients died postoperatively in the DS group. Wound infection developed in 3 patients in the ES, and in 8 patients in the DS group. Retained stones remained in 3 cases of the DS and in 1 case of the ES group. The operative procedures were easier to perform in the ES group than in the DS, as estimated by the duration of operation. The operation time was 76.7 +/- 4.6 min (mean p S.E.) in the ES and 98.0 +/- 7.3 min in the DS group. There was a statistically significant difference between the 2 groups (p less than 0.01). The results suggest that early surgery in the treatment of acute cholecystitis is recommended. The complications of failed medical treatment can be avoided by early operation without added risk of mortality or complications.