Objective: To define the incidence of problematic common bile duct calculi in patients undergoing laparoscopic cholecystectomy.
Summary Background Data: In patients selected for laparoscopic cholecystectomy, the true incidence of potentially problematic common bile duct calculi and their natural history has not been determined. We evaluated the incidence and early natural history of common bile duct calculi in all patients undergoing laparoscopic cholecystectomy with intraoperative and delayed postoperative cholangiography.
Methods: Operative cholangiography was attempted in all patients. In those patients in whom a filling defect was noted in the bile duct, the fine bore cholangiogram catheter was left securely clipped in the cystic duct for repeated cholangiography at 48 hours and at approximately 6 weeks postoperatively.
Results: Operative cholangiography was attempted in 997 consecutive patients and was accomplished in 962 patients (96%). Forty-six patients (4.6%) had at least one filling defect. Twelve of these had a normal cholangiogram at 48 hours (26% possible false-positive operative cholangiogram) and a further 12 at 6 weeks (26% spontaneous passage of calculi). Spontaneous passage was not determined by either the number or size of calculi or by the diameter of the bile duct. Only 22 patients (2.2% of total population) had persistent common bile duct calculi at 6 weeks after laparoscopic cholecystectomy and retrieved by endoscopic retrograde cholangiopancreatography.
Conclusions: Choledocholithiasis occurs in 3.4% of patients undergoing laparoscopic cholecystectomy but more than one third of these pass the calculi spontaneously within 6 weeks of operation and may be spared endoscopic retrograde cholangiopancreatography. Treatment decisions based on assessment by operative cholangiography alone would result in unnecessary interventions in 50% of patients who had either false positive studies or subsequently passed the calculi. These data support a short-term expectant approach in the management of clinically silent choledocholithiasis in patients selected for LC.
Although laparoscopic cholecystectomy has been widely adopted as the procedure of choice for gallbladder removal, there is uncertainty about the management of common bile duct calculi in this setting. This is particularly so for those patients where choledocholithiasis is not predicted by preoperative imaging, usually ultrasonography of the biliary tree. In such circumstances many surgeons do not perform routine operative cholangiography, and clinical experience suggests that the frequency of subsequent symptoms or complications from biliary calculi is low and in the order of 2-3%. This is 30-50% less than that predicted by operative cholangiography, suggesting overdiagnosis, spontaneous passage, or silent persistence of many common duct calculi. A significant proportion of patients may therefore undergo unnecessary biliary instrumentation with its inherent morbidity and mortality.1-5 Where a confident diagnosis of choledocholithiasis was made, 20-50% patients who underwent preoperative endoscopic retrograde cholangiopancreatography (ERCP) had no demonstrable calculi.6-11 Similarly, almost 20-40% of patients who have bile duct filling defects at per-operative cholangiography have either a negative surgical bile duct exploration or a negative postoperative ERCP.12-14
Patient selection for biliary intervention has been flawed partly because of the lack of a sensitive noninvasive imaging modality and also because the incidence and natural history of asymptomatic common bile duct calculi has not been determined in patients selected for laparoscopic cholecystectomy. In this study of patients undergoing laparoscopic cholecystectomy, we prospectively define the true incidence of common bile duct calculi and their early natural history by undertaking intraoperative cholangiography and delayed postoperative cholangiography in those who had demonstrable intraoperative filling defects in their bile ducts.