Abnormal intraoperative cholangiography: Treatment options and long- term follow-up

Objective: To determine the long-term outcome in patients with filling defects on intraoperative cholangiography. Design: Case series; retrospective review. Setting: Community teaching hospital. Patients: All patients (n=872) undergoing cholecystectomy from July 1993 through June 1995. Of 281 intraoperative cholangiograms performed, 89 had abnormal findings. Defects were classified as stone (n=47), unsure (n=29), and artifact (n=13). Medical records were reviewed for immediate and long-term follow-up results. Intervention: Need for common bile duct exploration (CBDE) or endoscopic retrograde cholangiopancreatography (ERCP). Outcome: Morbidity and interventions required 1 to 3 years after surgery. Results: Of the 47 patients with suspected stones, 24 underwent successful operative bile duct clearance. One patient required irrigation. Of the 22 patients who left the operating room with unresolved stones, only 2 ERCPs were required. Of the 29 patients with unsure filling defects, operative clearance was successful in 1; irrigation achieved clearance in 4. Only 1 of the 24 patients who left the operating room with unsure filling defects required subsequent ERCP. Conclusions: Observation of common bile duct defects of 4 mm or smaller is an appropriate clinical alternative. Defects of 5 mm or larger represent a gray area, although few 5- to 8-mm stones will cause subsequent symptoms. In our experience, if stone extraction is clinically important, especially if the patient has jaundice, open CBDE is more effective than transcystic laparoscopic CBDE.