The long-term follow-up of patients with positive intraoperative cholangiograms during laparoscopic cholecystectomy

Excerpt

We read with interest the article by Wagner et al. [3]. The authors successfully highlighted that simple transcystic maneuvers may clear common bile duct (CBD) stones in 71% of cases with a positive intraoperative cholangiogram that would otherwise have a postoperative endoscopic retrograde cholangiopancreatography (ERCP). It remained unclear why patients who had open common bile duct exploration (CBDE) were excluded from the group of patients with attempted transcystic clearance and whether a decision to proceed to open CBDE was made on cholangiographic evidence. Simple transcystic manipulation of CBD stones has been shown to be effective, as evidenced by retained stone clearance in an x-ray department following saline flushing through a T-tube after 1 mg glucagon injection[1]. In our experience, 52 of 279 abnormal cholangiograms were clear after flushing with glucagon injection (18.6%) and a further 37 were clear after dormia basket trawling under fluoroscopy (13.3%) prior to the insertion of a choledochoscope. However, this was achieved in a series of 1,408 all-comers treated by single-session management, 28% of whom were emergent admissions with deranged LFTs and/or jaundice. In units without the equipment and expertise for performing laparoscopic choledochoscopic bile duct exploration, the normal practice would be preoperative magnetic resonance cholangiopancreatography (MRCP) followed by ERCP for patients with suspected CBD stones. The authors have demonstrated that simple transcystic manipulation can clear the ducts to avoid unnecessary cost and prolonged inpatient stay. The simple techniques described should be easily performed by most surgeons practicing laparoscopic cholecystectomy. …