Correspondence
history of jaundice or pancreatitis are all reliable indicators of bile duct stones3. Furthermore. the authors demonstrate that endoscopic retrograde cholangiopancreatography (ERCP) is a more accurate way of detecting duct stones than either IVC or ultrasonography and perform ERCP and endoscopic sphincterotomy on all patients with bile duct stones before operation. Do they therefore now intend to abandon IVC altogether and instead carry out ERCP on all patients with abnormal liver function tests or a history of jaundice or pancreatitis? It would appear from their figures that such a policy would have resulted in eight additional ERCP investigations but would have saved 100 intravenous cholangiograms and up to 60 operative cholangiograms. A. D. N. Scott Professorial Surgical Unit St Bartholomew's Hospital London E C l A 7 B E UK
1. 2. 3.
Pernthaler H, Sandbichler P, Schmid Th, Margraiter R. Operative cholangiography in elective cholecystectomy. Br J Surg 1990; 77: 399-400. Scott ADN, Greville AC, McMillan L, Wellwood JMcK. Laser laparoscopic cholecystectomy - the results of the technique in 210 patients. Ann R Coil Surg Engl (in press). Hauer-Jensen M, Karesen R, Nygaard K et al. Consequences of routine peroperative cholangiography during cholecystectomy for gallstone disease: a prospective, randomised study. World J Surg 1986: 10: 996-1002.
Authors' reply Sir We are grateful for the interest shown by Mr Scott in our paper and would like to address some of the issues raised by him. We would first disagree with his comment that 'The discovery of asymptomatic bile duct stones . . . would probably not be regarded as an indication for conversion to open cholecystectomy'. The natural history of asymptomatic ductal stones is unknown, and factors such as stone size, duct calibre etc. which can all be deduced from an operative cholangiogram must be considered before they can be dismissed as being unimportant. It is true that our one presumed bile duct injury occurred in the presence of a normal operative cholangiogram. However, we have found operative cholangiography very useful in delineating the anatomy in some of our more difficult laparoscopic cholecystectomies. All of our patients with proven duct stones had abnormal liver biochemistry but an equal number of patients with abnormal liver function tests did not have duct stones detected on intravenous or operative cholangiography. It is incorrect to suggest that we are advocating abandoning intravenous cholangiography (IVC) and liberalizing our indications for endoscopic retrograde cholangiopancreatography (ERCP). ERCP has an essential diagnostic and therapeutic role in patients considered for laparoscopic cholecystectomy; its widespread use, of course, should not occur as there are significant risks and a high failure rate associated with it. Our study was taken to assess the value of IVC in identifying ductal stones before operation and to compare it with operative cholangiography. This, we believe, we have adequately shown. We therefore suggest that operative cholangiography should be reserved for selective use provided that the bile duct has been adequately imaged before operation and attention is directed to the clinical and biochemical indicators of bile duct stones. W. P. Joyce Department of Surgery St Vincent's Hospital Dublin 4 Ireland
596
Letter 2
Sir We were interested to read the recent report from Joyce er al. (Br J Surg 1991; 78: 1174-6) advocating the use of intravenous cholangiography (IVC) before laparoscopic cholecystectomy as an alternative to intraoperative cholangiography. Their findings support those of Huddy and Southam', who found that IVC and operative cholangiography are equally reliable at detecting common bile duct (CBD) stones. Huddy and Southam also pointed out that using preoperative IVC instead of operative cholangiography would reduce operating time, provide advance knowledge of biliary anatomy, and allow better planning of the operative procedure. Many surgeons have employed selective operative cholangiography with traditional open cholecystectomy when historical, biochemical or ultrasonographic findings suggest the presence of CBD stones. Since March 1991 we have employed selective preoperative IVC in association with laparoscopic cholecystectomy according to the same criteria. We have reviewed our last 100 cholecystectomies, of which 74 were performed laparoscopically. Twenty-six were planned as open procedures during this early phase of our experience with laparoscopic techniques because of anticipated difficulties (previous upper abdominal incision or an acutely inflamed gallbladder) or because CBD stones were strongly suspected (clinical jaundice or recent pancreatitis). CBD stones were present in ten of the 100 patients. Six of those undergoing open cholecystectomy had CBD stones identified on operative cholangiography and proceeded to duct exploration. Two patients who were jaundiced and two others whose stones were identified by preoperative IVC underwent endoscopic retrograde cholangiopancreatography (ERCP) and duct clearance before proceeding to laparoscopic cholecystectomy. Preoperative IVC was performed selectively in 22 cases on the basis of subclinical abnormalities of liver function tests (bilirubin > 17 pnol/l, alkaline phosphatase > 199 units/l, alanine transaminase >40 units/l) or a CBD > 7 mm in diameter on ultrasonography. Five of the 22 cases undergoing IVC had evidence of CBD stones and therefore proceeded to ERCP. Stones were identified and cleared in two patients, while three others were found to have clear duct systems with evidence that stones had recently passed. The remaining 17 cases had normal ducts on IVC and have therefore been able to avoid unnecessary ERCP. None of the patients has developed clinical features of retained CBD stones after a median follow-up of 5 months. We are pleased with the quality of IVC and, as yet, have recorded no adverse reactions apart from one patient who reported nausea on infusion of contrast. On the basis of these early results, we intend to continue with our policy of using selective preoperative IVC in preference to operative cholangiography. Further follow-up and repeated auditing of our results will be required before the long-term effects of this policy become known.
B. R. Tulloh D. C. R. A d a m S. Haynes K. R. Poskitt Department of Surgery Cheltenham General Hospital Cheltenham GL53 7 A N UK
T. J. Egan P. V. Delaney Limerick Regional Hospital Limerick Ireland
1.
Huddy SPJ, Southam J. Is intravenous cholangiography an alternative to the routine per-operative cholangiogram? Postgrad Med J 1989; 65: 896-9.
Br. J. Surg., Vol. 79, No. 6, June 1992
history of jaundice or pancreatitis are all reliable indicators of bile duct stones3. Furthermore. the authors demonstrate that endoscopic retrograde cholangiopancreatography (ERCP) is a more accurate way of detecting duct stones than either IVC or ultrasonography and perform ERCP and endoscopic sphincterotomy on all patients with bile duct stones before operation. Do they therefore now intend to abandon IVC altogether and instead carry out ERCP on all patients with abnormal liver function tests or a history of jaundice or pancreatitis? It would appear from their figures that such a policy would have resulted in eight additional ERCP investigations but would have saved 100 intravenous cholangiograms and up to 60 operative cholangiograms. A. D. N. Scott Professorial Surgical Unit St Bartholomew's Hospital London E C l A 7 B E UK
1. 2. 3.
Pernthaler H, Sandbichler P, Schmid Th, Margraiter R. Operative cholangiography in elective cholecystectomy. Br J Surg 1990; 77: 399-400. Scott ADN, Greville AC, McMillan L, Wellwood JMcK. Laser laparoscopic cholecystectomy - the results of the technique in 210 patients. Ann R Coil Surg Engl (in press). Hauer-Jensen M, Karesen R, Nygaard K et al. Consequences of routine peroperative cholangiography during cholecystectomy for gallstone disease: a prospective, randomised study. World J Surg 1986: 10: 996-1002.
Authors' reply Sir We are grateful for the interest shown by Mr Scott in our paper and would like to address some of the issues raised by him. We would first disagree with his comment that 'The discovery of asymptomatic bile duct stones . . . would probably not be regarded as an indication for conversion to open cholecystectomy'. The natural history of asymptomatic ductal stones is unknown, and factors such as stone size, duct calibre etc. which can all be deduced from an operative cholangiogram must be considered before they can be dismissed as being unimportant. It is true that our one presumed bile duct injury occurred in the presence of a normal operative cholangiogram. However, we have found operative cholangiography very useful in delineating the anatomy in some of our more difficult laparoscopic cholecystectomies. All of our patients with proven duct stones had abnormal liver biochemistry but an equal number of patients with abnormal liver function tests did not have duct stones detected on intravenous or operative cholangiography. It is incorrect to suggest that we are advocating abandoning intravenous cholangiography (IVC) and liberalizing our indications for endoscopic retrograde cholangiopancreatography (ERCP). ERCP has an essential diagnostic and therapeutic role in patients considered for laparoscopic cholecystectomy; its widespread use, of course, should not occur as there are significant risks and a high failure rate associated with it. Our study was taken to assess the value of IVC in identifying ductal stones before operation and to compare it with operative cholangiography. This, we believe, we have adequately shown. We therefore suggest that operative cholangiography should be reserved for selective use provided that the bile duct has been adequately imaged before operation and attention is directed to the clinical and biochemical indicators of bile duct stones. W. P. Joyce Department of Surgery St Vincent's Hospital Dublin 4 Ireland
596
Letter 2
Sir We were interested to read the recent report from Joyce er al. (Br J Surg 1991; 78: 1174-6) advocating the use of intravenous cholangiography (IVC) before laparoscopic cholecystectomy as an alternative to intraoperative cholangiography. Their findings support those of Huddy and Southam', who found that IVC and operative cholangiography are equally reliable at detecting common bile duct (CBD) stones. Huddy and Southam also pointed out that using preoperative IVC instead of operative cholangiography would reduce operating time, provide advance knowledge of biliary anatomy, and allow better planning of the operative procedure. Many surgeons have employed selective operative cholangiography with traditional open cholecystectomy when historical, biochemical or ultrasonographic findings suggest the presence of CBD stones. Since March 1991 we have employed selective preoperative IVC in association with laparoscopic cholecystectomy according to the same criteria. We have reviewed our last 100 cholecystectomies, of which 74 were performed laparoscopically. Twenty-six were planned as open procedures during this early phase of our experience with laparoscopic techniques because of anticipated difficulties (previous upper abdominal incision or an acutely inflamed gallbladder) or because CBD stones were strongly suspected (clinical jaundice or recent pancreatitis). CBD stones were present in ten of the 100 patients. Six of those undergoing open cholecystectomy had CBD stones identified on operative cholangiography and proceeded to duct exploration. Two patients who were jaundiced and two others whose stones were identified by preoperative IVC underwent endoscopic retrograde cholangiopancreatography (ERCP) and duct clearance before proceeding to laparoscopic cholecystectomy. Preoperative IVC was performed selectively in 22 cases on the basis of subclinical abnormalities of liver function tests (bilirubin > 17 pnol/l, alkaline phosphatase > 199 units/l, alanine transaminase >40 units/l) or a CBD > 7 mm in diameter on ultrasonography. Five of the 22 cases undergoing IVC had evidence of CBD stones and therefore proceeded to ERCP. Stones were identified and cleared in two patients, while three others were found to have clear duct systems with evidence that stones had recently passed. The remaining 17 cases had normal ducts on IVC and have therefore been able to avoid unnecessary ERCP. None of the patients has developed clinical features of retained CBD stones after a median follow-up of 5 months. We are pleased with the quality of IVC and, as yet, have recorded no adverse reactions apart from one patient who reported nausea on infusion of contrast. On the basis of these early results, we intend to continue with our policy of using selective preoperative IVC in preference to operative cholangiography. Further follow-up and repeated auditing of our results will be required before the long-term effects of this policy become known.
B. R. Tulloh D. C. R. A d a m S. Haynes K. R. Poskitt Department of Surgery Cheltenham General Hospital Cheltenham GL53 7 A N UK
T. J. Egan P. V. Delaney Limerick Regional Hospital Limerick Ireland
1.
Huddy SPJ, Southam J. Is intravenous cholangiography an alternative to the routine per-operative cholangiogram? Postgrad Med J 1989; 65: 896-9.
Br. J. Surg., Vol. 79, No. 6, June 1992
