Cholangiography During Laparoscopic Cholecystectomy
Routine
Danny
V.
the accepted procholecystectomy Laparoscopi cedure ofc choice for removal of the gallbladder. The of is
now
performance routine intraoperative cholangiography during open cholecystectomy is controversial,1,2 and the debate continues with regard to the laparoscopic aphas been advocated to diagproach.3 Cholangiographyand nose choledocholithiasis to clarify the ductal anatcase is reported to illustrate this latter indication. A omy.4
tis, Fla.
for
publication
The
proximal common
duct is
found. The distal cystic duct was clipped, and four clips were placed on the cystic artery. An operative cholangiogram showed almost complete occlusion of the proximal common duct (Fig 1). The most proximal clip on the artery was removed and a second roentgenogram (Fig 2) showed restoration of normal ductal anatomy. The postoperative course was uneventful.
partially occluded by a clip.
Fig 2.—The common duct is normal after removing the proximal ar¬ terial clip.
October 5, 1991. F. K. Medical Center, Atlan-
Department of Surgery, J.
Reprint requests to 142 JFK Cir, Atlantis,
Fig l.
tomy was performed. At surgery, hydrops of the gallbladder was
Cantwell).
A 47-year-old man presented with acute cholecystitis at another hospital. The diagnosis was confirmed with a positive biliary flow study and an ultrasound study showing multiple stones, with one impacted in the neck of the gallbladder. The common duct was of normal caliber, but the bilirubin level was slightly elevated at 22 \g=m\mol/L.All other liver enzyme levels were normal. Four weeks later, an elective laparoscopic cholecystecFrom the
MD
COMMENT There is understandable reluctance to carry dissection of the cystic duct well onto the common duct laparoscopically. Bleeding or ductal injury might occur that would be difficult to remedy. Failure to clearly identify the proximal common duct leaves it at risk of potential injury. Opera¬ tive cholangiography can be easily performed laparoscopically with a variety of methods.3,5 The cystic artery and duct are dissected and identified. Clips are usually placed on the artery before the cholangiogram, but it is not divided. The assistant surgeon performs the cholangiog¬ raphy using a mushroom-tipped catheter, as described by Olsen.6 The duct is usually dilated with microscissors to
REPORT OF A CASE
Accepted
Cantwell,
FL 33462 (Dr
—
Downloaded From: http://archsurg.jamanetwork.com/ by a University of Manitoba User on 06/15/2015
facilitate cannulation. C-arm fluoroscopy permits rapid, complete evaluation of the ductal anatomy. The roentgenograms are obtained before dividing any structures in the porta hepatis. An accidental choledochotomy can be easily managed, whereas complete division is a surgical disaster. Unsuspected common duct stones were found in 4% of cases. Experience with repetitive cannulations us¬ ing a dedicated surgical team improved the speed and performance of the procedure. Occasionally, a tiny cystic duct was difficult to cannulate, but the cholangiogram usually added approximately 5 minutes to the operation and was successfully obtained in the last 300 consecutive cases.
This potential common duct injury illustrates the value of the cholangiogram in clarifying the ductal anatomy, even when the critical structures have apparently been identified. The length of the cystic duct and the relation-
ship of the clipped cystic artery to the common duct can be appreciated. Surgeons should consider the potential benefits of performing routine cholangiography rather than rationalize reasons for omitting it. References 1. Gregg RO. The case for selective cholangiography. Am J Surg. 1988;155:540-551. 2. Mills JL, Beck DE, Harford FJ Jr. Routine operative cholangiography. Surg Gynecol Obstet. 1985;161:343-351. 3. Phillips EH, Berci G, Carroll B, Daykhovski L, Sackier J, Paz-Partlow M. The
importance of intraoperative cholangiography during laparoscopic cholecystectomy. Am Surg. 1990;56:792-795. 4. Andr\l=e'\n-SanbergA, Alinder G. Accidental lesions of the common bile duct at cholecystectomy. Ann Surg. 1985;201:328-332. 5. Reddick EJ, Olsen DO. Outpatient laparoscopic laser cholecystectomy. Am J Surg. 1990;160:485-489. 6. Olsen DO. Laparoscopic cholecystectomy. Am J Surg. 1991; 161:339-344.
In Other AMA
journals
ARCHIVES OF INTERNAL MEDICINE A
Prospective Study of Maturity-Onset
Coronary
Diabetes Mellitus and Risk of
Heart Disease and Stroke in Women
Jo Ann E. Manson, MD; Graham A. Colditz, MB, BS; Meir J. Stampfer, MD; Walter C. Willett, MD; S. Krolewski, MD; Bernard Rosner, PhD; Ronald A. Arky, MD; Frank E. Speizer, MD; Charles H. Hennekens, MD
Andrzej
We examined the relationship of maturity-onset clinical diabetes mellitus with the subsequent incidence of coronary heart disease, stroke, total cardiovascular mor¬ tality, and all-cause mortality in a cohort of 116 177 US women who were 30 to 55 years of age and free of known coronary heart disease, stroke, and cancer in 1976. During 8 years of follow-up (889 255 person-years), we identified 338 nonfatal my¬ ocardial infarctions, 111 coronary deaths, 259 strokes, 238 cardiovascular deaths, and 1349 deaths from all causes. Diabetes was associated with a markedly increased risk of nonfatal myocardial infarction and fatal coronary heart disease (age-adjusted relative risk [RR] 6.7; 95% confidence interval [CI], 5.3 to 8.4), ischemie stroke (RR 5.4; 95% CI, 3.3 to 9.0), total cardiovascular mortality (RR 6.3; 95% CI, 4.6 to 8.6), and all-cause mortality (RR 3.0; 95% CI, 2.5 to 3.7). A major independent effect of diabetes persisted in multivariate analyses after simultaneous control for other known coronary risk factors (for these end points, RR [95% CI] 3.1 [2.3 to 4.2], 3.0 [1.6 to 5.7], 3.0 [1.9 to 4.8], and 1.9 [1.4 to 2.4], respectively). The absolute excess coronary risk due to diabetes was greater in the presence of other risk fac¬ tors, including cigarette smoking, hypertension, and obesity. These prospective data indicate that maturity-onset clinical diabetes is a strong determinant of cor¬ onary heart disease, ischemie stroke, and cardiovascular mortality among middleaged women. The adverse effect of diabetes is amplified in the presence of other cardiovascular risk factors, many of which are modifiable. (Arch Intern Med. =
=
=
=
=
1991;151:1141-1147). Reprint requests
to 180
Longwood Ave, Boston,
MA 02115
(Dr Manson).
Downloaded From: http://archsurg.jamanetwork.com/ by a University of Manitoba User on 06/15/2015
Routine
Danny
V.
the accepted procholecystectomy Laparoscopi cedure ofc choice for removal of the gallbladder. The of is
now
performance routine intraoperative cholangiography during open cholecystectomy is controversial,1,2 and the debate continues with regard to the laparoscopic aphas been advocated to diagproach.3 Cholangiographyand nose choledocholithiasis to clarify the ductal anatcase is reported to illustrate this latter indication. A omy.4
tis, Fla.
for
publication
The
proximal common
duct is
found. The distal cystic duct was clipped, and four clips were placed on the cystic artery. An operative cholangiogram showed almost complete occlusion of the proximal common duct (Fig 1). The most proximal clip on the artery was removed and a second roentgenogram (Fig 2) showed restoration of normal ductal anatomy. The postoperative course was uneventful.
partially occluded by a clip.
Fig 2.—The common duct is normal after removing the proximal ar¬ terial clip.
October 5, 1991. F. K. Medical Center, Atlan-
Department of Surgery, J.
Reprint requests to 142 JFK Cir, Atlantis,
Fig l.
tomy was performed. At surgery, hydrops of the gallbladder was
Cantwell).
A 47-year-old man presented with acute cholecystitis at another hospital. The diagnosis was confirmed with a positive biliary flow study and an ultrasound study showing multiple stones, with one impacted in the neck of the gallbladder. The common duct was of normal caliber, but the bilirubin level was slightly elevated at 22 \g=m\mol/L.All other liver enzyme levels were normal. Four weeks later, an elective laparoscopic cholecystecFrom the
MD
COMMENT There is understandable reluctance to carry dissection of the cystic duct well onto the common duct laparoscopically. Bleeding or ductal injury might occur that would be difficult to remedy. Failure to clearly identify the proximal common duct leaves it at risk of potential injury. Opera¬ tive cholangiography can be easily performed laparoscopically with a variety of methods.3,5 The cystic artery and duct are dissected and identified. Clips are usually placed on the artery before the cholangiogram, but it is not divided. The assistant surgeon performs the cholangiog¬ raphy using a mushroom-tipped catheter, as described by Olsen.6 The duct is usually dilated with microscissors to
REPORT OF A CASE
Accepted
Cantwell,
FL 33462 (Dr
—
Downloaded From: http://archsurg.jamanetwork.com/ by a University of Manitoba User on 06/15/2015
facilitate cannulation. C-arm fluoroscopy permits rapid, complete evaluation of the ductal anatomy. The roentgenograms are obtained before dividing any structures in the porta hepatis. An accidental choledochotomy can be easily managed, whereas complete division is a surgical disaster. Unsuspected common duct stones were found in 4% of cases. Experience with repetitive cannulations us¬ ing a dedicated surgical team improved the speed and performance of the procedure. Occasionally, a tiny cystic duct was difficult to cannulate, but the cholangiogram usually added approximately 5 minutes to the operation and was successfully obtained in the last 300 consecutive cases.
This potential common duct injury illustrates the value of the cholangiogram in clarifying the ductal anatomy, even when the critical structures have apparently been identified. The length of the cystic duct and the relation-
ship of the clipped cystic artery to the common duct can be appreciated. Surgeons should consider the potential benefits of performing routine cholangiography rather than rationalize reasons for omitting it. References 1. Gregg RO. The case for selective cholangiography. Am J Surg. 1988;155:540-551. 2. Mills JL, Beck DE, Harford FJ Jr. Routine operative cholangiography. Surg Gynecol Obstet. 1985;161:343-351. 3. Phillips EH, Berci G, Carroll B, Daykhovski L, Sackier J, Paz-Partlow M. The
importance of intraoperative cholangiography during laparoscopic cholecystectomy. Am Surg. 1990;56:792-795. 4. Andr\l=e'\n-SanbergA, Alinder G. Accidental lesions of the common bile duct at cholecystectomy. Ann Surg. 1985;201:328-332. 5. Reddick EJ, Olsen DO. Outpatient laparoscopic laser cholecystectomy. Am J Surg. 1990;160:485-489. 6. Olsen DO. Laparoscopic cholecystectomy. Am J Surg. 1991; 161:339-344.
In Other AMA
journals
ARCHIVES OF INTERNAL MEDICINE A
Prospective Study of Maturity-Onset
Coronary
Diabetes Mellitus and Risk of
Heart Disease and Stroke in Women
Jo Ann E. Manson, MD; Graham A. Colditz, MB, BS; Meir J. Stampfer, MD; Walter C. Willett, MD; S. Krolewski, MD; Bernard Rosner, PhD; Ronald A. Arky, MD; Frank E. Speizer, MD; Charles H. Hennekens, MD
Andrzej
We examined the relationship of maturity-onset clinical diabetes mellitus with the subsequent incidence of coronary heart disease, stroke, total cardiovascular mor¬ tality, and all-cause mortality in a cohort of 116 177 US women who were 30 to 55 years of age and free of known coronary heart disease, stroke, and cancer in 1976. During 8 years of follow-up (889 255 person-years), we identified 338 nonfatal my¬ ocardial infarctions, 111 coronary deaths, 259 strokes, 238 cardiovascular deaths, and 1349 deaths from all causes. Diabetes was associated with a markedly increased risk of nonfatal myocardial infarction and fatal coronary heart disease (age-adjusted relative risk [RR] 6.7; 95% confidence interval [CI], 5.3 to 8.4), ischemie stroke (RR 5.4; 95% CI, 3.3 to 9.0), total cardiovascular mortality (RR 6.3; 95% CI, 4.6 to 8.6), and all-cause mortality (RR 3.0; 95% CI, 2.5 to 3.7). A major independent effect of diabetes persisted in multivariate analyses after simultaneous control for other known coronary risk factors (for these end points, RR [95% CI] 3.1 [2.3 to 4.2], 3.0 [1.6 to 5.7], 3.0 [1.9 to 4.8], and 1.9 [1.4 to 2.4], respectively). The absolute excess coronary risk due to diabetes was greater in the presence of other risk fac¬ tors, including cigarette smoking, hypertension, and obesity. These prospective data indicate that maturity-onset clinical diabetes is a strong determinant of cor¬ onary heart disease, ischemie stroke, and cardiovascular mortality among middleaged women. The adverse effect of diabetes is amplified in the presence of other cardiovascular risk factors, many of which are modifiable. (Arch Intern Med. =
=
=
=
=
1991;151:1141-1147). Reprint requests
to 180
Longwood Ave, Boston,
MA 02115
(Dr Manson).
Downloaded From: http://archsurg.jamanetwork.com/ by a University of Manitoba User on 06/15/2015
