Operative cholangiography. The case for selective instead of routine operative cholangiography.
The role of routine operative cholangiography was studied prospectively in 124 surgical patients undergoing cholecystectomy over a 23-month period. The reliability of preoperative and operative clinical risk factors for common bile duct (CBD) pathology were correlated with the operative and cholangiographic findings. Though several of these clinical risk factors (jaundice, dilated CBD, elevated alkaline phosphotase) were present in over 80 per cent of the patients with CBD pathology, none had an overall predictive accuracy greater than 40 per cent. The operative cholangiogram was superior to the clinical criteria in distinguishing patients with common bile duct pathology from those patients with disease limited to the gallbladder provided that a dilated CBD was not considered an absolute indication for CBD exploration. Operative cholangiography was the best overall screening test for identifying patients with CBD pathology. A subgroup of patients was identified in whom this screening test was not needed. Of our study group, 44 per cent had no clinical risk factors for CBD pathology present, and no unsuspected CBD calculi were found by the use of routine cholangiography in any of these patients. Based on this clinical study and a critical review of the current literature, adequate evidence to support the policy of routine operative cholangiography was not found. In fact, a policy of selective cholangiography performed only on patients clinically at risk of having CBD pathology appears indicated. This approach would not only decrease the incidence of negative CBD exploration, but also would reduce the overall cost of cholecystectomy by 52 million dollars annually without any increase in patient risk.