Endoscopy 2004; 36(12): 1045-1049
DOI: 10.1055/s-2004-825955
Original Article
© Georg Thieme Verlag KG Stuttgart · New York

Selective Endoscopic Cholangiography for the Detection of Common Bile Duct Stones in Patients with Cholelithiasis

D.  Katz1 , M.  Nikfarjam1 , A.  Sfakiotaki1 , C.  Christophi1
  • 1 Dept. of Surgery, University of Melbourne, Austin Hospital, Victoria, Australia
Further Information

Publication History

Submitted 30 January 2004

Accepted after Revision 28 July 2004

Publication Date:
01 December 2004 (online)

Background and Study Aims: The detection and management of common bile duct (CBD) stones in patients undergoing laparoscopic cholecystectomy continues to be controversial. Several diagnostic and therapeutic strategies have been suggested. These include intraoperative cholangiography, selective endoscopic retrograde cholangiopancreatography (ERCP), magnetic resonance cholangiopancreatography, and endoscopic ultrasonography. The aim of this study was to evaluate the efficacy of selective ERCP in detecting CBD stones in patients with cholelithiasis before laparoscopic cholecystectomy.
Patients and Methods: In a prospective study, patients with cholelithiasis who presented during a 6-year period were assessed on a selective basis with ERCP for suspected CBD stones before laparoscopic cholecystectomy. ERCP was carried out if the patient had any of the following criteria: a dilated CBD on ultrasound, gallstone pancreatitis, or abnormal liver function tests. Intraoperative cholangiography was not performed in any of the patients. Long-term follow-up was undertaken.
Results: The study included 427 patients. On the basis of selective criteria, ERCP was carried out in 41 patients (9.6 %), with confirmed CBD stones in 22 cases (53.7 %). The most useful predictor of CBD stones on ERCP was the presence of a dilated CBD in association with abnormal liver function tests. In this situation, CBD stones were identified in 14 of 17 cases (82 %). Abnormal liver function tests alone had a sensitivity of 50 % (four of eight). All other parameters used in isolation had a lower detection rate. During a median follow-up period of 6 years (range 1-10 years), six of 386 patients (1.6 %) with initially normal imaging and biochemical tests presented again with retained stones. All were successfully managed by ERCP and sphincterotomy. There were no major complications.
Conclusions: Preoperative selective ERCP is effective in detecting clinically significant CBD stones. However, there is a high false-negative rate when a single criterion is used to guide therapy. Multivariate analysis of preoperative parameters for risk stratification, in conjunction with other imaging modalities, may make it possible to minimize unnecessary ERCPs.

References

  • 1 Diagnosis and treatment of common bile duct stones (CBDS). Results of a consensus development conference. Scientific Committee of the European Association for Endoscopic Surgery (E.A.E.S.).  Surg Endosc. 1998;  12 856-864
  • 2 Rosenthal R J, Steigerwald S D, Imig R, Bockhorn H. Role of intraoperative cholangiography during endoscopic cholecystectomy.  Surg Laparosc Endosc. 1994;  4 171-174
  • 3 Topal B, Van de Moortel M, Fieuws S. et al . The value of magnetic resonance cholangiopancreatography in predicting common bile duct stones in patients with gallstone disease.  Br J Surg. 2003;  90 42-47
  • 4 Buscarini E, Tansini P, Vallisa D. et al . EUS for suspected choledocholithiasis: do benefits outweigh costs? A prospective, controlled study.  Gastrointest Endosc. 2003;  57 510-518
  • 5 Fulcher A S. MRCP and ERCP in the diagnosis of common bile duct stones.  Gastrointest Endosc. 2002;  56 S178-182
  • 6 Jendresen M B, Thorboll J E, Adamsen S. et al . Pre-operative routine magnetic resonance cholangiopancreatography before laparoscopic cholecystectomy: a prospective study.  Eur J Surg. 2002;  168 690-694
  • 7 Flowers J L, Zucker K A, Graham S M. et al . Laparoscopic cholangiography: results and indications.  Ann Surg. 1992;  215 209-216
  • 8 Rosseland A R, Glomsaker T B. Asymptomatic common bile duct stones.  Eur J Gastroenterol Hepatol. 2000;  12 1171-1173
  • 9 Nataly Y, Merrie A E, Stewart I D. Selective use of preoperative endoscopic retrograde cholangiopancreatography in the era of laparoscopic cholecystectomy.  Aust NZ J Surg. 2002;  72 186-189
  • 10 Bergamaschi R, Tuech J J, Braconier L. et al . Selective endoscopic retrograde cholangiography prior to laparoscopic cholecystectomy for gallstones.  Am J Surg. 1999;  178 46-49
  • 11 Kruis W, Roehrig H, Hardt M. et al . A prospective evaluation of the diagnostic work-up before laparoscopic cholecystectomy.  Endoscopy. 1997;  29 602-608
  • 12 Choudari C P, Fogel E, Kalayci C. et al . Therapeutic biliary endoscopy.  Endoscopy. 1999;  31 80-87
  • 13 Taylor O M, Sedman P C, Jones B M. et al . Laparoscopic cholecystectomy without operative cholangiogram: 2038 cases over a 5-year period in two district general hospitals.  Ann R Coll Surg Engl. 1997;  79 376-380
  • 14 Thornton D J, Robertson A, Alexander D J. Laparoscopic cholecystectomy without routine operative cholangiography does not result in significant problems related to retained stones.  Surg Endosc. 2002;  16 592-595
  • 15 Barkun J S, Fried G M, Barkun A N. et al . Cholecystectomy without operative cholangiography: implications for common bile duct injury and retained common bile duct stones.  Ann Surg. 1993;  218 371-377; discussion 377-379
  • 16 Binmoeller K F, Schafer T W. Endoscopic management of bile duct stones.  J Clin Gastroenterol. 2001;  32 106-118
  • 17 Phillips E H. Routine versus selective intraoperative cholangiography.  Am J Surg. 1993;  165 505-507
  • 18 Nies C, Bauknecht F, Groth C. et al . [Intraoperative cholangiography as a routine method? A prospective, controlled, randomized study; in German.] .  Chirurg. 1997;  68 892-897
  • 19 Sarli L, Pietra N, Franze A. et al . Routine intravenous cholangiography, selective ERCP, and endoscopic treatment of bile duct stones before laparoscopic cholecystectomy.  Gastrointest Endosc. 1999;  50 200-208
  • 20 Chan A C, Chung S C, Wyman A. et al . Selective use of preoperative endoscopic retrograde cholangiopancreatography in laparoscopic cholecystectomy.  Gastrointest Endosc. 1996;  43 212-215
  • 21 Schreurs W H, Juttmann J R, Stuifbergen W N. et al . Management of common bile duct stones: selective endoscopic retrograde cholangiography and endoscopic sphincterotomy: short- and long-term results.  Surg Endosc. 2002;  16 1068-1072
  • 22 Onken J E, Brazer S R, Eisen G M. et al . Predicting the presence of choledocholithiasis in patients with symptomatic cholelithiasis.  Am J Gastroenterol. 1996;  91 762-767
  • 23 Wang C H, Mo L R, Lin R C. et al . Rapid diagnosis of choledocholithiasis using biochemical tests in patients undergoing laparoscopic cholecystectomy.  Hepatogastroenterology. 2001;  48 619-621
  • 24 Trondsen E, Edwin B, Reiertsen O. et al . Prediction of common bile duct stones prior to cholecystectomy: a prospective validation of a discriminant analysis function.  Arch Surg. 1998;  133 162-166
  • 25 Kama N A, Atli M, Doganay M. et al . Practical recommendations for the prediction and management of common bile duct stones in patients with gallstones.  Surg Endosc. 2001;  15 942-945
  • 26 Demartines N, Eisner L, Schnabel K. et al . Evaluation of magnetic resonance cholangiography in the management of bile duct stones.  Arch Surg. 2000;  135 148-152
  • 27 Koo K P, Traverso L W. Do preoperative indicators predict the presence of common bile duct stones during laparoscopic cholecystectomy?.  Am J Surg. 1996;  171 495-499
  • 28 Abboud P A, Malet P F, Berlin J A. et al . Predictors of common bile duct stones prior to cholecystectomy: a meta-analysis.  Gastrointest Endosc. 1996;  44 450-455
  • 29 Del Santo P, Kazarian K K, Rogers J F. et al . Prediction of operative cholangiography in patients undergoing elective cholecystectomy with routine liver function chemistries.  Surgery. 1985;  98 7-11
  • 30 Frey C F, Burbige E J, Meinke W B. et al . Endoscopic retrograde cholangiopancreatography.  Am J Surg. 1982;  144 109-114
  • 31 Acosta M J, Rossi R, Ledesma C L. The usefulness of stool screening for diagnosing cholelithiasis in acute pancreatitis: a description of the technique.  Am J Dig Dis. 1977;  22 168-172
  • 32 Calvo M M, Bujanda L, Calderon A. et al . Role of magnetic resonance cholangiopancreatography in patients with suspected choledocholithiasis.  Mayo Clin Proc. 2002;  77 422-428
  • 33 Fulcher A S, Turner M A, Capps G W. et al . Half-Fourier RARE MR cholangiopancreatography: experience in 300 subjects.  Radiology. 1998;  207 21-32
  • 34 Reinhold C, Taourel P, Bret P M. et al . Choledocholithiasis: evaluation of MR cholangiography for diagnosis.  Radiology. 1998;  209 435-442
  • 35 Soto J A, Barish M A, Alvarez O, Medina S. Detection of choledocholithiasis with MR cholangiography: comparison of three-dimensional fast spin-echo and single- and multisection half-Fourier rapid acquisition with relaxation enhancement sequences.  Radiology. 2000;  215 737-745
  • 36 Becker C D, Grossholz M, Becker M. et al . Choledocholithiasis and bile duct stenosis: diagnostic accuracy of MR cholangiopancreatography.  Radiology. 1997;  205 523-530
  • 37 Prat F, Amouyal G, Amouyal P. et al . Prospective controlled study of endoscopic ultrasonography and endoscopic retrograde cholangiography in patients with suspected common bile duct lithiasis.  Lancet. 1996;  347 75-79
  • 38 Canto M I, Chak A, Stellato T, Sivak M V. Endoscopic ultrasonography versus cholangiography for the diagnosis of choledocholithiasis.  Gastrointest Endosc. 1998;  47 439-448
  • 39 Chak A, Hawes R H, Cooper G S. et al . Prospective assessment of the utility of EUS in the evaluation of gallstone pancreatitis.  Gastrointest Endosc. 1999;  49 599-604
  • 40 Sivak M V Jr. EUS for bile duct stones: how does it compare with ERCP?.  Gastrointest Endosc. 2002;  56 S175-177
  • 41 Mark D H, Flamm C R, Aronson N. Evidence-based assessment of diagnostic modalities for common bile duct stones.  Gastrointest Endosc. 2002;  56 S190-194

C. Christophi, M. D.

Department of Surgery, University of Melbourne

Austin Hospital, LTB 8 · Studley Road, Heidelberg · Melbourne, Victoria 3084 · Australia

Fax: +61-3-9458 1650 ·

Email: surgery-armc@unimelb.edu.au