Intra-operative or CT cholangiography- which is better for biliary imaging in laparoscopic cholecystectomy?

Australia: The use of intra-operative cholangiography (IOC) in laparoscopic cholecystectomy (LC) is controversial. However, a recent study published in BMC Surgery has shown CTC (CT cholangiography) or IOC for biliary imaging to be beneficial in reducing bile leak and bile duct injury.

The findings suggest that preoperative CTC may offer a reliable alternative for assessing biliary anatomy, potentially reducing operating times, complication rates, and open conversions. In a retrospective analysis, researcher Douglas Chung aimed to evaluate the safety and effectiveness of routine preoperative CTC compared to routine IOC.:

A single-centre retrospective analysis was conducted, involving all elective laparoscopic cholecystectomies performed between 2017 and 2021. Data were collected from a general surgical database and electronic medical records. Among the 1,079 patients included in the study, 129 (12.0%) underwent routine preoperative CTC, 786 (72.8%) underwent routine IOC, and 161 patients (14.9%) did not undergo either modality.

● Comparing the CTC and IOC groups, the CTC group showed higher rates of open conversion (3.1% vs. 0.6%, p = 0.009), subtotal cholecystectomies (3.1% vs. 0.8%, p = 0.018), and longer hospital stays (1.47 vs. 1.18 nights, p = 0.015).

● When comparing the CTC and IOC groups combined against those who did not undergo either modality, the latter group had reduced operative time (66.29 vs. 72.47 minutes, p = 0.011).

● However, they also experienced an increased rate of bile leak (1.9% vs. 0.4%, p = 0.037) and bile duct injury (1.2% vs. 0.2%, p = 0.049).

● Linear regression analysis revealed a co-dependence between operative complications.

The study findings support the use of biliary imaging, either CTC or IOC, in reducing the incidence of bile leak and bile duct injury during laparoscopic cholecystectomy. Therefore, the routine use of biliary imaging in LC is recommended. However, routine IOC demonstrated superiority over routine CTC in terms of preventing conversions to open surgery and subtotal cholecystectomy. Further research is needed to establish criteria for a selective CTC protocol, which may help optimize the balance between effectiveness and efficiency in surgical decision-making.

It is important to note that the study was retrospective, and further prospective research is warranted to validate these findings and explore additional factors that may impact the selection of biliary imaging modalities in laparoscopic cholecystectomy.

Reference:

Chung, D. (2023). Comparison of pre-operative computed tomography cholangiography and intraoperative cholangiography in laparoscopic cholecystectomy: a retrospective analysis. BMC Surgery, 23(1), 187. https://doi.org/10.1186/s12893-023-02089-1.