Page 17 - World Journal of Laparoscopic Surgery

ORIGINAL ARTICLE
Intraoperative Cholangiography during Cholecystectomy

Using a Biliary-nose Tube: Routinely Used in Patients with

Main Bile Duct Stones

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Salvatore Fazzotta , Gaspare Genova , Gianni Pantuso , Salvatore Buscemi , Vincenzo Davide Palumbo , Giuseppe Damiano ,
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Attilio Ignazio Lo Monte , Pietro Genova 8
AbstrAct
Background: Nowadays, the “gold standard” treatment for gallbladder stones is laparoscopic cholecystectomy but the risk of iatrogenic biliary
duct injuries is increased compared to “open” surgery. Intraoperative cholangiography (IOC) can be useful to avoid biliary injuries but it can also
be a no-safe procedure in center in which it is not routinely performed.
Aim and objective: The aim of our study is to trust the efficacy of IOC in a patient with common bile duct (CBD) and gallbladder stones using
a biliary-nose tube.
Materials and methods: 135 patients with gallbladder and CBD stones were treated with sequential therapy and randomly divided into two
groups. Laparoscopic cholecystectomy was performed within 24/48 h. During endoscopic retrograde cholangiopancreatography, a biliary-nose
catheter was left to perform cholangiography during the following surgical procedure. Group A had also a cholangiography at the beginning
of the surgical procedure in order to evidence biliary duct structure.
Results: Cholangiography avoided a lesion of the biliary ducts in nine patients. Only a patient had a residual stone in the CBD. The dissection
at Calot’s triangle was faster in group A patients without differences between the surgeons involved.
Conclusion: The biliary-nose tube can be useful in patients with gallbladder and CBD who underwent cholecystectomy for different reasons:
it lets the surgeon performing IOC faster and without risk linked to the technique used; it reduces the risk of biliary injuries; and surgeons feel
more safe and calm during the surgical procedure.
Keywords: Endoscopic sphincterotomy, endoscopic retrograde cholangiopancreatography, Gallbladder stones, Laparoscopy, Video laparoscopic
cholecystectomy.
World Journal of Laparoscopic Surgery (2021): 10.5005/jp-journals-10033-1425

bAckground
1–8 Department of Surgical, Oncological and Stomatological Disciplines
Today the “gold standard” treatment of gallbladder stones (DICHIRONS), University of Palermo, Palermo, Italy
is laparoscopic cholecystectomy. Nevertheless, the risk of an Corresponding Author: Salvatore Buscemi, Department of Surgical,
iatrogenic injury of the biliary ducts has increased from two to four Oncological and Stomatological Disciplines (DICHIRONS), University
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times compared to “open” surgery. The incorrect visualization of of Palermo, Palermo, Italy, Phone: +39 3357593376, e-mail: salvatore.
the cystic duct, the common bile duct (CBD), and the cystic artery is buscemi02@unipa.it
often responsible for lots of injuries in both techniques. 3,4 How to cite this article: Fazzotta S, Genova G, Pantuso G, et al.
Anatomical changes can involve the hepato-cystic triangle, due Intraoperative Cholangiography during Cholecystectomy Using a
to acute or chronic inflammatory phenomena, as well as frequent Biliary-nose Tube: Routinely Used in Patients with Main Bile Duct
5,6
anatomical variations. They have always been an important Stones. World J Lap Surg 2021;14(1):15–19.
element of operative outcome and they can reduce long-term Source of support: Nil

survival and patient’s quality of life. 7,8 Conflict of interest: None
In 1932, Mirizzi developed intraoperative cholangiography (IOC),
an imaging technique to evidence biliary ducts intraoperatively. 9
This method has been widely applied in North American The introduction in 1974 of endoscopic retrograde
clinical practice in association with open cholecystectomy since cholangiopancreatography (ERCP) with the endoscopic
the early 1950s. 10 sphincterotomy, offered for the first time an alternative to
At the beginning of the technique, surgeons explored the reoperation for the treatment of residual CBD stones. 15
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CBD biliary tract during the cholecystectomy in 30–65% of cases. Video laparoscopic cholecystectomy (VLC) in 1988, opened
However, surgical exploration of CBD was associated with a significant again the debate around the routine or selective use of IOC for the
increase in mortality and morbidity. Based on these observations, a increased CBD iatrogenic lesions associated with VLC. 16,17 Different
routine use of the IOC associated with cholecystectomy has been factors can be involved: the incorrect identification of the anatomical
proposed. 11,12 The IOC associated with open cholecystectomy structures; a large number of anatomical biliary duct variations and
decreased the incidence of misrecognition of asymptomatic vascular abnormalities; the anatomical changes due to prolonged
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lithiasis of the CBD that is 7%. The routine use of IOC reduces the and repeated inflammatory processes involving the gallbladder and
requirement of CBD surgical exploration from 66% to <5%. 14 the adjacent tissues; and surgeons learning curve. 18–20

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