Page 18 - World Journal of Laparoscopic Surgery

Intraoperative Cholangiography Using a Biliary-nose Tube
Nowadays, IOC has a marginal role in lots of surgical centers Table 1: Form used to divide patients into two subgroups
because few surgeons use it routinely, most of them use it Age <40 years −1
occasionally or do not use it. 21,22 >40 years +1
Nowadays, ultrasound (US) technology, the ERCP, and MRI allow
a higher diagnostic accuracy on the stones’ presence. 23,24 Sex Male +1
On the other hand, lots of studies showed that the IOC Female −1
associated with the VLC decreases the incidence of misrecognition Murphy’s sign Negative −1
of asymptomatic CBD stones that is usually around 7%. 13,25 It can also Positive +1
avoid possible complications linked to the surgical procedure. 26–28 Symptoms time- Recent/accidental reporting/asymptomatic −1
In addition, ERCP stones removal with the “inverse sequential” frame <2 years −1
treatment may not be always successful and this situation requires >2 years +1
to carry out a new surgical procedure. 29,30 Previous episodes of jaundice or subitterus +1
Moreover the surgical centers in which IOC is not routinely
used, reported a higher risk of biliary injuries performing IOC than No previous episodes of jaundice or subitterus −1
in centers in which IOC is routinely performed. 31–33 Jaundice at first diagnosis +1
For these reasons, we designed a prospective randomized Previous episodes of cholangitis +1
study to verify the usefulness of routinely IOC during laparoscopic Previous episodes of cholecystitis +1
cholecystectomy, using a biliary-nose tube, inserted in a patient Previous recurrent biliary pain +1
having main bile duct stones, previously treated by ERCP. Previous biliary pain sporadic and infrequent −1
US abdominal Non complicated −1
Aims And objectives findings Complicated +1
This prospective randomized study aim is to verify the importance MRI valuation Normal anatomy −1
of IOC during laparoscopic cholecystectomy, testing its features in Possible alterations +1
avoiding biliary injuries especially in difficult anatomical conditions. If the sum was ≥0, the patient belonged in the risk group of complicated
We also tried to propose a form taking into account patients’ surgical dissection
features to hypothesize the surgical complexity of the procedure.

Table 2: Study parameters considering the applied form of Table 1
mAteriAls And methods
We enrolled in our study patients with gallbladder and CBD stones Study parameters Group A Group B
diagnosed at US and MRI, undergoing endoscopic sphincterotomy Number of patients 68 67
before laparoscopic cholecystectomy. In all patients, a biliary- Male 22 21
nose tube had been left inside the bile duct during ERCP and Female 46 46
cholecystectomy had been performed in 24/48 hours after Risk group expected (≥0) 45 (66.2%) 42 (62.7%)
endoscopic sphincterotomy. No-risk group expected (<0) 23 (33.8%) 25 (37.3%)
In the period from January 1, 2011 to December 31, 2015, 135 IOC before dissection Yes No
patients with inclusion criteria were recruited. Patients’ age ranged IOC before cutting Yes Yes
from 41 to 84 years, 43 were male (31.8%) and 92 female (68.1%).
Anamnestic data were collected for each patient, as well as all Positioning time radiological equipment 5′12″ 4′40″
(minutes)
the diagnostic data obtainable from the instrumental exams used
to do the diagnosis.
Some features taken from clinical history and imaging data
were taken into account to develop an evaluation form that In group A, the ICO was performed through the biliary-nose tube
could allow to preview surgical dissection difficulties. In the form, at the beginning of the surgical procedure and once isolated the
we attributed the number 1 with a negative sign (−) when the cystic duct and artery. In group B, the ICO was performed after
predictivity of difficulties was negative and with a positive sign (+) dissection, before cystic duct and artery section.
if it was positive (Table 1). According to the preoperative study form, we hypothesized
In patients with a positive-sum (risk group), we expected to find 87 patients (64.4%) who have had unfavorable local anatomical
altered locoregional anatomical conditions, while in the negative- conditions (risk group) and 48 (35.5%) in which unfavorable
sum (no-risk group), these conditions were not expected. In cases locoregional conditions were not expected (no-risk group).
of a sum equal to 0, the patient was attributed to the subgroup of In group A, after random division, 68 patients were included
those with probable alterations. with 45 patients (66.1%) of risk group. In group B were enrolled 67
We divided all the patients randomly into two groups (Table 2) patients, including 25 (37.3%) of no-risk group and 42 (62.6%) of
and we valued: risk group.
All the procedures were performed by three different surgeons:
• The real correspondence with the prediction of anatomical two seniors, who had done 382 and 259 open cholecystectomies,
findings; respectively, with an IOC percentage of 83% and 87%, 150 and 167
• The time needed in surgical dissection; VLC with an IOC percentage of 6 and 7.2%; a junior surgeon, younger
• The biliary duct integrity; and not expertise, who had done 29 open cholecystectomies
• IOC time; performing an IOC in 12 cases (41.4%) and 47 VLC with an IOC in
• The presence of residual stones in CBD. 6 cases (12.7%).

16 World Journal of Laparoscopic Surgery, Volume 14 Issue 1 (January–April 2021)