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Intraoperative Cholangiography vs Laparoscopic Ultrasound

MAterIAls And Methods distal CBD was identified by injecting another 5 cc of contrast.
Study Population The fluoroscopy arm was shifted cephalad, and another 5 cc of
contrast is injected to visualize the common hepatic duct and the
This cross-sectional study was conducted at the Surgery Department proximal hepatic radicals. When the cholangiogram was done, the
of Suez Canal University Hospital, Ismailia, Egypt. It was performed clamp and catheter were removed and two clips were placed just
on patients who were presented to the surgery outpatient clinic and distal to the ductotomy.
were scheduled for elective LC for symptomatic cholelithiasis. This
study included patients who were scheduled for LC for symptomatic Statistical Analysis
cholelithiasis and were stratified as low-risk of having CBD stones. The formula for the sample size was as follows: n (per
The patients who fulfilled the inclusion criteria were allocated to test) = [α/2 + β/2] * [(p * (1 − p )) + (p * (1 − p ))]/[p − p ]
2
2
2
1
1
1
2
2
a sampling frame and randomized by simple random sampling. where n = the sample size required in each group, p = sensitivity
1
Ethical approval was obtained from the Surgery Department at of LUS in choledocholithiasis = 96%, p = sensitivity of IOC in
2
Suez Canal University Hospital. Patients were notified about the choledocholithiasis = 75%, α depends on desired significance
study, and the informed written consent was obtained prior to level (95%) = 1.96, and β depends on desired power (90%) = 1.28.
participation in the study. Thus, the sample included 53 patients who fulfilled the inclusion
We included patients with symptomatic cholelithiasis between criteria. A data entry form was created using Epi Info 7.0, and
the ages of 18 years (for easy laparoscopic instrumentation the same software was utilized for statistical analysis along
with LUS 10-mm probe) and 65 years (more comorbidities with the SPSS 16 for advanced statistics. Continuous data were
as a relative contraindication to LC). We excluded patients expressed as mean and stander deviation, and categorical data
with contraindications to LC, complicated cholelithiasis were expressed as frequencies and percentages. Continuous
(e.g. obstructive jaundice and acute pancreatitis), previous data with normal distribution were compared using the
gastrointestinal surgery, contrast hypersensitivity, previous Student’s t-test or ANOVA, while the Mann–Whitney/Wilcoxon
endoscopic retrograde cholangiopancreatography (ERCP), and two-sample test was used to compare two-sample variables
CBD stent due to radiological falsies, or conversion to open with other distributions. The accuracy indexes of LUS and IOC
cholecystectomy during LC. were expressed as sensitivity, specificity, positive predictive
value (PPV), negative predictive value (NPV), and diagnostic
Data Collection odds ratio (DOR) with 95% confidence interval. The significance
All enrolled patients were subjected to history taking for level was considered at 0.05×.
exclusion criteria and comorbidities, clinical examination for
signs of cholelithiasis, laboratory investigations (liver functions results
and coagulation profile), and a recent transabdominal US
examination that includes sizes of the gallbladder and CBD, wall Baseline Data
thickness, presence of stones, masses, polyps, or fluid around Our study enrolled 53 patients: 17 males and 3 females. The
the gallbladder, as well as the status of the pancreatic head. mean ages for male and female groups were 41.35 ± 8.48
Patients then underwent intraoperative LUS before dissection and 40.06 ± 11.85 years, respectively (age was statistically
of Calot’s triangle and IOC video fluoroscopy examination of the comparable between both genders; p = 0.69). Of the patients,
extrahepatic biliary tree. 22 (41.5%) had multiple stones and 31 (58.5%) had solitary stones
on preoperative US.
Laparoscopic Ultrasound
We introduced the deflectable multifrequency (7.5–10 MHz) Intra- and Postoperative Complication Rates
endosonography linear probe through a 10-mm port, while the No intraoperative complications occurred in all enrolled
camera was placed through the midepigastric port. First, the liver patients. In terms of 30 days’ follow-up, only nine (17%) had
was scanned and the CBD was identified. The gallbladder and liver postoperative complications that included chest infections (three),
were retracted superiorly and cephalad. Sometimes the junction intraabdominal collection (two), urinary tract infection (one), and
of the right and left hepatic ducts could be seen. The CBD was wound infections (three). No mortalities were recorded during
followed to the duodenum. A transverse view of the bile duct the follow-up period.
could be obtained by acute deflection of the transducer.
LUS vs IOC Success Rates
Intraoperative Cholangiography LUS was successful in all 53 (100%) cases, while IOC was successful
We initially dissected the Calot’s triangle to identify the cystic in 50 (94.3%) cases. Using the Chi-square test to compare the
duct and artery, which was divided between clips. To apply the success rate between LUS and IOC, we observed no significant
cholangiocatheter, we dissected the cystic duct free for about difference between both tests (OR = 1.0061; p = 0.08). The reasons
3 cm and then applied a ligature on the junction of the GB and for the three observed failures in IOC included narrow cystic duct,
the cystic duct. The cholangiocatheter was introduced through thick valves at cystic duct, and technical failure.
the midclavicular port or through a separate puncture in the right
upper quadrant. Utilizing dynamic fluoroscopy, we obtained a Time to Complete the Procedure
scout film to localize the tip of the cholangiocatheter. First, only In terms of the time to complete the procedure, LUS took
2 to 3 cc of a water-soluble contrast dye with 25% concentration 12.53 ± 2.56 minutes to complete with a range of 6 to 17 minutes,
(diatrizoic acid: Gastrografin and sometimes Omnipaque) were while IOC took 8.66 ± 2.77 minutes to complete with a range
injected identifying the cystic duct–CBD junction. The fluoroscopy of 7 to 15 minutes. Comparing both procedures using the
unit was shifted caudally a few centimeters, and the course of the Mann–Whitney/Wilcoxon Test showed a significantly longer

70 World Journal of Laparoscopic Surgery, Volume 14 Issue 2 (May–August 2021)