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Intraoperative Cholangiography vs Laparoscopic Ultrasound
point was assurance of true-positive results, which was defined All seven patients underwent ERCP (13.2%). This proportion
as CBD stone extraction by ERCP for the clinically manifested CBD was statistically insignificant (p = 0.8) due to the fact that the
stones if evident during follow-up. selected sample was the low-risk group for CBD stones. Of the seven
LUS was successfully carried out in all 53 patients with a success patients who underwent ERCP, five showed CBD stones and were
rate of 100%, while IOC was successful in 50 patients (94.34%). The extracted, and the finding was included as end point true positive.
difference in the success rate between LUS and IOC was statistically The true incidence of concomitant CBD stones in our series was
insignificant (p = 0.08). These results correlates with the literature 9.43% by ERCP. Our results of accuracy indexes analysis of LUS and
as the IOC success rate was reported to range from 83 to 100% IOC correlate with the literature we reviewed regarding diagnosis
by several studies, such as the systematic review by Ford and of CBD stones. 25
22
colleagues. IOC failure was due to technical problem in the C-arm, The study limitations include the relatively small sample size,
narrow cystic duct that could not be cannulated and thick valves of which may have hindered the detection of significant differences
Heister at the cystic duct totally obscuring the duct lumen. between the two modalities. Further, one of the secondary
IOC took less time to complete compared to LUS in our series, objectives (the evaluation of the liver parenchyma using LUS) could
and this difference was statistically significant (p = 0.001). This can not be investigated, which was due to time restrictions. Future
be explained in part by the fact that LUS takes a longer learning studies should enroll a larger sample size and attempt to avoid the
curve, 23,24 and in this study, it was the first time to utilize this restrictions mentioned in our study. Further, longer-term follow-up
modality; in another part, the IOC requires less laparoscopic surgical may provide more data regarding this comparison.
skills with little familiarity with the technique. We carried out a linear In conclusion, our analysis showed noninferiority between IOC
regression analysis to see if there was a correlation between LUS and LUS in terms of CBD stone detection; however, IOC had a higher
and IOC regarding time to complete. We found a significant positive ability to visualize the anatomy of the biliary tracts and vascular
correlation between LUS and IOC time. The learning curve was structures/anomalies.
longer for LUS than for IOC. LUS took a longer time to complete in
the first 30 patients and then started to decline. IOC had less steep orcId
learning curve with time to complete dropping by 20 patients.
IOC had an accuracy rate of 100% in defining biliary ducts at Mohamed Elkerkary https://orcid.org/0000-0002-3998-265X
the porta hepatis compared to 84.9% (45 patients) for LUS with
a failure rate of 15.1%. Data analysis showed a nonsignificant references
difference between the two modalities (p = 0.6). This failure rate 1. Santambrogio R, Montorsi M, Bianchi P, et al. Common bile duct
can be explained by the difficulty in locating the US probe with exploration and laparoscopic cholecystectomy: role of intraoperative
good alignment to obtain images of biliary structures at the porta ultrasonography. J Am Coll Surg 1997;185(1):40–48. DOI: 10.1016/
hepatis. Further, the imaging planes of LUS are totally different from s1072-7515(97)00013-6.
the classical transverse and longitudinal planes of transabdominal 2. Giger U, Michel JM, Vonlanthen R, et al. Laparoscopic cholecystectomy
US. This issue was raised by several authors and came to the same in acute cholecystitis: indication, technique, risk and outcome.
Langenbeck’s Arch Surg 2005;390(5):373–380. DOI: 10.1007/s00423-
25
conclusion. Similar findings also occurred when evaluating the 004-0509-4.
two modalities for the accuracy in defining extrahepatic biliary 3. Dubois F, Icard P, Berthelot G, et al. Coelioscopic cholecystectomy.
ducts (CBD, CHD, and cystic duct). The failure of LUS was mainly at Ann Surg 1990;211(1):60–62. DOI: 10.1097/00000658-199001000-
the area of the distal CBD, where it was covered by the gases of the 00010.
duodenum, and probably with the increase in the learning curve, 4. Pesce A, Piccolo G, La Greca G, et al. Utility of fluorescent
this issue can be resolved. Several studies demonstrated similar cholangiography during laparoscopic cholecystectomy: a systematic
25
results, making IOC the gold standard in defining biliary anatomy. review. World J Gastroenterol 2015;21(25):7877–7883. DOI: 10.3748/
wjg.v21.i25.7877.
While LUS detected vascular structures in 52 patients, it failed to 5. Ding GQ, Cai W, Qin MF. Is intraoperative cholangiography necessary
demonstrate anomalies in the vascular structures in all patients. during laparoscopic cholecystectomy for cholelithiasis? World J
Owing to the wide variability of vascular anomalies in this region of Gastroenterol 2015;21(7):2147–2151. DOI: 10.3748/wjg.v21.i7.2147.
the human body, the false-negative results have high probability. 6. Connor S, Garden OJ. Bile duct injury in the era of laparoscopic
In the absence of a gold standard test to compare, these results cholecystectomy. Br J Surg 2006;93(2):158–168. DOI: 10.1002/bjs.5266.
cannot be ascertained. 7. Way LW, Stewart L, Gantert W, et al. Causes and prevention
LUS detected CBD stones in 6 out of 53 patients (11.32%), while of laparoscopic bile duct injuries: analysis of 252 cases from a
IOC detected CBD stones in 7 out of 50 patients (14%). The difference human factors and cognitive psychology perspective. Ann Surg
in the rate of detection of CBD stones by the two modalities was 2003;237(4):460–469. DOI: 10.1097/01.SLA.0000060680.92690.E9.
statistically insignificant (p = 0.45). Several studies showed that 8. Hublet A, Dili A, Lemaire J, et al. Laparoscopic ultrasonography as a
good alternative to intraoperative cholangiography (IOC) during
the incidence of concomitant gallstones and CBD stones range laparoscopic cholecystectomy: results of prospective study. Acta
from 11 to 21% at time of surgery. 26,27 In our study, we wanted to Chir Belg 109(3):312–316. DOI: 10.1080/00015458.2009.11680431.
assess the true-positive incidence of CBD stones and to evaluate 9. Halawani HM, Tamim H, Khalifeh F, et al. Impact of intraoperative
the clinically significant proportion. All patients were followed up cholangiography on postoperative morbidity and readmission:
postoperatively for 6 months with expectant approach and were analysis of the NSQIP database. Surg Endosc 2016;30(12):5395–5403.
informed about the possibility of having CBD stones. They were DOI: 10.1007/s00464-016-4896-8.
informed about warning symptoms and instructed to return to the 10. Martin B, Ong EGP. Selective intraoperative cholangiography during
hospital if any occurred plus their follow-up appointments. During laparoscopic cholecystectomy in children is justified. J Pediatr Surg
2018;53(2):270–273. DOI: 10.1016/j.jpedsurg.2017.11.017.
follow-up, seven patients (13.21%) were suspected of having CBD 11. Giulea C, Enciu O, Bîrcǎ T, et al. Selective intraoperative
stones. A former study reported that CBD stones may take up to cholangiography in laparoscopic cholecystectomy. Chirurgia
18 months from LC to manifest clinically. 28 2016;111(1):26–32. PMID: 10917468.

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