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Symptomatic retained gallstones are a rare but potentially morbid condition. Post-cholecystectomy patients presenting with vague complaints or perihepatic abscesses should be considered for retained gallstones. Traditional treatment was incision and drainage or exploratory laparotomy with washout. The current standard is minimally invasive procedures. In this case report, two different and unpublished combination methods between surgery and interventional radiology were used to extract retained stones. The first patient underwent needle-wire localization pre-operatively to identify the retained stone. The surgeon cut down along the wires and excised the stone. The second patient had a 10 French drain placed to drain the abscess surrounding the stone. The surgeon cut down along the drain, as the drain's pigtail and retained stone were located in the abscess cavity. Based on this case report, we propose using the successful method of combined interventional radiology and general surgery procedures to excise larger and deeper retained dropped gallstones., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Gallstone ileus is an uncommon but well-described occurrence in general surgery. However, discrepancy regarding optimal surgical management with 1 or 2 stage operation is still debated. This case report presents a 73-year-old woman who presented to the emergency department (ED) with a small bowel obstruction due to a gallstone lodged in a portion of the proximal ileum. The patient was also noted to have persistent cholelithiasis and cholecystoduodenal fistula. A single-stage surgery involving enterolithotomy, cholecystectomy, fistula repair, and cholangioscopy was performed. The patient progressed well and was discharged home without recurrent symptoms. Therefore, in a hemodynamically stable patient with persistent cholelithiasis or choledocholithiasis, it is reasonable to perform a definitive single-stage operation., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Gallstone ileus is a rare complication of complicated gallbladder disease. Typically the result of a cholecystocholeduodenal fistula, a gallstone enters the small bowel and impacts in the ileum causing an obstruction. In this case study, a 74-year-old male presented to the emergency department with nausea, vomiting, and constipation for 2 weeks. CT revealed pneumobilia and a 3.1 cm calcified mass in the terminal ileum. The patient was successfully treated with a robotic-assisted enterotomy alone without complications.

Laparoscopic cholecystectomy has become the gold standard for patients with gallbladder disease. However, spilled gallstones occur in up to 18% of laparoscopic cholecystectomies, which may result in retained gallstones. Though most do not cause issues, there may be abscess formation from 4 months to 10 years postoperatively. We present a 78-year-old patient who formed a subhepatic abscess 3 months postoperatively from his laparoscopic cholecystectomy secondary to a 1 cm retained gallstone. The abscess was percutaneously drained by interventional radiology (IR), and the stone was subsequently removed by IR using a percutaneous approach. Open and laparoscopic approaches have been previously described for abscess drainage and removal of gallstones. In this case, both the abscess and stone were drained and removed percutaneously by IR. Though this is an uncommon entity, percutaneous decompression can aid in preventing such patients from undergoing additional surgery.

Background: Cholelithiasis is a common gallbladder finding leading to cholecystitis in 7% of cases. Sonographic imaging or computed tomography scans are commonly employed for the diagnosis of benign gallbladder disease. Air within the gallbladder might carry various diagnoses. As opposed to pathologic air in the gallbladder seen in emphysematous cholecystitis, gas-containing gallstones are no more pathological than the exclusive presence of gallstones. In the present report, we review the incidence, physiology, typical characteristics, and clinical significance of gas-containing gallstones within the gallbladder., Methods: We performed an institutional review of all patients with benign gallbladder disease over the past 16 years (2005 to 2021) to identify patients with gas-containing gallstones in the gallbladder. We performed a review of the literature following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) to identify all reported cases of patients with gas-containing biliary calculi within the gallbladder., Results: Our institutional review identified 5 patients with gas-containing biliary calculi in 1252 consecutive cholecystectomies; 4 of which had cholecystitis, while 1 was an incidental finding. Our review of the literature identified 30 manuscripts documenting 54 unique patients with gas-containing biliary calculi. None of these patients had consequential pathology related to gas in the stones other than that caused by the gallstones (ie, biliary colic and cholecystitis)., Conclusions: Gas-containing biliary calculi are uncommon. How gas finds itself within gallstones within the gallbladder is not entirely clear. Gas-containing gallstones should not be interpreted as free gas within the gallbladder or within an abscess.

Background: Whether concomitant cholecystectomy is needed during laparoscopic sleeve gastrectomy (LSG) in patients with asymptomatic cholelithiasis is controversial. In this study, our aim is to show the follow-up results in patients with asymptomatic cholelithiasis who underwent LSG alone., Methods: Patients undergoing primary LSG between March 2018 and September 2020 with asymptomatic gallbladder stones were included in this retrospective study. All patients underwent abdominal ultrasound (US) before surgery. Patients' demographics and postoperative outcomes were recorded., Results: A total of 180 patients underwent primary LSG and completed the 1-year follow-up. The study population consisted of 42 patients (23%) with asymptomatic cholelithiasis. The mean age was 41.1±7.1 years (31-56, 63% female), and mean body mass index (BMI) was 44 ± 6.7 kg/m 2 . Average BMI decreased to 31.1 ± 4.7 kg/m 2 at 6 months and to 27.3 ± 3.6 kg/m 2 at 1 year. The average follow-up period was 17 ± 5.7 months (range, 12-28 months). Of the 42 patients, only 1 patient (2.4%) became symptomatic during the follow-up period., Discussion: We do not recommend cholecystectomy in patients with asymptomatic gallstones during the same session with LSG. An observational approach should be adopted for these patients.

Laparoscopic cholecystectomy remains one of the most common surgical operations. Common bile duct stones (CBDS) are estimated to be present in 10%-20% of individuals with symptomatic gallstones. Preoperative magnetic resonance cholangiopancreatography (MRCP) and intraoperative cholangiography (IOC) remain the most common methods of evaluation, with subsequent endoscopic retrograde cholangiopancreatography (ERCP) for stone extraction if positive for CBDS. We examined our experience with preoperative MRCP versus IOC for the management of the jaundiced patient with cholelithiasis. This is a retrospective single-institution study that examined all laparoscopic cholecystectomies performed over a 15-month period between 2017 and 2018. Outpatient elective cases were excluded from the analysis. Charts were reviewed for demographics, operative details, and whether an MRCP, IOC, or ERCP was performed. Data were evaluated using a 2-sample t -test. A total of 460 patients underwent laparoscopic cholecystectomy over a 15-month period. Of those, 147 underwent either an MRCP or an IOC for clinical suspicion for CBDS. ERCP after MRCP was nontherapeutic in 11/32 (34%) compared with 2/12 (17%) of patients following IOC. The sensitivity and specificity of MRCP were 91% and 80%, respectively, with a positive predictive value of 66% and a negative predictive value of 96%. The sensitivity and specificity of IOC were 83% and 97%, respectively, with a positive predictive value of 83% and a negative predictive value of 97%. MRCP and IOC have unique advantages and disadvantages. MRCP has greater sensitivity, but poor specificity, resulting in unnecessary ERCPs with associated morbidity and increased costs to the patient.

The finding of gallbladder polyps on imaging studies prompts further workup. Imaging results are often discordant with final pathology. The goal of this study is to compare polypoid lesions of the gallbladder found on preoperative ultrasound (US) with final pathologic diagnosis after cholecystectomy to help guide clinical decision-making. A retrospective study was conducted identifying adult patients who were diagnosed with polyps via US and who underwent cholecystectomy from 2008 through 2015. Imaging data, final pathology, and demographics were manually reviewed. A total of 2290 cholecystectomy patients had US-based polyps. Of these, 1661 patients (73%) did not have polyps on final pathology; primarily, stones or sludge were identified. Adenomyosis was diagnosed in 61 patients (2.7%). A total of 556 patients (24.2%) had pathologic polypoid lesions with the following breakdown: 463 (20.2%) cholesterol polyps, 43 other benign polyps (1.8%), 40 adenomas (1.7%), and 10 adenocarcinomas (0.4%). All patients with adenocarcinoma were older than 40 years and 91 per cent had US findings of polyps >10 mm. Ultrasound alone is an unreliable method of detecting real gallbladder polyps. This large database study found a very low risk of cancer. Size on US and patient age should be considered in the selection of appropriate surgical candidates with sonographic "polyps."

Several studies addressed that preoperative endoscopic retrograde cholangiopancreatography (ERCP) for common bile duct (CBD) clearance, followed by interval laparoscopic cholecystectomy (two-stage approach), constitutes the most common practice in cases of uncomplicated mild acute biliary pancreatitis. Between June 1998 and December 2002, 44 patients (35 females and 9 males with a median age of 62 years) suffering from uncomplicated mild acute biliary pancreatitis were treated in our unit. All patients were electively submitted to surgery after subsidence of the acute symptoms, and for definitive treatment we favored the single-stage laparoscopic management, avoiding preoperative ERCP. All patients underwent laparoscopic cholecystectomy plus fluoroscopic intraoperative cholangiogram (IOC). If filling defect(s) were detected in the IOC, a finding suggestive of concomitant choledocholithiasis, laparoscopic common bile duct exploration (LCBDE) was added in the same sitting. Twenty patients were operated upon within 2 weeks since the attack of the acute symptoms and constitute the early group (n=20), whereas 24 patients underwent an operation later on and constitute the delay group (n=24). We retrospectively compare the safety, effectiveness, and outcome after the single-stage laparoscopic management between the two groups of patients. Laparoscopic cholecystectomy alone constituted the definitive treatment in 38 patients, while an additional LCBDE was performed in the remaining 6 patients (14%), and all operations were achieved laparoscopically. There was no statistically significant difference between the groups in terms of operative time, incidence of concomitant choledocholithiasis, morbidity rate, and postoperative hospital stay. During the follow-up, none of the patients experienced recurrent pancreatitis. In uncomplicated mild acute biliary pancreatitis cases, a single-stage definitive laparoscopic management, avoiding preoperative ERCP, can be safely performed during the same admission, after the improvement of symptoms and local inflammation. Postoperative ERCP should be selectively used in patients in whom the single-stage method failed to resolve the problem.

Approximately 20 per cent of laparoscopic cholecystectomies performed for acute cholecystitis require conversion to open cholecystectomy because of severe inflammation. In a retrospective review of 125 consecutive patients undergoing laparoscopic surgery for gallbladder disease from January 1995 through June 1997, 31 had acute cholecystitis. Eight patients underwent a subtotal cholecystectomy because of severe inflammation. There were no conversions to open cholecystectomy and no intraoperative complications. Selected patients were evaluated and treated for common duct stones with preoperative endoscopy to avoid intraoperative cholangiography. One patient had a retained common duct stone successfully managed with postoperative endoscopy. Laparoscopic subtotal cholecystectomy is a safe and effective alternative to conversion to open cholecystectomy for severe inflammation associated with acute cholecystitis. Endoscopic assessment and treatment of common duct stones when indicated either before or after surgery omits the use of intraoperative cholangiography and potential injury to the inflamed ducts.

A prospective study of patients with symptomatic cholelithiasis was undertaken to determine the effectiveness of identifying clinically significant choledocholithiasis with selective cholangiography. Between 1991 and 1995, 262 patients presented to the senior author (K.W.M.) with acute or chronic cholecystitis. Sixteen patients had a preoperative endoscopic retrograde cholangiopancreatography (ERCP) for an elevated alkaline phosphatase or total bilirubin greater than twice the normal value or an ultrasound finding suspecting choledocholithiasis. Ten of the ERCP patients had choledocholithiasis, with eight patients having successful clearance by ERCP. Ninety other patients had intraoperative cholangiography for abnormal serum liver biochemistries, a history of jaundice or pancreatitis, or a dilated common bile duct (CBD) (>6 mm) on ultrasound. Fourteen of the intraoperative cholangiography patients and the two remaining ERCP patients had choledocholithiasis requiring CBD exploration for clearance of their stones. There were no false-positive cholangiograms, and there were no bile duct injuries in this series. With 100 per cent follow-up of at least 2 years, only one patient required ERCP clearance of a retained CBD stone 13 months after cholecystectomy. The positive predictive value and the negative predictive value for the selective cholangiography criteria are 23 per cent and 99 per cent, respectively. In conclusion, clinically significant choledocholithiasis can be found effectively with selective cholangiography. Also, utilizing selective cholangiography reduces the number of routine cholangiograms by 60 per cent.

Intraoperative cholangiography was first introduced by Mirizzi in 1931. He recommended its routine use. The debate over the appropriate role of intraoperative cholangiography was renewed by the widespread acceptance of laparoscopic cholecystectomy in 1988. We reviewed our experience to determine the most appropriate use of intraoperative cholangiography. Seven hundred thirty-four consecutive cases of laparoscopic cholecystectomy performed between January 1, 1991 and December 31, 1993 were reviewed. The Routine Group of 276 cases, performed by 3 surgeons practicing routine cholangiography, was compared to the Selective Group of 458 cases, performed by 16 surgeons practicing selective cholangiography. The groups were similar in terms of age, sex, and extent of disease. No statistically significant difference was found between the two groups in number of successful cholangiograms, filling defects, misinterpretation of cholangiograms, complications, or length of hospitalization. One common duct injury occurred in the Routine Group. The rate of conversion to open cholecystectomy was higher in the Routine Group. A cholangiogram added 14 minutes to the average duration of surgery and $737 to the average cost. We found that routine cholangiography did not increase common duct stone detection, did not decrease common duct injury, and did not increase technical skill, but it did increase cost. We feel that intraoperative cholangiography should be used selectively where choledocholithiasis is suspected or biliary anatomy is unclear.

Management of a common duct stone detected during laparoscopic cholecystectomy remains controversial. Although endoscopic retrograde cholangiopancreatography with sphincterotomy is a procedure preferred by many authors, it has a reported 15 per cent reported morbidity, 1 per cent mortality, 5 per cent failure rate, and 5 per cent incidence of late ampullary stenosis. Cystic duct dilatation with the introduction of a choledoscope and a basket remains an alternative but has a risk of a common duct tear and difficulty in manipulation of instrument should the cystic duct enter the common duct at an angle, and it causes difficulty in extraction of larger stones. In our experience, a choledochotomy with removal of stones during the laparoscopic cholecystectomy is a satisfactory direct approach. We reviewed all of the cholecystectomies performed in the regional hospital since the introduction of the laparoscopic technique. There were 425 cases of laparoscopic cholecystectomies performed with cholangiography, with detection of a stone in 11 patients. In these patients, choledochotomies were performed by making an incision on the anterior surface of the common duct using scissors. The cystic duct should not be divided following cholangiography since provided traction. Following exploration using a Fogarty catheter, a T tube was placed, and a T tube cholangiogram was performed prior to its removal. With this technique, we successfully removed the stones in 10 cases. In one, an impacted stone was removed in the X-Ray Department, 6 weeks postoperative and enables cholecystectomy and bile duct stones to be removed in one session with no increase in morbidity or mortality.

To evaluate the prevailing methods of management and assess the safety of laparoscopic treatment of choledocholithiasis, a retrospective review of all common bile duct explorations (CBDE) initiated during laparoscopic cholecystectomy at the Medical College of Georgia was performed. From December 1990 until December 1994, 604 laparoscopic cholecystectomies were performed. In 28 of these patients (26 female, 2 male) with an age range of 17 to 60 years, CBDE was initiated; 21 were performed laparoscopically, and 7 were converted to open CBDE. The procedure was successful in completely clearing the duct of stones in 24 of 28 cases (17 laparoscopic, 7 open). Postoperative endoscopic retrograde cholangiopancreatography was successfully employed in three of the cases of retained stones, and in the fourth, the stone was felt to be small enough to pass without further intervention. Biliary balloon catheters were successfully used to clear the duct in 8 of 17 laparoscopic CBDEs, and a laparoscopic choledochoscope introduced through the cystic duct was used in 7 cases; both were used in 2 cases. The open CBDEs were performed in standard fashion utilizing balloon catheters and choledochoscopy. The only operative complications were the four above-mentioned cases of retained stones. In summary, choledocholithiasis encountered during the course of laparoscopic cholecystectomy can frequently be managed with a laparoscopic CBDE.

Perioperative endoscopic retrograde cholangiopancreatography (ERCP) and sphincterotomy (ES) offer the ability to remove common bile duct stones (CBDS) and still use the laparoscopic technique for cholecystectomy. The accuracy of predicting choledocholithiasis has been variable in several studies. The indications and complications of perioperative ERCP and ES with laparoscopic cholecystectomy (LC) are presented here. Between 6/1/90 and 11/11/93, 484 LC were performed at Santa Barbara Cottage Hospital. A total of 38 patients underwent perioperative ERCP; 33 patients underwent preoperative ERCP with 3/33 (9%) failing to cannulate the ampulla; 15 patients had choledocholithiasis; and 14/15 (93%) were cleared by ES. Fifteen patients had a normal CBD on ERCP. There were no deaths in this group of patients, seven of 38 (18%) had complications, including bleeding and post ERCP hyperamylasemia. Patients who had a normal CBD and underwent preoperative ERCP (9/15, 60%) had a history of gallstone pancreatitis or hyperamylasemia that was resolved or resolving before ERCP. Patients without stones on ERCP or cholangiogram (11/15, 73%) had a normal bilirubin (avg. 1.0 mg/dL; Range 0.4-2.3). Patients with choledocholithiasis (8/15, 53%) had a history of jaundice or elevated bilirubin before ERCP (avg. 2.59 mg/dL; range 0.2-9.3). ERCP with ES and laparoscopic cholecystectomy is a safe and effective method for the management of symptomatic cholelithiasis with choledocholithiasis. A history of gallstone pancreatitis or hyperamylasemia that is resolving or resolved in the absence of an elevated bilirubin does not require preoperative ERCP before LC with cholangiogram.

At Georgia Baptist Medical Center, 1616 patients underwent laparoscopic cholecystectomy between December 1989 and December 1992; and 103 perioperative endoscopic retrograde cholangiopancreatography (ERCP) procedures were performed, 79 preoperative and 24 postoperative. Endoscopic sphincterotomy with stone extraction was performed in 49 patients (4.7%). Normal ERCP was noted in 46 patients (44%), four patients failed stone extraction preoperatively, and two patients failed extraction postoperatively (5.7%). Four patients had small stones (< 2 mm) managed expectantly without sphincterotomy. Ten laparoscopic common bile duct explorations and eight open common bile duct explorations were performed without retained stones after these procedures. The incidence of detected choledocholithiasis requiring intervention was 4.4 per cent, which is significantly lower than the published incidence of 8 to 15 per cent. It is assumed that a higher percentage of stones may have been detected with liberal or routine use of cholangiography. The clinical significance of these potentially missed stones have not been manifest in our series to date. The authors believe that although improved patient selection may lower the percentage of normal ERCP, this combination of minimally invasive techniques provides a satisfactory approach to choledocholithiasis.

Laparoscopic cholecystectomy has emerged as the treatment of choice for uncomplicated cholelithiasis. Despite early concerns, many surgeons have applied this new technique to more complicated biliary tract disease states, including biliary pancreatitis. To evaluate the safety of laparoscopic cholecystectomy in this setting, we retrospectively reviewed 29 patients with clinical and laboratory evidence of biliary pancreatitis who underwent this procedure between March 1990 and December 1992. The severity of pancreatitis was determined by Ranson's criteria. Two patients had a Ranson's score of 6, one of 5, one of 4, five scored 3, nine scored 2, nine also scored 1, and two patients scored 0. The mean serum amylase level on admission was 1,610 (range 148 to 7680). All patients underwent laparoscopic cholecystectomy during the same hospital admission for biliary pancreatitis, with the mean time of operation being 5.5 days from admission. Operative time averaged 123 minutes (range 60-220 minutes). Intraoperative cholangiography was obtained in 76 per cent of patients. Three patients had choledocholithiasis on intraoperative cholangiography and were treated with choledochoscopy, laparoscopic common bile duct exploration, and saline flushing of the duct. The mean length of hospital stay was 11 days (range 5-32 days). There were seven postoperative complications requiring prolonged hospitalization with all but one treated non-operatively. One patient with a preoperative Ranson score of 6 developed necrotizing pancreatitis and subsequently required operative pancreatic debridement and drainage. There were no deaths in this series and no postoperative wound infections. The average recovery period for return to work was 2 weeks. These statistics compare favorably with literature reports for open cholecystectomy in biliary pancreatitis.(ABSTRACT TRUNCATED AT 250 WORDS)

The management of suspected and/or unsuspected common bile duct (CBD) stones in patients undergoing laparoscopic cholecystectomy (LC) is controversial. Decisions on whether to perform an open CBD exploration versus employing therapeutic options such as preoperative/post-operative endoscopic retrograde cholangiography (ERCP) or endoscopic duct exploration are polemic. To determine indications, timing, benefits, and potential morbidity of these approaches, we gathered data on 401 patients undergoing LC within the last 18 months. Indications for preoperative ERCP included jaundice (40%), dilated ducts (28%), elevated amylase (19%) or alkaline phosphatase (21%), suspicion of CBD stones by ultrasound (17%) and "other" (17%). Indications for postoperative ERCP were retained stones (33%) and CBD evaluation (67%). Indications for CBD exploration included abnormal cholangiogram (64%), palpable stones (18%), and other (18%). A significant correlation was observed between suspected stones by ultrasound and stones found by ERCP (P < 0.01). For patients in the "other" category, preoperative ERCP was universally negative (P = 0.04). Overall ERCP morbidity was 4/59 (6.8%), and the overall failure rate for clearing CBD stones was 2/28 (7.1%). The timing of the ERCP did not affect morbidity/mortality. Multivariate analysis revealed that age (P << 0.001), the presence of pre-existing medical risk factors (P << 0.001), and duration of LC (P = 0.0034), but not ERCP (P = 0.08), were the important factors determining LC morbidity. In summary, common bile duct stones can be successfully cleared endoscopically in the majority of patients undergoing LC. Patients with suspected CBD stones should undergo pre-operative ERCP, and strict criteria should be applied in the selection of these patients.(ABSTRACT TRUNCATED AT 250 WORDS)

The high incidence of calculous biliary tract disease accounts for surgical operation upon the biliary tract disease accounts for surgical operation upon the biliary tract being the most frequently performed within the abdomen. Untreated surgically critical sequelae tend to occur with advancing age and duration of the disease. The more common of these are: acute cholecystitis, choledocholithiasis, acute obstructive suppurative cholangitis, biliary enteric fistulas, liver abscess, related pancreatitis, and biliary cirrhosis. The greater the pathological changes in the biliary tract and the more debilitated the individual, the greater is the risk of surgery. However, the risk is even greater without operation.

The pseudocalculus formation was first noted by Caroli in 1960, and was first called a sign by Beneventano and Schein in 1968. It is a cholangiographic illusion that appears as a filling defect in the distal common bile duct when static or "spot" films are exposed during the contractile phase of choledochal sphincter activity. Although first noted and most frequently seen in T-tube cholangiography, it is seen also during intravenous and intraoperative cholangiography. Because it mimics radiographically an impacted stone in the distal common bile duct, its delineation is critical to avoid unnecessary instrumentation of the common bile duct or even reoperation. In this review the authors discuss briefly the anatomy and physiology of the distal common bile duct and the etiology, differential diagnosis, and recognition of the pseudocalculus sign.

Two-hundred and seven consecutive patients with suspected choledocholithiasis were treated at three university-affiliated hospitals. Twenty-one patients had residual common bile duct (CBD) stones documented after previous biliary tract operations and 28 patients had retained stones in the CBD on predischarge postoperative t-tube cholangiograms. Use of operative cholangiography was analyzed to determine correlation with the incidence of retained and residual CBD stones. Operative cystic duct cholangiography was not done in any patient who developed residual stones after simple cholecystectomy. Twenty-five of the 28 patients (86%) with retained stones either left the operating room with an abnormal postexploration cholangiogram or did not have a postexploration cholangiogram. Only three patients (10%) had falsely negative postexploration t-tube cholangiograms. The percentage of abnormal postoperative CBD exploration cholangiograms that showed filling defects as opposed to ampullary obstruction was significantly higher in patients with retained stones versus patients not having retained stones (P less than or equal to 0.0009). The vast majority of cases of retained and residual stones could be attributed to poor surgical judgment regarding either use or interpretation of operative cholangiography.

This case is reported because of its rarity and in order to demonstrate that, using ERCP, it can be difficult at times to differentiate not only primary from metastatic diseases of the common duct, but also both of these malignant conditions from benign choledocholithiasis.

In six patients who had undergone cholecystectomy and common bile duct exploration, the postoperative T-tube cholangiogram demonstrated stones. Endoscopic cholangiography demonstrated a normal common bile duct in 2 patients and stones in 4 patients. In the latter group, endoscopic papillotomy and stone extraction were successful.

The role of routine operative cholangiography was studied prospectively in 124 surgical patients undergoing cholecystectomy over a 23-month period. The reliability of preoperative and operative clinical risk factors for common bile duct (CBD) pathology were correlated with the operative and cholangiographic findings. Though several of these clinical risk factors (jaundice, dilated CBD, elevated alkaline phosphotase) were present in over 80 per cent of the patients with CBD pathology, none had an overall predictive accuracy greater than 40 per cent. The operative cholangiogram was superior to the clinical criteria in distinguishing patients with common bile duct pathology from those patients with disease limited to the gallbladder provided that a dilated CBD was not considered an absolute indication for CBD exploration. Operative cholangiography was the best overall screening test for identifying patients with CBD pathology. A subgroup of patients was identified in whom this screening test was not needed. Of our study group, 44 per cent had no clinical risk factors for CBD pathology present, and no unsuspected CBD calculi were found by the use of routine cholangiography in any of these patients. Based on this clinical study and a critical review of the current literature, adequate evidence to support the policy of routine operative cholangiography was not found. In fact, a policy of selective cholangiography performed only on patients clinically at risk of having CBD pathology appears indicated. This approach would not only decrease the incidence of negative CBD exploration, but also would reduce the overall cost of cholecystectomy by 52 million dollars annually without any increase in patient risk.

The accuracy of the clinical indications for common bile duct exploration was studied in a group of 495 patients. The patients were divided into two groups: operative cholangiography was performed in 5 per cent of cases in Group A and 62 per cent of cases in Group B. The results demonstrate the high efficiency of this procedure, its safety, accuracy (82%), and its effectiveness in the discovery of unexpected stones and in shortening of hospitalization. Analysis of the results point out the indications for intraoperative cholangiography: It should be carried out in all biliary tract operations, except for those in which other clinical indications for exploration already exist (palpable stones in the common bile duct or the combination of dilated common bile duct either with jaundice at the time of operation or with history of severe jaundice in the past). Under all other circumstances an operative cholangiogram should be performed.

The use of the Fogarty biliary balloon catheter has added to the safety of common duct exploration. Review of our own series seems to support this concept. With this adjunct adn a careful anatomic dissection of the biliary system, one can decide to do cholangiography or common duct exploration based on carefully considered clinical factors when stones are suspected. Perhaps neither need to be done in many instances. Without trying to question the virtures of operative cholangiography, we believe that it can be used selectively rather than routinely.