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Introduction

Intra-operative fluorocholangiography (IOF) allows real time demonstration of biliary anatomy and identification of common bile duct stones irrespective of size or site of the stones. However, routine use of IOF for detection of unsuspected choledocholithiasis ignited a debate during the open era that continued into the current laparoscopic era.

Absence of conclusive preoperative predictors of choledocholithiasis, rise in the number of preoperative endoscopic retrograde cholangiography pancreatography (ERCP) /endoscopic sphincterotomy (ES) and availability of laparoscopic ductal stones clearance rekindled the interest and re-ignited the debate in the clinical utility of pre-operative magnetic resonance cholangiography (MRCP) and laparoscopic IOF.

Aims

To assess indications and utilization of IOF during laparoscopic cholecystectomy at Aneurin Bevan Health Board and to compare its clinical utility to MRCP in order to evaluate -their impact on patients management.

Methods:

All the laparoscopic cholecystectomy (LC) procedures performed during the period of January 2008 to 2010 were retrieved from computerized database. We examined the indications and findings of IOF and MRCP and their impact on the treatment strategy.

Results:
A total of 700 consecutive cases of LCs were performed. Liver enzymes were elevated in 273 of 700 (39%) patients. MRCP was carried out in 139 of 700 (20%) patients. A hundred and eighteen patients (118) had pre operative MRCP, while 21 patients had postoperative MRCP. Forty two (42) patients (6%) underwent ERCP, half of these (21/42) were performed before surgery and other half was performed after it. A total of 182 (26%) underwent IOF during LC.

Choledocholithiasis was noted in 46 patients (6.6%), 70% of the 46 were detected by MRCP and 30 % by IOC. MRCP reported common bile duct stones (CBDS) in 32 (27%). IOC was performed in 21 patients who had a negative MRCP revealing a stone in a single case.
A hundred and three ((18.4%) of 558 patients who did not undergo MRCP had IOF and stones were seen in 13/103 patients (2.3%). Eleven patients out of the 13 went on to have a successful single-stage laparoscopic clearance.

Conclusions:

MRCP is an accurate non-invasive diagnostic and triaging modality while IOF remains to be the gold standard when CBD stones are suspected. IOF document site and size of known CBD stones and detect unsuspected ones in patients, who may benefit from a single stage laparoscopic common bile duct clearance. A leaner preoperative choledocholithiasis predictability criterion is desirable to reduce the redundancy in MRCP and IOF utilization.