Snow L L, Weinstein L S, Hannon J K, Lane D R
Department of Surgery, University of South Alabama College of Medicine, Mobile 36607, USA.
Surg Endosc. 2001 Jan;15(1):14-20. doi: 10.1007/s004640000311.
There is still some controversy over whether to use laparoscopic operative cholangiograms routinely (RLOC) or selectively (SLOC). Due to their high cost as well as other issues, in March 1997 we converted from RLOC to SLOC. The purpose of this study was to validate that decision.
The results of 2043 laparoscopic cholecystectomies (LC) were compiled and analyzed. The results of RLOC in 1556 patients undergoing LC from March 1990 through February 1997 were compared to the results of SLOC in 16 patients undergoing LC from March 1989 through February 1990 and 471 patients undergoing LC from March 1997 through December 1998. The literature was reviewed and data were compiled. Reasons that are typically given for operative cholangiograms (OC) were collected and scrutinized. Finally, cost surveys for RLOC and related procedures were obtained.
Overall, laparoscopic operative cholangiogram (LOC) was attempted in 1661 patients and was successful in 1656 cases (99.7%). Bile duct stones (BDS) were evident in 166 patients. Laparoscopic bile duct exploration (LBDE) was attempted in all cases. None were referred for preoperative endoscopic retrograde cholangiopancreatography (ERCP). In the RLOC group, evidence of BDS was observed in 136 patients (9%). Forty-two were unsuspected (2.8%) and five were false positive (0.3%). In a collection of other RLOC studies, the average rate of unsuspected BDS was 2.9%, while the average rate of false positive cholangiograms was 1.6%. In the SLOC group, LOC was indicated in 139 of 487 patients (28.6%). None of the patients who did not have a LOC developed symptomatic residual BDS in < or = 11 years of follow-up. In a large collection of other SLOC studies, the rate of symptomatic residual BDS was 0.3%. A cost survey in February 1997 revealed that the average minimum global charge (MGC) for an OC was $1283.21; for a transcystic duct LBDE it was $1055.10, and for a transcholedochal LBDE it was $3263.61 [corrected]. The MGC for an ERCP with papillotomy was $4303.00. Thus, to avoid one patient with symptomatic residual BDS, 354 unnecessary procedures (333 RLOC, 18 LBDE, and three postoperative ERCP) costing $473,927.52 would be performed. There were no false negatives, bile duct injuries, or other complications attributable to RLOC or SLOC.
The increased morbidity and cost of RLOC to avoid symptomatic residual BDS is not justified. All other reasons given for RLOC are either flawed or indicate that the procedure can be safely employed selectively. SLOC is an effective method of verifying suspected BDS and is safer and less expensive than RLOC.
对于是否常规使用腹腔镜手术胆管造影（RLOC）还是选择性使用（SLOC）仍存在一些争议。由于其成本高昂以及其他问题，1997年3月我们从RLOC转为SLOC。本研究的目的是验证这一决策。
收集并分析了2043例腹腔镜胆囊切除术（LC）的结果。将1990年3月至1997年2月接受LC的1556例患者的RLOC结果与1989年3月至1990年2月接受LC的16例患者以及1997年3月至1998年12月接受LC的471例患者的SLOC结果进行比较。查阅文献并收集数据。收集并仔细审查了通常进行手术胆管造影（OC）的原因。最后，获得了RLOC及相关手术的成本调查结果。
总体而言，1661例患者尝试进行腹腔镜手术胆管造影（LOC），1656例成功（99.7%）。166例患者发现胆管结石（BDS）。所有病例均尝试进行腹腔镜胆管探查（LBDE）。无一例患者被转诊进行术前内镜逆行胰胆管造影（ERCP）。在RLOC组中，136例患者（9%）发现BDS证据。42例为未被怀疑的（2.8%），5例为假阳性（0.3%）。在其他RLOC研究的汇总中，未被怀疑的BDS平均发生率为2.9%，而胆管造影假阳性的平均发生率为1.6%。在SLOC组中，487例患者中有139例（28.6%）需要进行LOC。在随访≤11年期间，未进行LOC的患者均未出现有症状的残留BDS。在其他大量SLOC研究中，有症状的残留BDS发生率为0.3%。1997年2月的成本调查显示，OC的平均最低总费用（MGC）为1283.21美元；经胆囊管LBDE为1055.10美元，经胆总管LBDE为3263.61美元[已校正]。进行乳头切开术时ERCP的MGC为4303.00美元。因此，为避免1例有症状的残留BDS患者，将进行354例不必要的手术（333例RLOC、18例LBDE和3例术后ERCP），花费473,927.52美元。没有因RLOC或SLOC导致的假阴性、胆管损伤或其他并发症。
RLOC为避免有症状的残留BDS而增加的发病率和成本是不合理的。给出的支持RLOC的所有其他理由要么存在缺陷，要么表明该手术可以安全地选择性使用。SLOC是验证可疑BDS的有效方法，比RLOC更安全且成本更低。
