Kohn Annemarie, Creech Steve, Shayani Vafa
Department of Surgery, Loyola University Medical Center, Maywood, Illinois 60153, USA.
Am Surg. 2004 Mar;70(3):203-6; discussion 206-7.
Intraoperative cholangiography (IOC) remains a subject of much debate among laparoscopic surgeons. When IOC is indicated, the surgeon's preference for routine cholangiography (RC) or selective cholangiography (SC) may have an impact on the outcome of IOC and cholecystectomy. Hereafter, we present our experience with cholangiography in patients with clear indications for IOC when operated on by surgeons favoring SC versus RC. Between January 1, 1999, and December 1, 2000, 389 patients underwent laparoscopic cholecystectomy at Loyola University Medical Center. One hundred fifty-one patients had indication for IOC (jaundice, pancreatitis, increased liver function tests (LFTs), abnormal anatomy, ductal dilatation, or ductal stones identified on preoperative ultrasound), and they constitute the sample for this study. The results of IOC and subsequent outcome of cholecystectomy were reviewed using the electronic medical database. Thirty-nine patients were operated on by 2 surgeons favoring RC and 112 by 12 favoring SC. Patient demographics were similar in both groups. Only 30 (27%) of the SC group had attempted IOC with 28 successful IOCs (25% of all patients). In contrast, 38 (97%) of the RC group had successful IOC, which was significantly higher than the SC group (P < 0.0001 by chi2 test). Adverse events included conversions to open, postoperative endoscopic retrograde cholangiopancreatography, bile leak, repeat operative intervention, pancreatitis, elevated LFTs, intra-abdominal and wound infection, prolonged emesis, and persistent abdominal pain. Two (5%) adverse events occurred in the RC group, which was significantly less than the 33 (30%) adverse events in the SC group (P = 0.002 by chi2 test). Conversions to open were significantly less in the RC group, with no conversions in the RC group and 20 (18%) in the SC group (P = 0.005). There were no mortalities in this series. In a univariate analysis, age and gender did not correlate with increased risk of complications. In conclusion, surgeons who perform SC are less likely to attempt IOC even when IOC is indicated. More conversions to open and more adverse events occurred following cholecystectomy by those favoring SC. Our study further supports routine cholangiography during laparoscopic cholecystectomy.
术中胆管造影（IOC）在腹腔镜外科医生中仍是一个备受争议的话题。当需要进行IOC时，外科医生对常规胆管造影（RC）或选择性胆管造影（SC）的偏好可能会影响IOC和胆囊切除术的结果。在此，我们介绍在有明确IOC指征的患者中，由倾向于SC与RC的外科医生进行手术时胆管造影的经验。1999年1月1日至2000年12月1日期间，389例患者在洛约拉大学医学中心接受了腹腔镜胆囊切除术。151例患者有IOC指征（黄疸、胰腺炎、肝功能检查（LFTs）升高、解剖结构异常、胆管扩张或术前超声检查发现胆管结石），他们构成了本研究的样本。使用电子医疗数据库回顾了IOC的结果及随后的胆囊切除术结局。39例患者由2名倾向于RC的外科医生进行手术，112例由12名倾向于SC的外科医生进行手术。两组患者的人口统计学特征相似。SC组中只有30例（27%）尝试进行IOC，其中28例IOC成功（占所有患者的25%）。相比之下，RC组中有38例（97%）IOC成功，显著高于SC组（卡方检验P<0.0001）。不良事件包括转为开腹手术、术后内镜逆行胰胆管造影、胆漏、再次手术干预、胰腺炎、LFTs升高、腹腔和伤口感染、长时间呕吐以及持续性腹痛。RC组发生了2例（5%）不良事件，显著少于SC组的33例（30%）不良事件（卡方检验P = 0.002）。RC组中转开腹手术的情况明显较少，RC组无转开腹手术，SC组有20例（18%）（P = 0.005）。本系列中无死亡病例。单因素分析显示，年龄和性别与并发症风险增加无关。总之，即使有IOC指征，进行SC的外科医生也不太可能尝试IOC。倾向于SC的医生进行胆囊切除术后转为开腹手术的情况更多，不良事件也更多。我们的研究进一步支持在腹腔镜胆囊切除术中进行常规胆管造影。
