Hammarström L E, Holmin T, Stridbeck H, Ihse I
Departments of Surgery, University of Lund, Sweden.
J Am Coll Surg. 1996 May;182(5):408-16.
There has been a resurgence of interest in recent years in preoperative infusion cholangiography (PIC). The role of routine PIC compared to routine intraoperative cholangiography (IOC) has not been clearly defined.
In our department between 1985 and 1991, 1,042 of 1,576 consecutive patients with biliary calculous disease had elective cholecystectomy: 694 patients were prospectively scheduled for PIC, and 348 patients were randomly allocated to IOC. The patients in the PIC and IOC groups were similar with regard to age, history of biliopancreatic complications, and laboratory findings. The cost of PIC in Sweden is nearly five times greater than the cost of IOC.
Satisfactory opacification of the biliary system was obtained in 90.1 and 96.8 percent of patients who underwent PIC and IOC, respectively. Preoperative infusion cholangiography required support by IOC in 19.5 percent of patients. There were no statistically significant differences between the PIC and IOC groups with regard to the incidence (7 percent in both groups) of or positive predictive value (68 and 80 percent, respectively) for bile duct stones, rate of retained stones (6 and 20 percent, respectively), intraoperative (5.6 and 6.3 percent, respectively) or postoperative (13.3 and 15.9 percent, respectively) morbidity, or incidence of bile duct anomalies (0.9 and 0.3 percent, respectively). Median operative time was longer in patients with (95 minutes) compared to those without (75 minutes) IOC (p < 0.001). More postoperative complications occurred after bile duct exploration (26 of 75 patients) compared to cholecystectomy alone (114 of 917 patients, p < 0.001). The 30-day mortality was zero. Minor bile duct injuries occurred in two patients (0.2 percent) at cholecystectomy, (one with and one without bile duct exploration). In no patient was the cholangiographic finding of a biliary anomaly crucial for the safe execution of cholecystectomy.
In our study, PIC and IOC were comparable, but routine use of either method did not promote the safety of cholecystectomy and thus their routine use is not warranted. The shorter operative time and preoperative identification of common bile duct (CBD) stones provided by PIC might favor this examination when applied selectively in patients with increased risk of having CBD stones. However, this potential advantage is offset by the need for PIC to be supported by IOC in approximately 20 percent of patients. Also, the cost of PIC is greater than the cost of IOC.
近年来，术前经静脉胆管造影（PIC）再度引起人们的关注。与常规术中胆管造影（IOC）相比，常规PIC的作用尚未明确界定。
1985年至1991年期间，在我们科室，1576例连续性胆石症患者中有1042例行择期胆囊切除术：694例患者前瞻性安排行PIC，348例患者随机分配至IOC组。PIC组和IOC组患者在年龄、胆胰并发症病史及实验室检查结果方面相似。瑞典PIC的费用几乎是IOC的五倍。
分别有90.1%和96.8%接受PIC和IOC的患者获得了满意的胆管系统显影。19.5%接受PIC的患者需要IOC辅助。PIC组和IOC组在胆管结石的发生率（两组均为7%）或阳性预测值（分别为68%和80%）、残留结石率（分别为6%和20%）、术中（分别为5.6%和6.3%）或术后（分别为13.3%和15.9%）发病率或胆管异常发生率（分别为0.9%和0.3%）方面无统计学显著差异。与未行IOC的患者（75分钟）相比，行IOC的患者中位手术时间更长（95分钟）（p< 0.001）。与单纯胆囊切除术（917例患者中的114例，p< 0.001）相比，胆管探查术后发生更多术后并发症（75例患者中的26例）。30天死亡率为零。胆囊切除术中2例患者（0.2%）发生轻微胆管损伤（1例有胆管探查，1例无胆管探查）。在任何患者中，胆管造影发现的胆管异常对安全实施胆囊切除术均无关键意义。
在我们的研究中，PIC和IOC具有可比性，但常规使用这两种方法均未提高胆囊切除术的安全性，因此其常规使用并不合理。PIC提供的较短手术时间和术前对胆总管（CBD）结石的识别，在选择性应用于有CBD结石风险增加的患者时可能有利于此项检查。然而，约20%的患者需要IOC辅助PIC，这抵消了这一潜在优势。此外，PIC的费用高于IOC。
