Feasibility, benefit and risk of systematic intraoperative cholangiogram in patients undergoing emergency cholecystectomy

RESEARCH ARTICLE Feasibility, benefit and risk of systematic intraoperative cholangiogram in patients undergoing emergency cholecystectomy Pouya Iranmanesh1*, Olivier Tobler1, Sandra De Sousa1, Axel Andres1,2, JeanLouis Frossard2,3, Philippe Morel1,2, Christian Toso1,2 a1111111111 a1111111111 a1111111111 a1111111111 a1111111111 1 Department of Digestive and Transplant Surgery, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland, 2 Hepato-Pancreato-Biliary Centre, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland, 3 Department of Gastroenterology, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland * Abstract Background OPEN ACCESS Citation: Iranmanesh P, Tobler O, De Sousa S, Andres A, Frossard J-L, Morel P, et al. (2018) Feasibility, benefit and risk of systematic intraoperative cholangiogram in patients undergoing emergency cholecystectomy. PLoS ONE 13(6): e0199147. https://doi.org/10.1371/ journal.pone.0199147 Editor: Gianfranco D. Alpini, Texas A&M University, UNITED STATES The role of intraoperative cholangiogram (IOC) during cholecystectomy is debated. The aim of the present study was to evaluate the feasibility, benefit and risk of performing systematic IOC in patients undergoing cholecystectomy for acute gallstone-related disease. Methods Between July 2013 and January 2015, all patients admitted for an acute gallstone-related condition and undergoing same-hospital-stay cholecystectomy were prospectively followed. IOC was systematically attempted and predictors of IOC failure were analyzed. Received: August 8, 2017 Accepted: June 1, 2018 Published: June 28, 2018 Copyright: © 2018 Iranmanesh et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Data Availability Statement: All relevant data are within the paper and its Supporting Information files. Funding: Christian Toso (CT) was supported by the Swiss National Science Foundation (www.snf.ch), with the grant number PP00P3_139021. The funder had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Results Among the 581 enrolled patients, IOC was deliberately not performed in 3 cases. IOC was successful in 509/578 patients (88.1%). The main predictors of IOC failure were age, body mass index, male gender and associated acute cholecystitis. Thirty-two patients with suspected common bile duct stone on IOC underwent 38 unnecessary negative postoperative common bile duct investigations (32/509, 6.3%). There was one IOC-related adverse outcome (mild pancreatitis, 1/578, 0.2%). Conclusions IOC can be successfully and safely performed in the majority of patients undergoing cholecystectomy for acute gallstone-related disease. Although its positive predictive value is suboptimal and results in a number of unnecessary postoperative common bile duct investigations, IOC accurately rules out common bile duct stones in patients with acute gallstone-related conditions. PLOS ONE | https://doi.org/10.1371/journal.pone.0199147 June 28, 2018 1 / 12 Intraoperative cholangiogram during emergency cholecystectomy Competing interests: The authors have declared that no competing interests exist. Introduction Acute gallstone-related disease represents a heavy burden in terms of financial cost, and number of emergency room visits, accounting for more than one million urgent medical consultations in the United States yearly [1,2]. This disease includes acute cholecystitis, gallstone migration into the common bile duct (CBD), acute cholangitis and gallstone pancreatitis. According to current guidelines, patients admitted with an acute gallstone-related disease should undergo laparoscopic cholecystectomy during the same hospital stay [3–5]. The role of intraoperative cholangiogram (IOC) during elective and emergency cholecystectomy is debated. Some authors advocate for its systematic use [6–8] and others advise for a selective use in patients with abnormal liver function tests (LFT) [9–11]. The guidelines of the American Society for Gastrointestinal Endoscopy (ASGE) and the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) make the use of IOC dependent on the institutional strategy and patients’ individual risk of presenting a CBD stone [12–14]. IOC allows for the identification of CBD stones, the early detection of biliary lesions and, for some authors, a decreased readmission rate after cholecystectomy [7,8,15,16]. Conversely, it also accounts for an increased operating room time (and costs), and carries a risk of adverse outcome such as biliary lesions [9–11]. Technical reasons such as severe inflammation or narrowness of the cystic duct can lead to IOC failure. No study in the current literature specifically focuses on the role of IOC during cholecystectomy for acute gallstone-related diseases. The objective of the present study was to analyze the feasibility, benefit and risk of performing systematic IOC in a cohort of patients undergoing cholecystectomy for acute gallstone-related disease. Materials and methods Setting, design and interventions This study was a retrospective analysis of a prospective database created between July 2013 and January 2015 at the Geneva University Hospitals, Geneva, Switzerland. In this institution, IOC is systematically performed during all cholecystectomies. Patients presenting to the emergency room with an acute gallstone-related disease were classified according to the ASGE/SAGES guidelines [12] as low-, intermediate- and high-risk of presenting a CBD stone. These patients underwent laparoscopic cholecystectomy during the same hospital stay and IOC was systematically attempted during the surgical procedure. According to the institution guidelines based on a randomized controlled trial [17], high-risk patients (defined by bilirubin level > 4 mg/dL, acute cholangitis according to the revised Tokyo guidelines [18], CBD stone confirmed on radiologic imaging or gallstone pancreatitis according to the revised Atlanta classification [19]) were scheduled for a preoperative CBD assessment first. This assessment was performed by either endoscopic ultrasound (EUS) or magnetic resonance cholangiopancreatography (MRCP), followed, when necessary, by CBD clearance by endoscopic retrograde cholangiopancreatography (ERCP), and a subsequent cholecystectomy with IOC. Low-risk (normal LFT) and intermediate-risk patients (abnormal LFT without high-risk criteria) were planned for initial cholecystectomy with IOC. All patients with a suspicion of CBD stone on IOC (positive IOC) were scheduled for a EUS or MRCP after surgery. All patients with no suspicion of CBD stone on IOC (negative IOC) were followed-up during a year after discharge to track readmissions and CBD investigations for m (...truncated)