Abstract
BACKGROUND AND AIMS: Intraoperative cholangiography (IOC) is commonly performed during cholecystectomy for definitive testing of choledocholithiasis. The aim of the study was to evaluate the accuracy of IOC in hospitalized patients with suspected choledocholithiasis and outcomes of those receiving ERCP. METHODS: Consecutive hospitalized patients who received cholecystectomy with IOC at 2 centers were identified. Abnormal IOC (filling defect, meniscus sign, and/or absence of duodenal contrast) was diagnosed by the surgeon. Retained stones were assessed by definitive testing (MRCP, EUS, common bile duct exploration, and/or ERCP) performed after IOC. RESULTS: Of 847 patients (mean age, 44 ± 17 years; 624 women (74%)), 43 (5%) met American Society for Gastrointestinal Endoscopy high- and 665 (79%) intermediate-probability criteria for choledocholithiasis. Forty-two surgeons performed a median of 4 IOCs (range, 1-166); 254 patients (30%) had positive IOCs. During a follow-up of 21.1 ± 22.4 months, 257 patients (30%) received definitive testing, and 129 (15%) had retained stones. Sensitivity, specificity, positive predictive value, and negative predictive value of IOC for choledocholithiasis were 94.6% (95% confidence interval [CI], 89.1-97.8), 81.6% (95% CI, 78.6-84.4), 48.0% (95% CI, 44.1-52.0), and 98.8% (95% CI, 97.6-99.4), respectively. ERCP performed in 218 patients (26%) at a median of 1 day (interquartile range, 1-2) after IOC led to 18 adverse events (8%), including pancreatitis in 14 (6%). CONCLUSIONS: Although IOC was highly sensitive for ruling out retained stones, specificity was modest, and more than half of the patients with abnormal IOCs would have received diagnostic ERCP without other testing. Given procedural risks, EUS or other less-invasive tests should be performed before ERCP in this population.