Patient evaluation and management with selective use of magnetic resonance cholangiography and endoscopic retrograde cholangiopancreatography before laparoscopic cholecystectomy.
OBJECTIVE
To assess the utility of triage guidelines for patients with cholelithiasis and suspected choledocholithiasis, incorporating selective use of magnetic resonance cholangiography (MRC) and endoscopic retrograde cholangiopancreatography (ERCP) before laparoscopic cholecystectomy (LC).


BACKGROUND
ERCP is the most frequently used modality for the diagnosis and resolution of choledocholithiasis before LC. MRC has recently emerged as an accurate, noninvasive modality for the detection of choledocholithiasis. However, useful strategies for implementing this diagnostic modality for patient evaluation before LC have not been investigated.


METHODS
During a 16-month period, the authors prospectively evaluated all patients before LC using triage guidelines incorporating patient information obtained from clinical evaluation, serum chemistry analysis, and abdominal ultrasonography. Patients were then assigned to one of four groups based on the level of suspicion for choledocholithiasis (group I, extremely high; group 2, high; group 3, moderate; group 4, low). Group 1 patients underwent ERCP and clearance of common bile duct stones; group 2 patients underwent MRC; group 3 patients underwent LC with intraoperative cholangiography; and group 4 patients underwent LC without intraoperative cholangiography.


RESULTS
Choledocholithiasis was detected in 43 of 440 patients (9.8%). The occurrence of choledocholithiasis among patients in the four groups were 92.6% (25/27), 32.4% (12/37), 3.8% (2/52), and 0.9% (3/324) for groups 1, 2, 3, and 4, respectively (P <.001). MRC was used for 8.4% (37/440) of patients. Patient triage resulted in the identification of common bile duct stones during preoperative ERCP in 92.3% (36/39) of the patients. Unsuspected common bile duct stones occurred in six patients (1.4%).


CONCLUSIONS
The probability of choledocholithiasis can be accurately assessed based on information obtained during the initial noninvasive evaluation. Stratification of risks for choledocholithiasis facilitates patient management with the most appropriate diagnostic studies and interventions, thereby improving patient care and resource utilization.
Liu
T H
TH
Department of Surgery, The University of Texas-Houston Medical School and Lyndon B. Johnson General Hospital, Houston, Texas, USA. terrence.h.liu@uth.tmc.edu
Consorti
E T
ET
Kawashima
A
A
Tamm
E P
EP
Kwong
K L
KL
Gill
B S
BS
Sellin
J H
JH
Peden
E K
EK
Mercer
D W
DW
D000465:Algorithms; D000681:Amylases / Q000097:blood; D002758:Cholangiography / Q000379:methods*; D002760:Cholangiopancreatography, Endoscopic Retrograde; D017081:Cholecystectomy, Laparoscopic; D042882:Gallstones / Q000000981:diagnostic imaging*; D006801:Humans; D007432:Intraoperative Period; D008111:Liver Function Tests; D008279:Magnetic Resonance Imaging; D018579:Patient Selection; D011446:Prospective Studies; D018570:Risk Assessment
D000681:Amylases