Selective intraoperative cholangiography and risk of bile duct injury during cholecystectomy. BJS 2015; 102: 952-958.

Published: 28th April 2015

Authors: B. Törnqvist, C. Strömberg, O. Akre, L. Enochsson, M. Nilsson


Whether intraoperative cholangiography can prevent iatrogenic bile duct injury during cholecystectomy remains controversial.


Data from the national Swedish Registry for Gallstone Surgery, GallRiks (May 2005 to December 2010), were analysed for evidence of iatrogenic bile duct injury during cholecystectomy. Patient‐ and procedure‐related risk factors for bile duct injury with a focus on the rate of intended intraoperative cholangiography were analysed using multivariable logistic regression.


A total of 51 041 cholecystectomies and 747 bile duct injuries (1·5 per cent) were identified; 9008 patients (17·6 per cent) were diagnosed with acute cholecystitis. No preventive effect of intraoperative cholangiography was seen in uncomplicated gallstone disease (odds ratio (OR) 0·97, 95 per cent c.i. 0·74 to 1·25). Operating in the presence (OR 1·23, 1·03 to 1·47) or a history (OR 1·34, 1·10 to 1·64) of acute cholecystitis, and open surgery (OR 1·56, 1·26 to 1·94), were identified as significant risk factors for bile duct injury. The intention to perform intraoperative cholangiography was associated with a reduced risk of bile duct injury in patients with concurrent (OR 0·44, 0·30 to 0·63) or a history of (OR 0·59, 0·35 to 1·00) acute cholecystitis.


Any proposed protective effect of intraoperative cholangiography was restricted to patients with (or a history of) acute cholecystitis.

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Kirsty McFarlane

3 years ago

We have read Törnqvist et al.’s article with interest. While we agree that intraoperative cholangiography (IOC) has its place in the assessment of symptomatic choledocholithiasis, we believe that its use has been largely superseded by preoperative magnetic resonance cholangiopancreatography (MRCP). The authors demonstrate the intention to perform IOC reduces the risk of bile duct injury in patients with acute cholecystitis, a sub group approximately 18% of the total cases assessed. More recently the prevalence of choledocholithiasis in acute cholecystitis detected by MRCP was 12.28% (1).

MRCP is a valuable tool in the detection of choledocholithiasis preoperatively (2) and asymptomatic patients with a MRCP showing no choledocholithiasis require no further preoperative investigations (3). Pre-operative detection of choledocholithiasis allows the surgeon the option of preoperative endoscopic retrograde cholangiopancreatography (ERCP) or common bile duct exploration at the time of laparoscopic cholecystectomy, depending on skills set and facilities available. MRCP is readily and quickly available in the UK (4).

There is a lack of literature on the cost-analysis of MRCP and IOC in the UK. However, the costs are greater than financial. IOC increases operative time and patient exposure to radiation and contrast medium, which are associated with additional risks to patients.

We challenge that, on balance, the risks associated with IOC in patients with symptomatic cholelithiasis outweigh the authors’ proposed benefits in patients with acute cholecystitis when a more risk averse method of detecting choledocholithiasis is available to UK patients.

Gemma Humm
Matthew Metcalfe

East and North Hertforshire NHS Trust
Lister Hospital
Corey’s Mill Lane
Stevenage, SG1 4AB

1. Hon-Phin Wong, Yu-Lun Chiu, Bei-Har Shiu, lu-Chang Ho. Preoperative MRCP to detect choledocholithiasis in acute calculus cholecystitis. J Hepatobiliary Pancreat Sci 2012; 19: 48-464.
2. Wen Chen, Jing-Jia Mo, Lin Lin, Chao-Qun Li, Jian-Feng Zhan. Diagnostic value of magnetic resonance cholangiopancreatography in choledocholithiasis. World J Gastroenterol 2015; 21: 3351-3360.
3. Gilijaca V, Gurusamy KS, Takwoingi Y, Higgie D, Poropat G, Štimac D, Davidson BR. Endoscopic ultrasound versus magnetic resonance cholangiopancreatography for common bile duct stones. Cochrane Database of Systematic Reviews 2015, Issue 2.
4. P Sanjay, C Kulli, FM Polignano, IS Tait. Optimal surgical technique use of intra-operative cholangiography (IOC), and management of acute gallbladder disease: the results of a nation-wide survey in the UK and Ireland. Ann R Coll Surg Engla 2010; 92: 302-306.

Kirsty McFarlane

3 years ago

We wish to thank Drs Humm and Metcalf for their commentary to our article in BJS.

The use of preoperative MRCP for the detection of choledocholithiasis is indeed a most valuable tool in the safe management of patient with gallstone disease. It not only enables a well prepared strategy for dealing with common bile duct stones but also provides valuable information on potential anatomical anomalies predisposing for bile duct injuries.

However, we do not believe that MRCP can replace IOC in the prevention of bile duct injuries. IOC not only identifies common bile duct stones but also confirms the structure believed to be the cystic duct. Misinterpretation of the anatomy in the hepatic pedicle together with inflammatory changes of the gallbladder has been pointed out as important mechanisms in bile duct injury cases (1), results supported by the present findings of cholecystitis being an important risk factor for injury. IOC will likely contribute to a down-staging effect in these cases as it facilitates the identification of a misinterpreted bile duct and prevents a complete transection with a subsequent complex repair. Furthermore, IOC enables early identification and management of a bile duct injury, an important prognostic factor as a delayed detection is associated with impaired survival (2).

We don’t believe that MRCP and IOC should be put against each other but rather seen as complementary modalities in the preventive efforts against biliary complications.

Björn Törnqvist
Department of Clinical Science
Intervention and Technology, Division of Surgery
Karolinska Institutet
SE-141 86 Stockholm

1. Nuzzo G, Giuliante F, Giovannini I, et al. Bile duct injury during laparoscopic cholecystectomy: results of an Italian national survey on 56 591 cholecystectomies. Arch Surg 2005; 140(10): 986-992.
2. Tornqvist B, Stromberg C, Persson G, et al. Effect of intended intraoperative cholangiography and early detection of bile duct injury on survival after cholecystectomy: population based cohort study. BMJ 2012; 345: e6457.