Research progress of cholangiography during laparoscopic cholecystectomy

Authors: Wen Tianfu, Dai Lingbo, Xu Honggen, Hua Changxing

Source: International Journal of Surgery, 2023, 50(4)

summary

With the widespread development of laparoscopic cholecystectomy in medical institutions at all levels, surgical complications have also increased, among which the incidence of bile duct injury remains high in complex laparoscopic cholecystectomy. The reason for this is that surgeons cannot accurately identify the relationship between the variant biliary tract and the cystic duct and the common bile duct, resulting in accidental injury to the bile duct, resulting in long hospital stays, increased medical costs, and reduced long-term quality of life for patients. Intraoperative cholangiography is an effective way to reduce the incidence of iatrogenic biliary injury as a visual biliary presentation method, however, most surgeons do not fully understand the cholangiography technique during cholecystectomy. This article reviews the clinical experience of intraoperative cholangiography combined with the application of cholangiography in laparoscopic cholecystectomy in recent years, aiming to deepen surgeons' understanding of intraoperative cholangiography, so that it can be better applied to clinical practice and benefit patients.

Laparoscopic cholecystectomy (LC) is the standard procedure for the treatment of benign gallbladder diseases, and in recent years, with the widespread development of this technique, the incidence of surgical complications has also increased, such as residual stones, long cystic duct stumps, and bile duct injury, among which bile duct injury is the most serious complication, which directly affects the quality of life and overall survival time of patients [1,2]. To reduce the risk of bile duct injury during LC surgery, surgeons seek a variety of approaches to reduce the incidence of intraoperative bile duct injury [3]. Intraoperative cholangiography (IOC) has been widely recommended and used in the prevention of intraoperative bile duct injury as an effective technique to avoid iatrogenic bile duct injury from various causes [4,5]. In order to have a fuller understanding of the IOC, this article will introduce the origin, application methods, indications, precautions and research progress of the IOC in recent years.

1 Overview of intraoperative cholangiogram

IOC was first proposed in 1931 by Mirizzi et al., but its use in cholecystectomy was not formally proposed by Pellegrini et al. until 1993 [6]. Initially, IOC was used in cholecystectomy to prevent residual intraoperative choledocholithiasis in patients with biliary pancreatitis who underwent cholecystectomy. Buddingh et al. [7] also concluded in a follow-up study that the conventional IOC group showed a significant advantage over the selective IOC group in the detection rate of common bile duct stones (4.8% vs. 1.0%, P=0.001). IOC during cholecystectomy not only confirms the presence of residual stones in the common bile duct during surgery, but also helps to detect common bile duct injury and biliary tract variation early [8]. When performing LC in the face of chronic atrophic cholecystitis, mainland scholars compared whether intravenous indocyanine green was injected intraoperatively to set up the IOC group and the non-IOC group, and found that the IOC group was easier to distinguish its anatomy than the non-IOC group and avoid damage to the biliary tract, which improved the safety and feasibility of the operation. Thus, the use of IOC intraoperatively avoids unnecessary exploration of the common bile duct [10]. Most biliary surgeons also agree that IOC has a place in surgical practice, particularly in the detection of extrahepatic common bile duct stones and in diagnosing bile duct injury.

2 Methods of intraoperative cholangiogram

2.1 Intraoperative biliary radiography

The conventional method of cholangio-ray angiography in LC surgery is to use cholangiography forceps to insert a cholangiography tube (silicone tube or ureter of appropriate caliber) into the cystic duct of 2.0~3.0 cm, clamp and clamp the cystic duct, drain the air in the catheter with 0.9% sodium chloride solution and confirm that there is no leakage, and slowly inject the contrast agent (such as compound gastrografin and iohexol imaging) after the bile is withdrawn, the general dose is 20~40 mL, and when the contrast medium is pushed into more than 2/3, the image is taken with a bedside X-ray machine or C-arm machine. In the process of filming, try to continuously observe the contrast agent in the intrahepatic and extrahepatic bile ducts, common bile ducts and into the duodenum from different angles and positions, and extract the residual contrast medium as much as possible after the imaging. Although intraoperative biliary tract X-ray imaging has the advantages of avoiding residual bile duct stones during LC surgery, avoiding unnecessary biliary exploration and discovering bile duct variations, there are still some disadvantages in the practical application of this technology, such as the operation is invasive, requires proprietary equipment, has the risk of radiation, and the risk of biliary retrograde infection caused by poor pressure control during contrast injection, etc., which urgently needs to be solved by biliary surgeons.

2.2 Intraoperative fluorescence biliary imaging

In recent years, with the widespread development and popularization of laparoscopic minimally invasive techniques and the improvement of safety awareness, the disadvantages of conventional radioactive IOC in laparoscopic surgery have become more prominent, such as excessive intraoperative time, exposure of patients and medical staff to radiation, and the often need for large fluoroscopy machines and additional human resources [11,12,13]. Therefore, some medical personnel conceived the use of television imaging to avoid this problem, and this idea was first realized in 1968 by Whitaker et al. [14] in the use of video fluoroscopy and moving image intensifier for cholangiogram, but the technology has been stalled due to various reasons such as equipment and concept. With the development of intraoperative fluorescence technology, it was not until 2009 that Ishizawa et al. [15] applied intraoperative fluorescence IOC technology to cholecystectomy, first indocyanine green was injected intravenously into the patient 1 h before cholecystectomy, and the bile ducts were visualized with a laparoscopic fluorescence imaging system during the operation.

Although the intraoperative application of fluorescent IOC technology can show the relationship between the cystic duct and the gallbladder triangle of the patient, and it has been proved that the application of this method in LC is safe and effective, and can avoid the shortcomings of traditional intraoperative cholangiography, its application has also brought some new problems, such as: (1) the consistency of the time of indocyanine green injection and the peak of fluorescence display, and the ideal time of indocyanine green injection has become a problem; (2) Background fluorescence of the liver can interfere with the best observation of extrahepatic areas. In order to solve the above problems, many scholars at home and abroad have also reported their own studies [16], Ishizawa et al. [17] reported the study on the correlation between the administration time and dose of indocyanine green and the body mass index of patients with LC fluorescence biliary tract scintigraphy, and the results showed that 96% of patients with a body mass index of 18.1~32.9 kg/m2 showed the confluence of the cystic duct and the common hepatic duct before separating the gallbladder triangle after injecting 2.5 mg of indocyanine green 30 min before surgery. Hong et al. [18] reported a study on the time and dose of hilar bile duct fluorescence, and the results showed that the structure of hilar biliary tract could be clearly visualized by indocyanine green dose of 0.05 mg/kg 30~60 min before exposure to the hilar hilum 30~60 min.

Although the above two scholars calculated the dosage and time of intravenous indocyanine green according to the patient's body mass index, they did not take into account the patient's own liver metabolism, and the fluorescence imaging of the biliary tract needed to wait for the excretion of indocyanine green from the liver to the back of the bile duct. To address the timing of biliary development, Graves et al. [19] described a technique to inject indocyanine green directly into the gallbladder, which provided an image of immediate irradiation of the relevant biliary system in LC, and later with the development of this technique, the cystic duct injection technique gradually emerged, which could minimize bile duct injury and optimize the visualization of IOC without affecting surgical outcomes.

3 Indications for intraoperative cholangiography

IOC has some value in cholecystectomy, but there is much controversy about whether IOC should be used selectively or routinely [20,21]. According to a recent meta-analysis published in 2021, routine IOC versus selective IOC use was shown to be a cost-effective intervention for intraoperative bile duct injury [3,9]. Alternatively, some scholars believe that IOC is time-consuming intraoperatively and that there is a risk of bile duct injury due to intraoperative insertion of an injectable contrast intubation, and that selective use is recommended [22,23,24,25,26]. The author believes that IOC, as an invasive procedure, has the advantages of quickly and safely identifying the bile duct anatomy and the presence or absence of bile duct stones in complex acute cholecystitis surgery, especially when it is difficult to identify the gallbladder colot triangle, but it also has the disadvantages of invasive operation, which may bring about side injuries, such as bile duct injury as described above.

The application of IOC should have its corresponding indications like other operations, which are summarized by the author into three indications: clinical, imaging and intraoperative anatomy: (1) clinical indications include history of jaundice or jaundice, abnormal liver function, acute pancreatitis or history of pancreatitis; (2) Imaging indications include detection of stones in the common bile duct, small gallstones or sediment-like stones, cystic duct dilation > 3 mm, and common bile duct dilation > 8 mm; (3) Intraoperative anatomical indications include difficulty in dissecting the common bile duct, uncertainty about the common bile duct, short cystic duct, and suspicion of bile duct injury. Referring to the above indications, we can avoid unnecessary bile duct damage and waste of medical resources caused by the overuse of IOC, and can also avoid the occurrence of residual bile duct stones or missing bile duct damage due to the neglect of IOC.

4 Evaluation criteria and corresponding precautions for intraoperative cholangiography

The clinical value of IOC is self-evident, but the quality of intraoperative imaging is critical to definitively identify the normality of extrahepatic bile duct anatomy, the presence or absence of bile duct stones, biliary tract tumors, and any condition of biliary injury or bile leakage. What is a high-quality biliary film and what characteristics it should have, which is worth discussing. The author believes that each high-quality cholangiography image should have the following signs: (1) it can fully show the length of the cystic duct and the junction angle between the cystic duct and the common hepatic duct; (2) the contrast medium can flow freely into the duodenum; (3) extrahepatic bile ducts and common bile ducts are filled; (4) The main intrahepatic bile ducts, such as the left bile duct, the right anterior bile duct and the right posterior bile duct, are developed separately. For the quality of fluorescent biliary tract imaging, indocyanine green should be injected reasonably and individually according to the part of the surgeon who needs to develop and the patient's own condition [27,28], so as to achieve the effect of assisting the surgeon in performing precise biliary surgery.

For a high-quality cholangiography video, what should we pay attention to during the operation? The author will make the following suggestions from the three aspects of cystic duct anatomy, contrast tube insertion and contrast agent injection: (1) In terms of cystic duct anatomy, firstly, after the cystic duct is isolated before gallbladder resection, a clip is clamped close to the ampulla of the gallbladder, and then angiography is performed to more easily show the relationship between the cystic duct and the common bile duct; Secondly, for gallbladder gangrene, difficult traction or thin gallbladder wall tension, easy to scratch when pulling the gallbladder, it is recommended to remove the gallbladder first, but the residual gallbladder neck canal is not too short, with 1.0~1.2 cm is appropriate, such an operation requires the surgeon and a helper to be skillful and tacitly cooperated, otherwise the relationship between the stump cystic duct and the common bile duct is not easy to be accurately exposed, and it is easy to accidentally injure the common bile duct; Thirdly, always note that the proximal cardiac cystic duct is clamped close to the common bile duct after the contrast is completed, and then the long-term cardiac gallbladder-neck canal is removed. (2) In terms of the placement of contrast tubes, the contrast tubes should not be placed too deep into the common bile duct, so as to avoid affecting the judgment due to incomplete biliary development due to too deep catheterization during imaging. (3) In terms of the injection of contrast medium, the head is lowered and the feet are high before the contrast agent is injected, and the gas in the catheter and syringe is fully discharged, so as not to mistake the bubbles for stones, after the injection of contrast agent, the horizontal position is taken for imaging, and the intrahepatic and external bile ducts are more clearly displayed, and the residual contrast agent needs to be extracted after the contrast, and attention must be paid to avoid the extravasation of the contrast agent when injecting the contrast agent, so as not to affect the effect of biliary imaging.

5 Summary

As a rapid, safe, and reliable bile duct identification technology, intraoperative IOC can not only effectively prevent intraoperative bile duct injury and improve the success rate of LC surgery, but also help to confirm whether there are residual biliary stones or biliary tract mass through intraoperative cholangiography, so as to avoid some unnecessary biliary exploration, reduce the chance of biliary tract injury, shorten the patient's hospital stay, and reduce the patient's economic burden, which is worthy of clinical promotion [29,30,31,32]. ]。 In recent years, although intraoperative laparoscopic ultrasound has achieved great success in distinguishing biliary anatomy and biliary stones, its learning curve is much longer than that of IOC.

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