Abstract
We report a 4-year experience of operative ultrasonography in 449 patients who underwent cholecystectomy for biliary lithiasis. Intraoperative ultrasonography and intraoperative cholangiography were performed in all of these patients and compared with the operative findings. The diagnostic accuracy of sonography was 97.5% and that of cholangiography was 94.4% in the patient group as a whole. The predictive value of a positive sonogram in this group was 96.4%, while that of a positive cholangiogram was lower at 86.9%. In 148 patients who underwent surgical exploration of the common duct, sonography appeared to have more accurately predicted presence or absence of stones (92.5%) than did cholangiography (79.8%). Use of these intraoperative screening tests together led to a positive common duct exploration in 76.6% of the 148 patients, which is higher than our previous experience in which common duct exploration was performed on the basis of clinical criteria. In 7% of the 301 cholecystectomized patients, unpredicted stones were detected at operative sonography and cholangiography. If the common duct exploration were to be performed based solely on the outcome of the sonogram, the rate of positive exploration could be 97%. Overall morbidity in this series was 9%, and retained stones following duct exploration were encountered in 1 patient. The overall mortality rate of the entire patient group was 0.9%. Operative ultrasonography of the biliary tract as a screening procedure is, in experienced hands, a reliable method and substitute for operative cholangiography.
Résumé
Au cours d'une période de 4 ans l'échographie opératoire des voies biliaires a été employée chez 449 malades qui ont subi une cholécystectomie pour lithiase biliaire et chez qui a été pratiquée ensuite une exploration cholangiographique. L'efficacité diagnostique des deux méthodes a été identique (97.5% pour l'échographie, 94.4% pour la cholangiographie). En ce qui concerne la valeur prédictive des deux explorations les taux furent respectivement de 96.4% et de 86.9%. Chez les opérés qui furent soumis à une exploration de la voie biliaire principale (148 patients) une différence significative se manifesta dans la fiabilité (92.5% contre 79.8%). Chez 7% des malades cholécystectomisés furent découverts des calculs insoupçonnés. Le taux d'exploration positive de la voie biliaire principale fut de 76.6%, taux plus élevé que celui observé lorsque l'exploration avait été basée sur de seuls critères cliniques. Si l'exploration de la voie biliaire avait reposé seulement sur les seules données de l'échographie le taux d'exploration positive aurait pu être de 97%. Dans cette série le taux de morbidité fut de 9%, celui de la mortalité de 0.9%. Un calcul résiduel fut observé chez un seul malade. On peut conclure de ces faits que l'échographie opératoire exercée par des mains expérimentées est une méthode sûre et un substitut valable de la cholangiographie opératoire.
Resumen
Se presenta la experiencia de 4 años con ultrasonografía operatoria del tracto biliar en 449 pacientes sometidos a colecistectomía por litiasis biliar en quienes se realizó tanto la ultrasonografía operatoria como la colangiografía. Los resultados numéricos son presentados con las cifras de la ultrasonografía primero, seguidas de la colangiografía. La eficacia diagnóstica de los dos procedimientos en la totalidad de la población examinada fue similar (97.5% versus 94.4%); se observaron diferencias en el valor de predicción de la prueba positiva, 96.3% versus 86.9%. También se observé una diferencia significativa en la certeza (92.5% versus 79.8%) en el grupo de pacientes que recibieron exploración del colédoco (148 pacientes). Se detectaron cálculos no sospechados en 7% de los pacientes colecistectomizados. La tasa de exploración positiva del colédoco fue de 76.6%, la cual es significativamente mayor que la de nuestra experiencia previa cuando la decision para realizar exploración del colédoco se hacia exclusivamente con base en criterios clínicos. Si la decision de explorar el colédoco se hiciese con base exclusivamente en el resultado del examen por ultrasonido, la tasa de exploración positiva podría ser de 97%. La morbilidad global en esta série fue de 9%, y se encontraron cálculos residuales en 1 de los pacientes. La mortalidad global incluyendo el grupo con exploración del colédoco fue de 0.9%. La ultrasonografía operatoria del tracto biliar como procedimiento de tamizaje en manos experimentadas es un método confiable y un sustituto viable de la colangiografía operatoria.
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Jakimowicz, J.J., Rutten, H., Jürgens, P.J. et al. Comparison of operative ultrasonography and radiography in screening of the common bile duct for calculi. World J. Surg. 11, 628–634 (1987). https://doi.org/10.1007/BF01655839
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DOI: https://doi.org/10.1007/BF01655839