For patients with predicted low risk for choledocholithiasis undergoing laparoscopic cholecystectomy, selective intraoperative cholangiography and postoperative endoscopic retrograde cholangiopancreatography is an effective strategy to limit unnecessary procedures.

BACKGROUND: There is debate about whether intraoperative cholangiography (IOC) should be performed routinely or selectively during laparoscopic cholecystectomy (LC) in patients with suspected choledocholithiasis. The timing of endoscopic retrograde cholangiopancreatography (ERCP) in these patients also is an issue. We reviewed the experience in our center, where a management algorithm limiting ERCP in relation to LC was adopted. METHODS: We retrospectively reviewed every LC performed by one surgeon during 6 years and the related ERCPs. RESULTS: A total of 264 LCs were performed. In 30 patients, stones were cleared or excluded by preoperative ERCP. In the remaining 234 LCs, 31 of 34 IOCs were successfully performed. Two of 31 IOCs were positive for bile duct stones; stone removal was successful in each patient at subsequent ERCP. Only 10 of 201 patients who did not have IOC required postsurgical ERCP within 10 weeks of LC, 3 of whom had common bile duct stones at ERCP. CONCLUSIONS: For patients who underwent LC, we performed selective IOC with postoperative ERCP for positive studies. Review of our experience using this algorithm showed it to be a powerful tool in limiting unnecessary ERCPs. Our data suggest that routine preoperative ERCP cannot be justified. Selective IOC during LC misses relatively few cases of biliary stones; these can be managed quickly by experienced endoscopists.

Long-term follow-up of patients with iron deficiency anaemia after a negative gastrointestinal evaluation.

OBJECTIVES: Our aim was to determine whether patients who have had a negative gastrointestinal evaluation (i.e. oesophagogastroduodenoscopy and a colonic examination) for iron deficiency anaemia are subsequently found to have recurrent anaemia or significant pathology. METHODS: From a prospectively entered endoscopy database, we identified a cohort of patients who had negative upper and lower gastrointestinal (GI) investigations for iron deficiency anaemia. We carried out a retrospective chart review of these patients to determine their outcome after a GI evaluation. In particular, we wished to determine the proportion of patients who had recurrent anaemia, became transfusion dependent or were found to have significant pathology. RESULTS: Sixty-nine patients, with an average age of 65.8 years (range 29-87), were followed up for a median of 5 years and 10 months (range 7-109). In 57 patients (83%), the anaemia resolved after the initial treatment period. Fifteen patients (22%) died during the follow-up period, two from a GI cancer and 13 from non-GI-related causes. Six patients (9%) developed persistent anaemia severe enough to require recurrent blood or iron transfusions. Seventeen patients (25%) had a transient recurrent anaemia and four (6%) were diagnosed with GI malignancies during the follow-up. CONCLUSION: For the majority of patients with the iron deficiency anaemia and a negative GI evaluation the outcome is favourable, although a proportion (6%) may subsequently be found to have significant GI pathology. We believe that this number could be minimized by the use of colonoscopy rather than barium enema. In addition, small bowel investigations should not be limited to those who are transfusion dependent, as is currently recommended.