Changing methods of imaging the common bile duct in the laparoscopic cholecystectomy era in Western Australia: implications for surgical practice.

OBJECTIVE: To assess changes in the use of endoscopic retrograde cholangiopancreatography (ERCP), intraoperative cholangiography (IOC), and surgical exploration of the common bile duct (CBD) associated with the introduction of laparoscopic cholecystectomy (LC). SUMMARY BACKGROUND DATA: The optimal strategy for dealing with potential stones of the CBD during LC remains controversial. METHODS: The authors conducted a population-based study of all cases of cholecystectomy (20,084) in Western Australia in the periods before, during, and after the introduction of LC (1988-1994). Index admissions were linked to previous or subsequent admissions for ERCP. Factors associated with ERCP were analyzed by multivariate regression models. RESULTS: Between 1988 and 1994, admissions for ERCP almost doubled, whereas the use of IOC decreased from 71% to 51%. Different trends were found for open and laparoscopic procedures. Exploration of the CBD declined because of the infrequent use of this procedure in LC. Preoperative ERCP was significantly more common in older patients and men; the reverse was found for IOC. There was an adjusted 3.5-fold increase in preoperative ERCP both during and after the introduction of LC. The adjusted odds ratios for IOC were 0.48 and 0.52 for these periods. CONCLUSIONS: The introduction of LC was associated with increasing reliance on ERCP to image the CBD and a decrease in the use of IOC. These changes were observed in both LC and open cholecystectomy. They suggest that the use of ERCP before cholecystectomy has partly replaced IOC for visualization of the CBD for suspected stones. Although more than 40% of patients undergoing LC had IOC, surgeons appear to be reluctant to perform surgical exploration of the CBD when stones are present. Savings in terms of both complications and cost can be expected if preoperative ERCPs performed for suspicion of uncomplicated CBD stones are replaced by IOC.