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Cystic Duct Cholangiography Leo Chaikof Henry Ford Hospital Medical Journal Volume 22 Number 3 Laurence S. Fallis, M.D. Commemorative Article 7 Issue 9-1974 Cystic Duct Cholangiography Leo Chaikof T. L. Friedlich R. A. Affifi H. Weizel Follow this and additional works at: https://scholarlycommons.henryford.com/hfhmedjournal Part of the Life Sciences Commons, Medical Specialties Commons, and the Public Health Commons Recommended Citation Chaikof, Leo; Friedlich, T. L.; Affifi, R. A.; and Weizel, H. (1974) "Cystic Duct Cholangiography," Henry Ford Hospital Medical Journal : Vol. 22 : No. 3 , 129-136. Available at: https://scholarlycommons.henryford.com/hfhmedjournal/vol22/iss3/7 This Article is brought to you for free and open access by Henry Ford Health System Scholarly Commons. It has been accepted for inclusion in Henry Ford Hospital Medical Journal by an authorized editor of Henry Ford Health System Scholarly Commons. Henry Ford Hosp. Med. Journal Vol. 22, No. 3, 1974 Cystic Duct Cholangiography Leo Chaikof, MD,* T.L. Friedlich, MD, R.A. Affifi, MD and H. Weizel, MD ALTHOUGH operative cholangiog­ raphy was first used in 1932 by Mirizzi,^'^ it is still not done routinely as part of the surgical procedure in biliary tract opera­ tions. According to Jolly, Baker et al,^ only 18% of members of the American Surgical Association use it routinely. De­ spite a great deal of discussion pro and con in the literature,^'" it appears that, if A series of 837 cystic duct cholangiograms the frequency of common duct explora­ has been reviewed. The technique is simple and safe to carry out. It is not time consuming tion can be reduced, certainly its as­ and does not require any unusual equipment. sociated morbidity and mortality can It has reduced the incidence of common duct also be decreased.'"" exploration and has decreased the incidence of retained common duct stones. It is stressed that, unless the operative cholangiogram ful­ Glenn and Beil'^ claimed 42.4% of fills the criteria of a normal cholangiogram, common duct explorations and Colcock especially in relation to size and tapehng of and Perey^^ claimed 72% of the the tower end of the duct, then common duct choledochetomies they surveyed, re­ exploration should be earned out. Its almost routine use can only increase the general spectively, were negative and unneces­ quality and accuracy of biliary tract surgery. sary. We will show that the incidence of common duct exploration as well as re­ tained common duct stones has been decreased with the use of cholangiog­ raphy. Method The patient is positioned on a Bucky diaphragm on the operating table. En­ dotracheal anesthesia with nonexplosive agents and muscle relaxants is then em­ ployed. The gall bladder field is exposed and the peritoneum overlying the am­ 'Resident, Henry Ford Hospital, 1957-61. At present. Director of Department of Medical pulla of the gall bladder toward the bile Education and Research, The Doctors' Hospi­ duct is split. The cystic duct and artery tal, Toronto, Ontario are then visualized and the cystic artery is ligated and divided. Occasionally, it is Address reprint requests to Dr. Chaikof at Doctor's Hospital Medical Centre, 25 Bruns­ somewhat easier to visualize the cystic wick Ave., Toronto, Ontario, Canada, M5S2L9 duct and to catheterize this first. 129 Chaikof, Friedlich, Affifi and Weizel Figure 1 Normal cystic duct cholangiogram. The cystic duct is ligated at its junction the distal part of this duct tense and to with the gallbladder. The tie is left long thread the cystic duct with a fine probe. to act as a traction suture, and a second This can also serve to delineate the fact loop tied distally and held on tension. that this so called difficult area is not The duct is then partially incised and a being produced by a stricture or a small #5 ureteral catheter is then inserted for a calculus. distance of 3-4 cms. Prior to the insertion of the ureteral catheter, a #20 needle is The catheter is then secured in place fixed into the proximal end of the cathe­ with a silk suture and a syringe contain­ ter and saline is flushed through the ing 20 cc of dye (Dilute Conray) is then catheter. This serves to test the patency attached. Radio-opaque materials such of the catheter before it is inserted and as sponges and clamps are then re­ also to rid it of air. Care should be taken moved and a sterile drape used to cover not to advance the catheter too far lest it the field. For radiologic films, the patient enter the duodenum. Care should also is placed in slight Trendelenburg posi­ be taken to make sure the catheter is in tion (so that the hepatic ducts will fill the cystic duct so that the dye will not better) at approximately 15-20° tilt to the extravasate. Occasionally, at a point ap­ right so that the biliary tract is not lo­ proximately 1.5 cms from its entry into cated over the vertebral column. When the common bile duct, the cystic duct the x-ray technician is ready, the may contain a valve which may be dif­ surgeon instills 5-10 cc of dye, the anes­ ficult to negotiate with the catheter. thetist momentarily stops the patient's When this happens it may help to hold breathing, and a film is obtained. A new 130 Cystic Duct Cholangiography Figure 2 Spasm of the sphincter of Oddi. Because of the normal configuration and tapering, and normal size of the duct, no surgical exploration was carried out. film is then inserted and the rest of the proaches and enters the ampulla. dye instilled and a second exposure This narrowing is in a tapered fash­ made. The developed films are brought ion and the presence of the config­ to the operating room for the surgeons uration is important. We do not ac­ to evaluate. They may then be evaluated cept a duct as normal even with dye by the radiologist. The 3-5 minute wait­ entering the duodenum and no vis­ ing time until the films are brought back ible filling defects if its lower end is is used to perform a cholecystectomy or cut across rather sharply with no an incidental appendectomy. tapering. The criteria of a normal cystic duct 4. The duct diameter is less than 12 cholangiogram are as follows: mms. 1. No filling defect in the ducts. 5. No excess retrograde filling of the 2. Contrast medium readily enters the intrahepatic ducts. Normally there duodenum. is filling of the tertiary radicles around the hilar area and there is 3. The terminal segment, usually ^V2 considerable range of normal in cms in length, narrows as it ap­ this parameter. When we refer to 131 Chaikof, Friedlich, Affifi and Weizel Figure 3 Radiologic film shows a sharp cutoff at the lower end of the duct, with a relatively normal size common duct, and dye readily entering the duodenum. Exploration revealed a stone at the lower end of the common bile duct (arrow). excess filling, we mean that the 2. The presence of persistent jaun­ small radicles extending toward the dice. peripheral areas of the liver are vis­ ualized. In our experience this in­ 3. The presence of a dilated common dicates some degree of obstruction bile duct. distally and usually warrants explo­ ration. It is apparent that the in­ The relative indications for common terpretation at this point becomes duct exploration are as follows: more accurate as experience in­ creases. 1. Multiple small stones in the gall bladder and/or cystic duct. Discussion of Cases 2. A past history of jaundice. Indications for Exploration. The follow­ ing may be listed as absolute indications 3. A past history of pancreatitis. for common duct exploration: 4. A clinical history of recurrent biliary 1. Palpating a stone in the duct. colic. 132 Cystic Duct Cholangiography TABLE I TABLE II CYSTIC DUCT CHOLANGIOGRAPHY SIZE OF COMMON BILE DUCT FELT ON 837 PATIENTS. BY OPERATING SURGEON TO BE No. % ENLARGED ON VISUAL INSPECTION Normal cfiolangiograms 719 86% AND PALPATION. Number of choledochetomies Clinically enlarged 40 required with old criteria 316 36% Cholangiograms Number of choledochetomies Normal 15 done 118 14% Abnormal (choledochetomy done) 25 Positive choledochetomies 86 74% Common duct explorations Unsuspected stones 27 3.2% Normal 8 Abnormal 17 5. "Thickened" head of pancreas. Results In Table 1, results of cystic duct 6. The presence of muddy bile or cholangiography show that 86% (719/837) gravel in the gall bladder or ducts. of all cystic duct cholangiograms were 7. Thickened and contracted gall normal. Using previously recognized bladder. criteria for common duct exploration, 36% (316/837) of all our cholecystecto­ At our institution we have done over mies would have required common duct 1,000 operative cholangiograms. Cho­ exploration. With the use of operative langiography is accepted almost as a cholangiography, only 14% (118/837) of routine procedure by almost all our patients had a common duct explo­ surgeons on our active staff. We feel that ration, a reduction of greater than 50%. visualization of the common bile duct by dye injected via the cystic duct has no In those patients undergoing common place where an absolute indication to duct exploration after a cystic duct open the common bile duct exists. In cholangiogram, 74% (86/118) had posi­ other words, in these situations the tive pathological findings while 26% common bile duct should be opened were normal. As illustrated in our own and explored without first doing a cystic series, negative common duct explora­ duct cholangiogram. tion will be decreased 50% or more with increasing reliance on operative cholan­ Patients with relative indications of giography. common duct exploration should have a cystic duct cholangiogram.
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