ABSTRACT
Different diagnostic modalities have been used to asses patients with cholelithiasis before laparoscopic cholecystectomy [LC] for the suspicion of choledocholithiasis. The aim of this study is to define predictive guidelines for patient management with selective use of magnetic resonance cholangio-pancreatography [MRCP] and endoscopic retrograde cholangiopancreatography [ERCP] before LC. ERCP is considered the gold standard for diagnosis and clearance of common bile duct [CBD] stones before LC. MRCP has recently developed as a noninvasive imaging modality for the detection of choledocholithiasis. However it needs further evaluation as regards its diagnostic accuracy in patient management before LC. Between October 2001 and December 2004, 128 patients [88 females, 40 males; mean age 48 [range 14-78 years] with cholelithiasis were prospectively evaluated before LC applying predictive guidelines that include patient information obtained from clinical assessment, blood chemistry tests, and abdominal ultrasonography. Patients were put into one of four groups according to the level of suspicion for choledocholithiasis [group 1, high; group 2, moderate; group 3, low; group 4, very low]. Group 1 patients underwent ERCP with or without endoscopic sphincterotomy for clearance of common bile duct stones; group 2 patients were subjected to MRCP; group 3 patients were operated on by LC with intraoperative cholangiography; and group 4 patients underwent LC without intraoperative cholangiography. CBD stones were demonstrated in 15 [11.7%] of 128 patients. The incidence of choledocholithiasis in groups 1, 2, 3 and 4 was 83.3% [10/12], 27.3% [3/11], 7.1% [1/14], and 1.1% [1/91]. rescectively [P < 0.001]. ERCP was successfull in diagnosis and therapeutic clearance of CBD stones before LC in 91.7% [11/12] of patients. It showed a sensitivity, a specificity, and an overall accuracy of 92.3%, 100%, and 91.7% respectively. MRCP was utilized in 8.6% [11/128] of patients. It was unable to detect a CBD stone in one patient, with a sensitivity, a specificity, and an overall accuracy of 75%, 100%, and 91% respectively. lntraoperative cholangiography detected a CBD stone in one patient in group 2, and in another patient in group 3 which were extracted using postoperative ERCP. Only one patient in group 4 had a missed CBD stone which was manifested three months after operation and the patient underwent ERCP with stone clearance. It was concluded that initial evaluation using certain predictive guidelines in patients with cholelithiasis can accurately predict the probability of choledocholithiasis with selective use of MRCP which is an accurate non invasive diagnostic method and ERCP for therapeutic clearance of CBD stones before LC. Thereby improving patient care and resource utilization