Abnormal cholangiograms during laparoscopic cholecystectomy. Is treatment always necessary?

BACKGROUND: Laparoscopic common bile duct exploration (LCBDE) is more expensive and time consuming than its conventional counterpart. Therefore, it should only be performed when there is near certainty that stones are present. The purpose of this study was to identify patients who should be spared LCBDE despite an abnormal intraoperative cholangiogram. METHODS: Of 700 consecutive laparoscopic cholecystectomies performed between 1989 and 1994 by a single surgeon (R.J.F.), 41 had abnormal intraoperative cholangiograms (6%). All 41 patients were treated by either immediate CBDE (19) (conventional or laparoscopic) or had postoperative follow-up cholangiograms (22). The patients were retrospectively assigned to one of three groups. Group I patients had a single "soft" indicator of choledocholithiasis. Group II patients had one or more of the following: (1) a highly suspicious abnormal intraoperative cholangiogram, (2) two or more "soft" indicators of choledocholithiasis, or (3) preoperative clinical findings such as elevated liver function studies or positive preoperative radiological studies. Group III patients had proven choledocholithiasis. RESULTS: In group I, there were 11 patients, none of whom underwent immediate CBDE. Eight of the 11 (73%) had normal follow-up cholangiograms due to either spontaneous stone passage or a false-positive intraoperative cholangiogram. There were 27 patients in group II; 19 underwent immediate CBDE with 100% stone recovery. The remaining 8 had delayed treatment and in five stones were recovered, while three had normal postoperative cholangiograms suggesting spontaneous stone passage. In group III, all three had negative follow-up cholangiograms despite proven choledocholithiasis. Spontaneous stone passage in this group seemed highly likely. CONCLUSIONS: The finding of a single soft indicator results in a low rate of stone recovery postoperatively, and these patients should not undergo LCBDE. In this series, spontaneous stone passage seemed highly likely in at least 3/22 (14%) and possibly as high as 14/22 (64%).

Diagnosis of femoropopliteal venous thrombosis: comparison of duplex sonography and plethysmography.

Duplex sonography and impedance plethysmography were correlated with contrast venography to compare the sensitivity, specificity, and accuracy of the two noninvasive techniques for the diagnosis of femoropopliteal venous thrombosis. Sensitivity, specificity, and accuracy of duplex sonography were 90%, 100%, and 97%, respectively, when compared with venography in 32 patients. Sensitivity, specificity, and accuracy of plethysmography were 100%, 63%, and 72%, respectively, when compared with venography in 25 patients. In 21 patients, plethysmography was either nondiagnostic or could not be done because of clinical difficulties. Eighteen of these patients had diagnostic duplex examinations. Duplex sonography exhibits similar sensitivity but higher specificity than plethysmography. Duplex sonography also permits diagnostic examinations in patients in whom diagnostic plethysmography cannot be performed.

Guidelines for use of lumbar spine radiography.

In deciding whether to obtain lumbosacral spine films, the emergency physician must not ask whether a diagnosis can be established, but whether obtaining films will affect management. Low back pain is a considerable problem for society with cost in billions of dollars. Gonadal radiation from lumbosacral radiographs is significant, and thus ordering films should be minimized. Plain radiographs are rarely indicated in otherwise healthy patients 20 to 50 years old with mechanical or root pain on initial presentation. In other patients alternative diagnostic methodologies such as computed tomography may be superior, with less radiation risk. Specific recommendations for emergency radiographic evaluation of the lumbosacral spine are offered.

A simple radiographic diagnosis of occult blow-out fractures.

Standard radiographs of the orbit may not provide conclusive diagnosis of a blow-out fracture. Conventional and computed tomography have been employed effectively to resolve questionable cases. These imaging modalities generally are unavailable after hours and on weekends. The exaggerated Waters views are plain film radiographs easily and routinely obtainable that can demonstrate an occult fracture of the orbital floor.

The next logical step in the emergency radiographic evaluation of cervical spine trauma: the five-view trauma series.

The five-view standard series is considered the golden standard in the radiographic evaluation of the cervical spine. Although the three-view trauma series has proved significantly more accurate than the cross-table lateral view in the emergency evaluation of patients with cervical spine trauma, this series does not deal with questionable findings. The introduction of a five-view trauma series, with the inclusion of supine oblique views, is the next logical step in the emergency evaluation of these patients. An algorithm for the emergency radiographic evaluation of patients with suspected cervical spine trauma is proposed.

The expanded role of the barium enema in the evaluation of patients presenting with acute abdominal pain.

The role of the barium enema in the evaluation of patients with acute abdominal pain is well established. It is utilized in the diagnosis and treatment of several suspected clinical entities, including appendicitis, diverticulitis, intussusception, and volvulus. There is another group of patients in whom a vague clinical presentation and an indeterminate bowel gas pattern fail to clarify the diagnosis. The role of the barium enema has been expanded as an early diagnostic aid in the evaluation of these patients. Based on abdominal film findings, three patient categories are presented, in whom the early use of a "judicious" barium enema may safely and quickly contribute to the preoperative definition of the underlying disease process, allowing for the correct mode of therapy to be undertaken.

Radiographic parameters in adult epiglottitis.

A retrospective study was undertaken to define precise radiographic criteria for the diagnosis of epiglottitis in the adult. We reviewed the standard lateral neck films of six patients over the age of 18 with epiglottitis and five with a normal epiglottis. Radiographic anatomy measured included the angle of the valleculae, retropharyngeal soft tissue width at C2, retrotracheal soft tissue width at C6, width of the epiglottis, width of the aryepiglottic folds, and the hypopharyngeal to tracheal air column ratio. The measurement differences were significant between the groups only for the width of the epiglottis and aryepiglottic folds (P less than .01). Width of the epiglottis greater than 8 mm and of the aryepiglottic folds greater than 7 mm seem highly suggestive of epiglottitis in the adult.

Clinical presentation of patients with acute cervical spine injury.

A retrospective review of 67 patients with acute cervical spine fracture and/or dislocation was conducted at two suburban community hospital emergency departments. The mean age was 39, and two-thirds of the patients were male. Motor vehicle accidents and falls accounted for more than 80% of all injuries. On emergency department evaluation, it was found that there was no history of loss of consciousness in 42 patients (63%), no associated cranio-facial injuries in 31 patients (46%), and a normal sensorimotor examination in 59 patients (88%). Thirty-four patients (50%) were evaluated for cervical range of motion, which was found to be normal in one-third of the cases. The absence of mental status changes, cranio-facial injuries, range of motion abnormalities, and focal neurological findings is, therefore, not uncommon in patients who have sustained cervical spine injury.

The modified odontoid view: an alternative visualization of the atlantoaxial joint.

The sensitivity of the cross table lateral view (CTLV) alone, as a determinant in the radiographic disposition in patients with cervical spine fracture/dislocation has been challenged. A cervical spine trauma series that includes the CTLV, the anteroposterior view (APV), and the open-mouth view (OMV) has been suggested. Whereas the CTLV and APV present no difficulty, the OMV is often not possible in the uncooperative or unconscious patient, or in those patients with rigid forms of neck support. The modified odontoid view (MOV) can replace the OMV in these patients. The MOV allows for satisfactory visualization of the C1/C2 complex and is easily obtained as a portable technique. In addition, it requires neither patient cooperation nor neck movement. The technique is described and its interpretation reviewed.

Lumbar spine x-rays: a multihospital study.

To define the usefulness of the lumbar spine x-ray series in the emergency department and to generate clinical criteria for optimizing its application, we retrospectively studied 552 consecutive emergency department patients for whom lumbar spine x-rays were ordered. Patients were divided into traumatic (47.6%) and nontraumatic (52.4%) groups. Three subgroups were created based on radiological findings: 1) "negative" (55.8%), 2) "possibly significant" (37%), and 3) "positive" (7.2%). The "positive" subgroup was compared with the other two subgroups in an attempt to define physical markers that correlated with positive radiological findings. Four clinical findings were present in significantly different frequencies between the positive group and others: an abnormal physical examination (90% vs 61.5%, respectively) (P less than .0001), tenderness (72.5% vs 41.2%) (P less than .0005), multiple positive findings (42.5% vs 20.7%) (P less than .005), and contusion or abrasion (15% vs 2.7%) (P less than .0005).

Increasing the diagnostic yield of portable skull films.

A three-year retrospective analysis was conducted at a 280-bed suburban community hospital with 27,000 annual emergency department visits. All patients with a discharge diagnosis of skull fracture were studied. There were 72 patients with skull fractures. Thirty-two (44.4%) of these patients had basilar skull fractures, located predominantly in the occipital bone. Of these, 19 (59.3%) had normal antero-posterior and lateral views, with the skull fracture detected only on the Towne view. Five of these patients had depressed skull fractures and three had intracranial lesions requiring surgical intervention. We conclude that, when the decision is made to obtain portable skull films, a Towne view must be included, as well as the antero-posterior and lateral views, to increase the diagnostic yield of portable skull films in patients with skull fractures.

Limitation of the cross table lateral view in detecting cervical spine injuries: a retrospective analysis.

A city-wide survey of 17 emergency departments revealed that 94.7% of physicians relied exclusively on the cross table lateral view in their initial radiologic disposition of patients suspected of having cervical spine injury, and most of these physicians think it is more than 90% effective in detecting potentially unstable injuries of the cervical spine. A three-year retrospective study was conducted in a midwestern suburban community hospital with 27,000 annual emergency visits to determine the incidence of false negative cross table lateral views of the cervical spine. Of 35 patients with cervical spine fracture/dislocation, we found three cases difficult to diagnose, and six in which this initial view was interpreted as normal. In all nine cases, a standard anteroposterior view (APV) or standard open mouth view (OMV) would have increased the diagnostic yield to 100%. A revised radiologic approach to the patient suspected of having cervical spine injuries is suggested.

Clinical trial of pantomography for the evaluation of mandibular trauma.

A trial study was conducted comparing the standard "four view" mandibular series and pantomography for th evaluation of mandibular trauma. During the six-month trial period a series of 17 patients with a total of 24 mandibular fractures was compiled. The pantomographs were more easily interpreted than the standard views because overlapping structures were blurred and spatial orientation was clear. In eight of the 17 patients the fractures were more clearly visualized by pantomography. Because the entire mandibule was seen so well on the pantomographs, no special views were required. Eleven patients had single fractures, which are in fact quite common.