Value and Consequences of Routine Intraoperative Cholangiography During Cholecystectomy Does routine intraoperative cholangiography prevent bile duct transection? Routine cholangiography is not warranted during laparoscopic cholecystectomy. Prospective evaluation of a selective approach to cholangiography for suspected common bile duct stones. Does selective peroperative cholangiography result in missed common bile duct stones? Bile duct leaks after laparoscopic cholecystectomy: value of contrast-enhanced MRCP Routine versus selective intra-operative cholangiography during laparoscopic cholecystectomy Evaluation of magnetic resonance cholangiography in the management of bile duct stones. [Intraoperative cholangiography as a routine method? A prospective, controlled, randomized study]. Over-the-Counter Supplement Interventions to Prevent Cognitive Decline, Mild Cognitive Impairment, and Clinical Alzheimer-Type Dementia Use of magnetic resonance cholangiography in the diagnosis of choledocholithiasis: prospective comparison with a reference imaging method Magnetic resonance cholangiography: comparison with endoscopic retrograde cholangiopancreatography. Consequences of routine peroperative cholangiography during cholecystectomy for gallstone disease: A prospective, randomized study Choledocholithiasis: evaluation of MR cholangiography for diagnosis. Aspirin after myocardial infarction: the importance of over-the-counter use. Real-world efficacy of prescription and over-the-counter nicotine replacement therapy. Breath-hold MR cholangiography with snapshot techniques: prospective comparison with endoscopic retrograde cholangiography. An over-the-counter moisturizer is as clinically effective as, and more cost-effective than, prescription barrier creams in the treatment of children with mild-to-moderate atopic dermatitis: a randomized, controlled trial. Diagnosing bile duct stones: comparison of unenhanced helical CT, oral contrast-enhanced CT cholangiography, and MR cholangiography. Consumer behavior in the setting of over-the-counter statin availability: lessons from the consumer use study of OTC Mevacor. Effectiveness of the nicotine inhaler for smoking cessation in an OTC setting. Choledocholithiasis: comparison of MR cholangiography and endoscopic retrograde cholangiography. Evaluation of a non-breath-hold MR cholangiography technique.
Since the introduction of laparoscopic cholecystectomy ( LC ) , an increase in accidental  common bile duct ( CBD )  injuries of up to 1.2–1.6 % has been reported . In the present prospect i ve study of 1,710 patients undergoing cholecystectomy ( 1,241 LC procedures and 469 open cholecystectomies [ OC ] ) , we tested the predicative value of routine intraoperative cholangiography ( IOC ) . The IOC was feasible in 92.4 % of the cases in the LC group and in 83 % of cases in the OC group and presented a complete depiction of the extrahepatic bile system in 98.3 % . Anatomic variations of the bile duct system , which influenced the operative management , were found in 13.2 % of cases ( 13.4 % LC versus 12.8 % OC ) . In 2.5 % of the patients , preoperatively undetected CBD stones were also found . Method -specific complications did not occur in any of the patients . Additionally , in a controlled subgroup analysis of 163 patients , we evaluated preoperative intravenous cholangiography ( IVC ) and IOC . Intravenous cholangiography showed only 72.4 % of the operation-relevant anatomic variations ( vs. 100 % by IOC ) ; in 6.1 % of the cases , there were reactions to the dye ( vs. none in IOC ) , and in only 28.6 % of the patients , CBD stones were detected ( vs. 71.4 % IOC ) . There were four bile duct injuries ( 0.29 % ) during LC and two ( 0.4 % ) during OC . All injuries were detected intraoperatively and fixed in the same setting without postoperative complications . In conclusion , we recommend the use of routine IOC during cholecystectomy . By this technique , anatomic variations of the bile duct system will be visualized and therefore accidental injuries will be avoided Background The role of routine intraoperative cholangiography is controversial . The aim of this study was to assess the impact of routine intraoperative cholangiography on the incidence of common bile duct injuries , and to evaluate the operative outcome of laparoscopic cholecystectomy carried out in a major teaching hospital and review the literature . Methods Prospect ively collected data on 3,145 laparoscopic cholecystectomies performed mainly by surgical trainees in the period 1990 to 2002 using routine intraoperative cholangiography with fluoroscopy were review ed . Results The mean age of the study sample ( 65.6 % male , 34.4 % female ) was 54 years , and 16.9 % of the patients had clinical acute cholecystitis . The conversion rate to open cholecystectomy was 4.3 % . Intraoperative cholangiography was attempted for 90.7 % of the patients with a 95.9 % success rate . Five patients ( 0.16 % ) had common bile duct injuries . Four injuries had occurred in the first 5 years . One injury ( 0.06 % ) had occurred after 1995 . This injury was identified intraoperatively and repaired laparoscopically . Routine intraoperative cholangiography prevented one definite common bile duct transection . Conclusions In this series using routine intraoperative cholangiography , there was a low rate and severity of common bile duct injuries , with a high intraoperative recognition rate . There was no bile duct transection or major injury requiring common bile duct reconstruction . Although intraoperative cholangiography helped in the immediate identification of injuries and the institution of appropriate therapy , injury was not completely prevented The role of intraoperative cholangiography during laparoscopic cholecystectomy was prospect ively evaluated in 514 patients undergoing laparoscopic cholecystectomy .  Before surgery , all patients were assigned to one of three groups depending on the likelihood of their having common bile duct stones . Stratification was based on objective historical , laboratory , or radiologic criteria . In 453 patients deemed unlikely to have stones , laparoscopic cholecystectomy was performed without cholangiography . Of these patients , four had retained stones ( 0.9 % ) . In 25 patients likely to have stones , preoperative endoscopic retro grade cholangiopancreatography identified stones in six patients ( 24 % ) . In 36 patients whose likelihood of having stones was deemed indeterminate , intraoperative cholangiography was performed at laparoscopic cholecystectomy . A common bile duct stone was identified in one patient ( 2.8 % ) . One common bile duct injury occurred in the group deemed unlikely to have stones , and this injury would not have been prevented by intraoperative cholangiography . We conclude that preoperative assessment will identify common bile duct stones and that routine cholangiography is not warranted . Meticulous dissection of the cystic duct at its origin at the infundibulum will prevent common bile duct injury INTRODUCTION Common bile duct ( CBD ) stones can cause serious morbidity or mortality , and evidence for them should be sought in all patients with symptomatic gallstones undergoing cholecystectomy .  Routine intra-operative cholangiography ( IOC ) involves a large commitment of time and re sources , so a policy of selective cholangiography was adopted . This study prospect ively evaluated the policy of selective cholangiography for patients suspected of having choledocholithiasis , and aim ed to identify the factors most likely to predict the presence of CBD stones positively . PATIENTS AND METHODS Data from 501 consecutive patients undergoing laparoscopic cholecystectomy ( LC ) for symptomatic gallstones , of whom 166 underwent IOC for suspected CBD stones , were prospect ively collected . Suspicion of choledocholithiasis was based upon : ( i ) deranged liver function tests ( past or present ) ; ( ii ) history of jaundice ( past or present ) or acute pancreatitis ; ( iii ) a dilated CBD or demonstration of CBD stones on imaging ; or ( iv ) a combination of these factors . Patient demographics , intra-operative findings , complications and clinical outcomes were recorded . RESULTS Sixty-four cholangiograms were positive ( 39 % ) . All indications for cholangiogram yielded positive results . Current jaundice yielded the highest positive predictive value ( PPV ; 86 % ) . A dilated CBD on pre-operative imaging gave a PPV of 45 % for CBD calculi ; a history of pancreatitis produced a 26 % PPV for CBD calculi . Patients with the presence of several factors suggestive of CBD stones yielded higher numbers of positive cholangiograms . Of the 64 patients having a laparoscopic common bile duct exploration ( LCBDE ) , four ( 6 % ) required endoscopic retro grade cholangiopancreatography ( ERCP ) for retained stones ( 94 % successful surgical clearance of the common bile duct ) and one ( 2 % ) for a bile leak . Of the 335 patients undergoing LC alone , three ( 0.9 % ) re-presented with a retained stone , requiring intervention . There were 12 ( 7 % ) requiring conversion to open operation . CONCLUSIONS A selective policy for intra-operative cholangiography yields acceptably high positive results . Pre-operatively , asymptomatic bile duct stones rarely present following LC ; thus , routine imaging of the biliary tree for occult calculi can safely be avoided . Therefore , a rationing approach to the use of intra-operative imaging based on the pre-operative indicators presented in this paper , successfully identifies those patients with bile duct stones requiring exploration . Laparoscopic bile duct exploration , performed by an experienced laparoscopic surgeon , is a safe and effective method of clearing the bile duct of calculi  , with minimal complications , avoiding the necessity for an additional intervention and prolonged hospital stay A prospect i ve r and omized trial was undertaken to determine if selective peroperative cholangiography result ed in greater morbidity and mortality from missed common bile duct ( CBD ) stones . Five hundred and thirty-nine consecutive cholecystectomies were performed over a 3-year period . Two hundred and fifty-four had indications for m and atory peroperative cholangiography and were excluded from the trial . The remaining 285 patients , without a history of jaundice , pancreatitis or abnormal liver function tests , were r and omized blindly into two groups . Group 1 underwent peroperative cholangiography ( PC ) and group 2 did not . If the surgeon found a dilated CBD at surgery then these patients were also excluded from the trial . Selective peroperative cholangiography revealed an unsuspected CBD calculus in 16 of the 132 patients ( 12 % ) . Up to the time of review no patient from group 2 presented with symptoms or complications from retained CBD stones . One patient in group 1 had endoscopic removal of a retained CBD calculus 16 months after cholecystectomy . All patients were sent a question naire at least three years after surgery and 210 responded ( 74 % ) . One hundred and thirty ( 62 % ) of the respondents had  peroperative cholangiography .  There were 11 deaths from unrelated causes . No difference between the two groups was found for postoperative dietary habit , dyspepsia , pain , flatulence , diarrhoea or signs of biliary obstruction . It seems from these results that a policy of selective cholangiography in our h and s may miss a 12 % incidence of unsuspected stones but , importantly , this does not appear to influence postoperative morbidity or mortality . ( ABSTRACT TRUNCATED AT 250 WORDS Background We assessed the role of mangafodipir-enhanced magnetic resonance ( MR ) cholangiography in the detection and location of bile duct leaks after laparoscopic cholecystectomy . Methods In a prospect i ve study , 34 patients with clinical suspicion of bile duct leak after laparoscopic cholecystectomy underwent MR imaging .  Our protocol included conventional heavily T2-weighted MR cholangiography and three-dimensional T1-weighted MR cholangiography after an intravenous bolus injection of mangafodipir trisodium . All studies were performed on a 1.5-T or 1-T scanner . Contrast-enhanced MR cholangiograms were evaluated for the presence and location of bile duct leaks . Correlation was obtained in all cases with surgery ( n = 15 ) , endoscopic retro grade cholangiography ( n = 5 ) , percutaneous drainage ( n = 5 ) , and clinical follow-up ( n = 9 ) . Results In 20 of 34 patients , bile duct leakage was proved by surgery , endoscopic retro grade cholangiography , or drainage . Contrast enhancement displayed the leakage in 19 of 20 patients and ruled out leaks in the other 14 patients ( 95 % sensitivity , 100 % specificity ) . The leak site was depicted in 14 patients and contrast-enhanced MR cholangiography successfully located the origin of the leak in 11 patients . Conclusions Contrast-enhanced MR cholangiography with intravenous mangafodipir trisodium can accurately diagnose the presence and location of bile duct leaks in patients who have undergone laparoscopic cholecystectomy Opinion is divided whether intra-operative cholangiography should be performed routinely or on a selective basis during laparoscopic cholecystectomy . We therefore performed the first prospect i ve r and omized trial of static cholangiography in patients who did not have indications for cholangiograms .  Laparoscopic cholecystectomy  was attempted on 164 consecutive patients , of whom 49 ( 30 % ) patients were excluded from the trial due to indications for or against cholangiography .  In the remaining 115 ( 70 % ) patients , 56 were r and omized to the cholangiography group while 59 patients did not receive cholangiograms .  Duration of postoperative hospitalization and interval to return to full activity were identical in the two groups . Static cholangiograms added 16 ± 1 min ( mean ± SEM ) to the procedures ( p<0.01 ) . Cholangiography  increased the total charges for the operation by almost $ 700 ( p<0.01 ) . Cholangiograms were performed successfully in 94.6 % of the patients and changed the operative management in 4 ( 7.5 % ) patients . There was 1 ( 1.9 % ) false negative study . Intra-operative cholangiography did not reveal aberrant bile ducts at risk of injury from the operative dissection . There was no mortality or cholangiogram-related morbidity in either group . In follow-up ranging from 2–12 months , there has been no clinical evidence of bile duct injury or retained common bile duct stones . In summary , in patients without indications for cholangiography , the performance of static cholangiograms markedly increased the operative time and cost of laparoscopic cholecystectomy  . The operative management of a minority of patients was changed by the information obtained , but laparoscopic cholecystectomy may be performed safely in the absence of cholangiograms with little risk of injury to the major ductal system or retained calculi . RésuméLes avis sont partagés quant à la pratique systématique , ou seulement élective , d'une cholangiographie lors de la cholécystectomie coelioscopique . Nous avons mené le premier essai r and omisé prospect if de cholangiographie peropératoire chez des patients n'ayant pas d'indication formelle de cholangiographie . Dans une série de 164 cholécystectomies coelioscopiques consécutives , 49 patients ( 30 % ) ont été éliminés de l'étude parce qu'il existait une indication ou une contreindication formelles à la cholangiographie peropératoire . Les 115 patients restants ( 70 % ) ont été r and omisés ; 56 ont eu une cholangiographie alors que 59 n'ont pas eu de cholangiographie peropératoire . La durée de l'hospitalisation postopératoire et le délai entre l'intervention et la reprise de travail étaient similaires dans les deux groupes . La cholangiographie a prolongé l'intervention de 16 ± 1 min ( moyenne ± écart type de la moyenne ) ( p<0.01 ) . Le coût supplémentaire d'une cholangiographie peropératoire a été estimé à environ 700 $ US ( p<0.01 ) . La cholangiographie a pu être effectuée chez 94.6 % des patients , et celle-ci a changé la tactique opératoire chez 4 ( 7.5 % ) patients . Il y a eu un résultat faussement négatif ( 1.9 % ) . La cholangiographie peropératoire n'a pas montré d'anomalie anatomique des voies biliares pouvant les compromettre lors de la dissection . La mortalité a été nulle dans chaque groupe . De même , il n'y a eu aucune morbidité en rapport direct avec la cholangiographie . Dans la période du suivi allant de 2 à 12 mois , il n'y a eu acune lésion biliaire ni de lithiase résiduelle de la voie biliaire cliniquement évidentes . En conclusion , chez un patients ans indication formelle de cholangiographie , la réalisation d'une cholangiographie peropératoire augmente considérablement la durée et le coût de l'intervention . La tactique opératoire a été très peu influencée très peu par les donées de la cholangiographie . La cholécystectomie coelioscopique peut être réalisée sans cholangiographie peropératoire systématique sans augmenter pour autant le risque de lésions des voies biliaires ou de calcul résiduel . ResumenLas opiniones se encuentran divididas respecto a si se debe realizar colangiografía intraoperatoria en forma rutinaria o en forma selectiva en el curso de una colecistectomía laparoscópica . Por ello hemos realizado el primer estudio aleatorizado de colangiografía estática en pacientes que no tenían indicaciones para colangiograma . Se intentó la colecistectomía laparoscópica en 164 pacientes consecutivos ; 49 ( 30 % ) fueron excluidos debido a indicaciones en favor o en contra de colangiografía . Los otros 115 pacientes ( 70 % ) se repartieron al azar 56 a colangiografía y 59 al grupo de no colangiografía . La duración de la hospitalización postoperatoria y del tiempo de retorno a actividad normal fueron idénticos en los dos grupos . Los colangiogramas estáticos añadieron 16 ± 1 min . al procedimiento ( p<0.01 ) y elevaron el costo de la operación en $ 700 ( p<0.01 ) . Los colangiogramas fueron exitosamente realizados en 49.6 % de los pacientes y modificaron el manejo operatorio en 4 ( 7.5 % ) ; hubo un falso positivo ( 1.9 % ) . La colangiografía intraoperatoria no reveló la prescencia de canales biliares aberrantes en riesgo de lesión por la disección opeatoria . No hubo mortalidad o morbilidad relacionada con la colangiografía , y en un seguimiento de 2–12 meses no se registró evidencia clínica de lesión de canales biliares o de cálculos retenidos en el colédoco . En resumen , en pacientes sin indicaciones para colangiografía , la realización de colangiogramas estáticos aumentó notoriamente el tiempo operatorio y el costo de la colecistectomia laparoscópica . Aunque el manejo operatorio de una minoría de pacientes sí fue modificado por la información obtenida , se considera que la colecistectomía laparoscópica puede ser practicada en forma segura en ausencia de colangiogramas con mínimo riesgo de lesión del sistema biliar o de cálculos retenidos HYPOTHESIS Magnetic resonance cholangiography ( MRC ) offers the potential for accurate , noninvasive detection of  common bile duct stones ( CBDSs ) before cholecystectomy , and for a consequent reduction in the incidence of preoperative negative diagnoses associated with endoscopic retro grade cholangiography ( ERC ) . DESIGN Prospect i ve cohort study : MRC results were correlated with ERC ( high-risk patients ) or intraoperative cholangiography ( moderate-risk patients ) . SETTING A university hospital providing primary , secondary , and tertiary care . PATIENTS Seventy patients with suspected CBDSs scheduled to undergo elective cholecystectomy between April 15 , 1997 , and September 30 , 1998 . Forty patients were considered at high risk and 30 at moderate risk for CBDSs , according to results of liver function tests and sonograms of the upper abdomen . MAIN OUTCOME MEASURES Confirmation or exclusion of CBDSs by MRC  was assessed by a panel of radiologists who were unaware of the ERC results . Results of ERC and intraoperative cholangiography were analyzed by the investigating gastroenterologists or surgeon . RESULTS Results of MRC were positive for CBDSs in 21 ( 52 % ) of 40 high-risk patients , a finding confirmed by preoperative ERC in 19 ( 90 % ) of 21 patients . Results of MRC were positive for CBDSs in 6 ( 20 % ) of 30 moderate-risk patients , all of which were confirmed by intraoperative cholangiography . Finally , CBDSs were present in 19 ( 48 % ) of 40 high-risk patients and 6 ( 20 % ) of 30 moderate-risk patients ( P = .02 ) . Overall sensitivity and specificity of  MRC  were 100 % and 95.6 % , respectively ; the positive and negative predictive values were 92.6 % and 100 % , respectively . CONCLUSIONS Magnetic resonance cholangiography is a reliable , noninvasive method for the detection or exclusion of CBDSs , and seems to reduce the frequency of negative diagnoses associated with ERC . Magnetic resonance cholangiography revealed no CBDSs in 19 ( 48 % ) of 40 patients at high risk for CBDSs . Thus , MRC-based diagnosis has the potential to reduce the number of invasive preoperative diagnostic procedures and their associated risks and overall health care costs A prospect i ve , controlled , r and omized trial was conducted in 275 patients with symptomatic gall stone disease , whose history , laboratory data or sonographical findings did not suggest common bile duct stones . Of these patients , 137 did not undergo intraoperative fluoroscopic cholangiography ( IOC ) , but in the remaining 138 patients IOC was attempted . In 111 cases ( 80.4 % ) the biliary system was sufficiently visualized . In 3 patients ( 2.7 % ) calculi in the cystic or common bile duct were diagnosed , which would have been overlooked without IOC . IOC was false-positive in one case . One year after the operation the patients were asked to return for a follow-up examination . Three patients in the group without IOC had had symptomatic passage of a stone , and one had a common bile duct stone removed by endoscopic papillotomy . A retained stone was discussed as etiology for a pancreatitis in a fifth patient in this group . No patient sustained long-term sequelae from the retained common bile duct stones . None of the patients in the IOC group had evidence of cholangiolithiasis at follow-up . There was no difference between the study groups concerning the incidence of post-operative complications . The operations with IOC  lasted significantly longer ( 92 + /- 31 min vs 77 + /- 28 min ) . According to our data and those published earlier , the additional financial and logistic expenditure associated with routine IOC is not justified . Patients with the preoperative suspicion of a common bile duct stone should have endoscopic bile duct clearance ( ERCP and EPT ) prior to cholecystectomy Fear of losing cognitive ability to Alzheimer disease and related dementias drives a growing industry of over-the-counter ( OTC ) supplements intended to boost brain health and prevent or slow cognitive decline . The Alzheimer 's Research and Prevention Foundation recommends that people be sure to take [ their ] vitamins and memory-specific nutrients and suggests optimal dosages for an array of vitamins and nutrients ( 1 ) . An estimated 63 % of older adults use OTC supplements ( 2 ) . In 2015 , Americans spent $ 37 billion on OTC supplements and $ 91 million on ginkgo bilobajust one of a growing number of supplements marketed to boost memory ( 3 ) . Whether any dietary or herbal supplement or specific food can prevent or delay cognitive decline is unclear . This review summarizes the evidence on efficacy and harms of OTC supplements to prevent or delay cognitive decline , mild cognitive impairment ( MCI ) , or clinical Alzheimer-type dementia . Methods We developed and followed a st and ard protocol ( https://effectivehealthcare.ahrq.gov/topics/cognitive-decline/ research - protocol ) . Data Sources and Search es We search ed Ovid MEDLINE , PsycINFO , EMBASE , and the Cochrane Central Register of Controlled Trials for relevant literature published between 2009 and July 2017 ( see Part A of the Supplement for search strategies ) . We identified studies published before 2009 by search ing citations in systematic review s and pertinent studies ( 48 ) . Supplement . Supplementary Material Study Selection Two investigators independently review ed titles and abstract s and screened the full text of potentially eligible references . We included r and omized and nonr and omized controlled trials of any OTC supplements  that enrolled adults with normal cognition or MCI . Because the review focused on prevention , we excluded studies of adults with dementia . We included only studies that followed participants for at least 6 months , reported incident MCI or dementia ( our main outcome of interest ) or cognitive performance outcomes , and were published in English . There were no restrictions on sample size or comparator type . Disagreements about eligibility were resolved by consensus . Data Extraction and Quality Assessment One review er extracted information on study design , population , intervention , comparator , setting , and funding source from eligible studies . For each study , 2 review ers read the full text and independently rated risk of bias for the overall study and for each outcome and time point as low , medium , or high according to Agency for Healthcare Research and Quality ( AHRQ ) guidance ( 9 ) . Outcomes and adverse events were extracted from studies with low to medium risk of bias . A second review er checked the quality of all data . Data Synthesis and Analysis We summarized results for studies with low to medium risk of bias by intervention , baseline cognitive status ( presumed normal cognition or MCI ) , and outcome . Because studies used highly variable outcome measures , neuropsychological tests were categorized according to the following 4 specific cognitive domains to facilitate analysis : executive function , attention , and processing speed ; memory ; language ; and visuospatial abilities ( see Supplement Table A1 for the list of cognitive outcomes that were used and Supplement Table A2 for measurement properties , including change indices , of neuropsychological tests that were used ) . We grouped executive function , attention , and processing speed because a large number of cognitive tests frequently measure all 3 of these related domains . Our preliminary work found that studies analyzed and reported cognitive test results in widely varying ways , frequently making it impossible to determine effect size or assess whether between-group differences in scores or subscores were clinical ly meaningful . We instead analyzed and report cognitive test results by direction of effect and statistical significance . When there were at least 2 studies or 1 large study ( > 500 participants ) for a treatment comparison , 2 review ers grade d strength of evidence for each outcome on the basis of study limitations , directness , consistency , and precision ; otherwise , strength of evidence was grade d as insufficient ( 10 ) . Assessment s were confirmed by consensus . Role of the Funding Source This review was funded by the National Institute on Aging and the AHRQ . These agencies and members of the National Academies Committee on Preventing Dementia and Cognitive Impairment helped refine the scope and review ed a draft report of findings . The authors are solely responsible for the content , preparation , and writing of the manuscript and the decision to su bmi t it for publication . Results We identified 63 publications of 56 unique studies covering 13 categories of OTC treatments ( Appendix Figure ) . A third of the studies were at least partially funded by industry . Eighteen were assessed as having high risk of bias and were not further analyzed . Table 1 depicts the interventions and population s of the 38 studies judged as having low or medium risk of bias . Detailed evidence tables and risk-of-bias assessment s are presented for studies involving adults with normal cognition in Part B of the Supplement and for studies involving adults with MCI in Part C of the Supplement ; these tables are also available in the parent technical report ( 11 ) . Table 2 summarizes the strength of evidence for the findings . Appendix Figure . Evidence search and selection . Table 1 . Number of Studies With Low or Moderate Risk of Bias , by Intervention Type and Population Table 2 . Effect of OTC Supplement Interventions Versus Control on Cognitive Outcomes in Adults With Normal Cognition and MCI * Table . Continued . -3 Fatty Acids Normal Cognition Seven r and omized trials with low to medium risk of bias ( n= 21027 ) that enrolled adults with presumed normal cognition compared -3 fatty acids with placebo ( 1218 ) . Interventions lasted from 6 months to more than 6 years . Five trials reported cognitive exclusion criteria , including a Mini-Mental State Examination ( MMSE ) score less than 22 ( 14 , 15 ) , less than 24 ( 13 ) , or less than 26 ( 16 , 17 ) out of a possible 30 points . One study used only docosahexaenoic acid ( DHA ) ( 17 ) ; all others used some combination of eicosapentaenoic acid ( EPA ) plus DHA . The largest study ( n= 15077 ) allowed participation of adults who were already using -3 supplementation  ( 18 ) . Population s varied in baseline health and risk for cognitive decline . Participants included patients with diabetes or impaired glucose tolerance ( 18 ) , patients with a history of ischemic heart disease ( 12 ) or coronary artery disease ( 14 ) , and healthy adults ( 13 , 1517 ) . None of the studies reported on incident Alzheimer-type dementia or MCI . A large multinational study of adults with diabetes or impaired glucose tolerance ( n= 15077 ) used a combination of clinical diagnosis or an MMSE score less than 24 and found no difference in probable dementia incidence between the EPA/DHA group and the placebo group at a median follow-up of 6.2 years ( hazard ratio [ HR ] , 0.93 [ 95 % CI , 0.86 to 1.0 ] ) ( 18 ) . Overall , studies provided low-strength evidence suggesting that -3 fatty acids do not improve cognitive performance in adults with normal cognition compared with placebo . Of 67 reported cognitive testsincluding 9 brief cognitive tests ( 12 , 14 , 17 , 18 ) ; 1 test of multidomain neuropsychological performance ( 13 ) ; 32 tests of executive function , attention , and processing speed ( 13 , 1518 ) ; and 25 memory tests ( 13 , 1517)only 5 showed scores that were statistically significantly better in -3treated groups than in control groups . These 5 tests were administered in 2 studies that had relatively short follow-up ( 6 months ) and included fewer than 5 % of the total participants in the 7 studies ( 16 , 17 ) . Four studies did not report adverse events , and no studies reported statistically significant differences in adverse events between the -3 and placebo groups . The parent technical report provides details on adverse events ( 11 ) . Subgroups were examined in 4 studies . No statistically significant differences in effect were found by age ( 12 , 14 , 15 , 18 ) , sex ( 14 , 15 , 18 ) , time since myocardial infa rct ion ( 14 ) , or diabetes status ( 18 ) . One study ( n= 884 ) with 4-year follow-up examined the comparative effectiveness of -3 fatty acids and B vitamins on cognition ( 12 ) . No between-group differences were found for any cognitive outcome between -3 fatty acids ( alone or in combination with B vitamins ) and B vitamins alone . Adverse events were not reported . MCI Evidence was insufficient for benefits of -3 fatty acids on cognitive outcomes compared with placebo after 1 year in the single small study of adults with MCI that we identified ( n= 36 ) ( 19 ) . No serious adverse events were reported . Soy Normal Cognition  Five r and omized trials with low to medium risk of bias that enrolled 35 to 350 participants ( n= 829 ) and lasted 6 months to 2.5 years compared soy supplementation with placebo ( 2025 ) . Population s included older adults without dementia ( 20 ) and generally healthy postmenopausal women ( 21 , 2325 ) . Baseline testing excluded persons with cognitive impairment in 2 of the studies ( 20 , 21 ) . Mean reported baseline MMSE scores  ranged from 28 to 29 ( 2023 ) . None of the trials reported MCI or Alzheimer-type dementia outcomes . Evidence was deemed insufficient to determine soy 's effect on brief cognitive test performance ( 21 , 25 ) and multidomain neuropsychological test performance ( 21 , 24 ) and low-strength for soy having no effect on executive function , attention , and processing speed ( 20 , 21 , 2325 ) or memory ( 2025 ) for up to 2.5 years . Two studies reported no serious adverse events and no statistically significant differences in adverse events between the soy and placebo groups ( 21 , 25 ) . MCI Evidence was insufficient to determine any beneficial effect on cognitive outcomes from soybean-derived phosphatidylserine at 2 doses ( 100 and 300 mg daily ) compared with placebo after 9 months in a single small study of adults Background Magnetic resonance cholangiography ( MRC ) is a new technique for non-invasive imaging of the biliary tract . Aim To assess the results of MRC in patients with suspected bile duct stones as compared with those obtained with reference imaging methods . Patients / Methods 70 patients ( 34 men and 36 women , mean ( SD ) age 71 ( 15.5 ) years ; median 75 ) with suspected bile duct stones were included ( cholangitis , 33 ; pancreatitis , three ; suspected post-cholecystectomy choledocholithiasis , nine ; cholestasis , six ; stones suspected on ultrasound or computed tomography scan , 19 ) . MR cholangiograms with two dimensional turbo spin echo sequences were acquired . Endoscopic retro grade cholangiography with or without sphincterotomy ( n = 63 ) , endosonography ( n = 5 ) , or intraoperative cho- langiography ( n = 2 ) were the reference imaging techniques used for the study and were performed within 12 hours of MRC . Radiologists were blinded to the results of endoscopic retro grade cholangiography and previous investigations . Results 49 patients ( 70 % ) had bile duct stones on reference imaging ( common bile duct , 44 , six of which impacted in the papilla ; intrahepatic , four ; cystic duct stump , one ) . Stone size ranged from 1 to 20 mm ( mean 6.1 , median 5.5 ) . Twenty seven patients ( 55 % ) had bile duct stones smaller than 6 mm . MRC diagnostic accuracy for bile duct lithiasis was : sensitivity , 57.1 % ; specificity , 100 % ; positive predictive value , 100 % ; negative predictive value , 50 % . Conclusions Stones smaller than 6 mm are still often missed by MRC when st and ard equipment is used . The general introduction of new technical improvements is needed before this method can be considered reliable for the diagnosis of bile duct stones BACKGROUND & AIMS Magnetic resonance cholangiography ( MRC ) is a noninvasive diagnostic modality capable of producing high- quality images of the biliary tree . The purpose of this study was to determine in a prospect i ve , blinded fashion the sensitivity and specificity of three-dimensional fast spin-echo ( 3D FSE ) MRC for the evaluation of biliary tract abnormalities . METHODS Forty-six patients referred for elective direct cholangiography ( 45 endoscopic retro grade cholangiopancreatography and 1 percutaneous transhepatic cholangiography )  were studied prospect ively with 3D FSE MRC during a 1-year period . All images were interpreted blindly by two radiologists . The presence of dilatation , strictures , and intraductal abnormalities was recorded . Sensitivity and specificity of 3D FSE MRC were determined using findings on direct cholangiography as the gold st and ard . RESULTS MRC images of diagnostic quality were obtained in 44 ( 95.7 % ) of the patients . Sensitivity for the detection of bile duct dilatation ( n = 27 ) , biliary strictures ( n = 10 ) , and intraductal abnormalities ( n = 7 ) was 96.3 % , 90 % , and 100 % , respectively . In addition , the MRC showed 16 of 17 patients with normal bile ducts ( specificity , 94.1 % ) . CONCLUSIONS MRC has a very high sensitivity and specificity in the evaluation of the biliary tract . Based on these data , we believe that the efficacy of MRC using 3D FSE is sufficient to warrant its use in the routine diagnosis of biliary tract disease To assess the value of routine peroperative cholangiography ( PC ) , 457 patients undergoing cholecystectomy for gallstone disease were prospect ively screened for the presence of 11 predefined criteria indicating possible choledocholithiasis . Two hundred and eighty patients who had no positive criteria and in whom preoperative endoscopic retro grade cholangiography ( ERC ) had not been performed were r and omized to PC or no PC .  The patients were followed up 12 months postoperatively , and those who had signs or symptoms of possible retained common bile duct calculi were referred to ERC . The difference in mean operative time between the 2 treatment groups was 23.3 minutes . Four patients ( 2.8 % ) in the PC group had unsuspected common bile duct calculi , and in 3 patients ( 2.1 % ) , the PC was false-positive . On follow-up , no case of retained common bile duct calculi was found in either group . The rate of postoperative complications was significantly higher in the PC group than in the non-PC group . It is concluded that PC should be performed only in patients with indications of common bile duct disease or in whom clarification of the anatomy is necessary . RésuméPour apprécier la valeur de la cholangiographie opératoire de routine , 457 sujets subissant une cholécystectomie pour lithiase vésiculaire ont été étudiés prospect ivement en fonction de 11 critères de présomption de lithiase cholédocienne . Deux cent quatre-vingts d'entre eux qui ne présentaient pas un critère de présomption et chez qui n'avait pas été pratiquée une cholangiographie rétro grade endoscopique ont été soumis à une cholangiographie opératoire à la suite d'un choix par tirage au sort . Ils furent ensuite suivis pendant une période de 12 mois au décours de l'intervention de manière que ceux qui présentaient des symptômes et des signes en faveur de la présence de calculs oubliés dans le cholédoque fussent soumis à une cholangiographie rétro grade endoscopique . Premier élément , la durée de l'intervention fut augmentée en moyenne de 23.3 minutes lorsque fut pratiquée la cholangiographie opératoire . Quatre malades ( 2.8 % ) ainsi explorés présentaient des calculs cholédociens . Trois cas de faux positifs ( 2.1 % ) furent enregistrés . Aucun cas de lithiase résiduelle n'a été découvert dans les 2 groupes . Le taux des complications postopératoires fut plus élevée lorsque la cholangiographie opératoire fut pratiquée . On peut conclure de ces faits , que cette exploration doit Être proposée seulement lorsque la présence de calculs dans la voie biliare principale est à envisager ou qu and il est nécessaire de préciser l'anastomie des voies biliares . ResumenCon el objeto de determinar el valor de la colangiografía peroperatoria ( CP ) , 457 pacientes programados para colecistectomía por enfermedad litiásica biliar fueron preoperatoriamente tamizados para establecer la presencia de 11 criterios predefinidos indic and o posible coledocolitiasis . Doscientos ochenta pacientes que no presentaban criterios positivos y en quienes la colangiografía retrógrada endoscópica ( CRE ) no había sido practicada fueron asignados al azar a CP o a no CP . Los pacientes fueron seguidos por 12 meses después de la operación , y aquellos con signos o síntomas de posibles cálculos retenidos en el colédoco fueron referidos para CRE . La diferencia en el tiempo operatorio promedio entre los 2 grupos fue de 23.3 minutos . Cuatro pacientes ( 2.8 % ) en el grupo con CP presentaron cálculos inesperados en el colédoco , y en 3 casos ( 2.1 % ) , la CP result ó falsapositiva . En el curso del seguimiento , ningÚn caso de cálculos retenidos en el colédoco fue hallado en uno u otro grupo . La tasa de complicaciones postoperatorias fue significativamente mayor en el grupo con CP que en el grupo sin CP . Se concluye que la CP debe ser practicada sólo en pacientes con criterios de patología coledociana o en quienes sea necesario clarificar la anatomía PURPOSE To evaluate the test performance of magnetic resonance ( MR ) cholangiography for help in diagnosing choledocholithiasis . MATERIAL S AND METHODS Fast spin-echo MR cholangiography was performed by using a torso multicoil array in 110 patients suspected of having bile duct obstruction . Axial and coronal images were review ed by two observers who were blinded to results of direct cholangiography and final diagnoses . The final diagnosis was established by using direct cholangiographic ( n = 103 ) or surgical ( n = 7 ) findings . RESULTS Of the 110 patients , 30 ( 27 % ) had choledocholithiasis , and 80 ( 73 % ) did not . Review er 1 used MR cholangiograms to achieve a sensitivity of 90 % , specificity of 100 % , positive predictive value of 100 % , negative predictive value of 96 % , and overall accuracy of 97 % . Review er 2 achieved a sensitivity of 90 % , specificity of 93 % , positive predictive value of 82 % , negative predictive value of 96 % , and overall accuracy of 92 % . Interobserver agreement for MR cholangiograms was 93 % ( kappa = 0.82 ) . CONCLUSION MR cholangiography exhibited excellent test performance and result ed in excellent interobserver agreement for the diagnosis of choledocholithiasis BACKGROUND Regular aspirin is beneficial after myocardial infa rct ion ( MI ) . Community-based surveys appear to show unsatisfactory uptake of aspirin after MI . This could be due to over-the-counter ( OTC ) use not being recorded . In a pilot study in one practice , 39 % of patients on aspirin after MI used OTC preparations . In addition , women and older patients were less likely to use aspirin . OBJECTIVES We aim ed to describe aspirin use following MI in general practice s in West London , including regimens and OTC use , and to demonstrate any association between aspirin use and gender , age or social class . METHODS We used a postal question naire survey . The setting was a r and om sample of six general practice s in Ealing , Hammersmith and Hounslow Health Authority who use Egton Medical Information Systems ( EMIS ) to store morbidity data . The subjects were registered patients with a history of MI . The main outcome measures were question naire data on aspirin use , regimen , OTC use , prescription charge exemption , age , gender , ethnic group and social class . RESULTS The prevalence of previously recorded MI in all age groups was 0.64 % . The response rate was 89 % . Regular  aspirin  was used by 80 % . Of these , 22 % use OTC aspirin . OTC use was significantly more common in those paying prescription charges .  Aspirin use was not associated with gender , age or social class . CONCLUSION This study demonstrated a high uptake of aspirin  among patients with previous MI as recorded by computer . OTC aspirin use was significant , and should be inquired about and recorded AIMS To assess smoking cessation rates achieved with nicotine gum and patch in simulated over-the-counter ( OTC ) and actual prescription ( Rx ) setting s. DESIGN Separate open-label studies with gum and patch in OTC and Rx setting s. PARTICIPANTS There were multiple sample s : OTC gum : 2981 smokers ; OTC patch : 2367 ; Rx gum : 324 ; Rx patch : 669 . INTERVENTIONS All smokers received active nicotine replacement . In the OTC setting , smokers self-selected doses of nicotine gum ( 2 or 4 mg Nicorette ) or patch ( 21 , 14 or 7 mg NicoDerm CQ ) . No intervention was provided . In the Rx setting , smokers were prescribed gum or patch by their physician . MEASUREMENTS Biochemically verified continuous smoking abstinence was assessed at 6 weeks ( 28-day abstinence ) and 6 months . FINDINGS OTC success rates were consistently higher than Rx rates : differences were significant at 6 weeks for both patch [ OR = 1.45 ( 1.05 - 1.98 ) ] and gum [ OR 2.92 ( 1.58 - 5.40 ) ] , and remained significant at 6 months for patch [ OR = 3.63 : ( 1.74 - 7.61 ) ] but not gum [ OR = 1.37 : ( 0.73 - 2.58 ) ] . Among OTC gum users . 16.1 % were abstinent at 6 weeks and 8.4 % at 6 months . For Rx gum users , abstinence rates were 7.7 % at 6 weeks and 7.7 % at 6 months . With OTC patch , 19.0 % were abstinent at 6 weeks and 9.2 % at 6 months . With Rx patch .  abstinence rates were 16.0 % at 6 weeks and 3.0 % at 6 months . CONCLUSIONS Smoking cessation rates achieved with nicotine gum and patch under OTC conditions were as good as those under real-world prescribing conditions PURPOSE To compare findings with magnetic resonance ( MR ) cholangiography with rapid acquisition with relaxation enhancement ( RARE ) and half-Fourier acquisition with single-shot turbo spin-echo ( hereafter , half Fourier RARE ) snapshot imaging techniques to those with endoscopic retro grade cholangiography ( ERC ) . MATERIAL S AND METHODS Heavily T2-weighted thick-section ( RARE ) and thin-section ( half-Fourier RARE ) MR cholangiography were performed prospect ively , on a 1.5-T imager , in the biliary tree of 61 consecutive patients before ERC . Findings at ERC were considered the st and ard of reference . The radiologist and endoscopist were blinded to each other 's report . On- and off-site MR cholangiographic readings were performed to detect stones ( n = 24 ) , biliary dilatation ( n = 34 ) , or stenosis ( n = 36 ) . RESULTS The sensitivity and specificity of MR cholangiography , respectively , calculated on a lesion-by-lesion basis , were 92.3 % and 95.8 % for cholangiolithiasis , 94.1 % and 92.6 % for duct dilatation , and 88.8 % and 84.0 % for stenosis . With snapshot MR cholangiography , on a patient-by-patient basis , differentiation between normal ( n = 15 ) and abnormal ( n = 46 ) results yielded a sensitivity of 92.4 % , a specificity of 83.4 % , and a positive predictive value of 95.6 % . Pitfalls were caused by flow artifacts , compression by vessels , and low contrast between calculi and surrounding parenchyma . CONCLUSION Snapshot MR cholangiography allowed noninvasive , accurate detection of biliary stones , strictures , and dilatation similar to that with ERC . Discrepancies regarding low- grade dilatation and strictures had no clinical relevance at retrospective review BACKGROUND Atopic dermatitis ( AD ) is a prevalent skin disorder with significant cost of treatment . Several prescription device moisturizers have been approved by the FDA to treat AD but are significantly more expensive than well-crafted over-the-counter ( OTC ) moisturizers . No studies have been performed to compare both the clinical efficacy and cost-efficacy of these prescription devices to OTC moisturizers . PURPOSE The purpose of this study is to compare the clinical efficacy and cost-efficacy of a glycyrrhetinic acid-containing barrier repair cream ( BRC-Gly , Atopiclair ® ) , a ceramide-dominant barrier repair cream ( BRC-Cer , EpiCeram ® ) and an OTC petroleum-based skin protectant moisturizer ( OTC-Pet , Aquaphor Healing Ointment ® ) as monotherapy for mild-to-moderate AD in children . METHODS Thirty-nine patients , age 2 - 17 years , with mild-to-moderate AD were r and omized 1:1:1 to receive one of three treatments-BRC-Gly , BRC-Cer or OTC-Pet-with instructions to apply the treatment three times daily for three weeks . Disease severity and improvement was assessed at baseline and on days 7 and 21 . RESULTS No statistically significant difference for any efficacy assessment was found between the three groups at each time point . The OTC-Pet was found to be at least 47 times more cost-effective than BRC-Gly or BRC-Cer . LIMITATIONS The relatively small sample size of 39 subjects was not sufficient to establish OTC-Pet as superior treatment in AD . CONCLUSIONS OTC-Pet  is as effective in treating mild-to-moderate AD as both BRC-Gly and BRC-Cer and is at least 47 times more cost-effective . NAME OF REGISTRY II-AF-ATD-Aquaphor , Comparing the Efficacy and Cost-Effectiveness of Aquaphor to Atopiclair and EpiCeram in Children with Mild to Moderate Atopic Dermatitis . REGISTRATION IDENTIFIER : NCT01093469 OBJECTIVE In this investigation we compared the diagnostic performance of unenhanced helical CT , oral contrast-enhanced CT cholangiography , and MR cholangiography for the diagnosis of choledocholithiasis . SUBJECTS AND METHODS Fifty-one patients referred for endoscopic retro grade cholangiography of suspected biliary stones were studied with unenhanced helical CT , MR cholangiography , and helical CT performed after oral administration of a cholangiographic contrast agent ( iopodic acid ) . The studies were r and omized for interpretation . Two radiologists evaluated the images by consensus and determined the presence and location of stones . We used retro grade cholangiography findings as the st and ard of reference . Sensitivity and specificity ( with 95 % confidence intervals [ CIs ] ) of the three examinations were calculated and compared using the exact form of the McNemar test . RESULTS Bile duct stones were revealed with retro grade cholangiography in 26 patients ( 51 % ) . Sensitivity was 65 % ( 95 % CI , 44.4 - 82 % ) for unenhanced helical CT , 92 % ( 95 % CI , 73 - 99 % ) for CT cholangiography , and 96 % ( 95 % CI , 78 - 99 % ) for MR cholangiography . Specificity was 84 % ( 95 % CI , 63 - 95 % ) for unenhanced helical CT , 92 % ( 95 % CI , 73 - 99 % ) for CT cholangiography , and 100 % ( 95 % CI , 83 - 100 % ) for MR cholangiography . The sensitivity of CT cholangiography and MR cholangiography was significantly higher than that of unenhanced helical CT ( p<0.01 ) . Differences in specificity were not significant . CONCLUSION Our results indicate that oral contrast-enhanced CT cholangiography and MR cholangiography are significantly more sensitive than unenhanced helical CT for the detection of bile duct calculi Despite the proven benefits of statins , large numbers of patients meeting guideline criteria for therapy are not receiving these drugs . It has been suggested that over-the-counter ( OTC ) availability of statins would allow more consumers to use statins and achieve cardiovascular risk reduction . However , concerns have been raised as to the consumers ' ability to self-manage hyperlipidemia and use statins safely . The Consumer Use Study of OTC Mevacor ( CUSTOM ) was design ed to define consumer behaviors in the setting of OTC statin availability . The study was conducted in a simulated OTC setting and allowed consumers to purchase once-daily lovastatin 20 mg . The CUSTOM data set includes > 3,300 consumers who evaluated OTC lovastatin for potential purchase at study sites and follow-up information on purchasers for up to 6 months of self-managed therapy . These data have been analyzed to address consumers ' knowledge of their cholesterol concentrations as well as their ability to make OTC use decisions based on their cardiovascular risk , avoid drug-drug interactions , self-manage their cholesterol treatment after deciding to use the OTC product , and maintain interactions with physicians while using lovastatin OTC . The results showed that most study participants appropriately self-selected OTC statin therapy and managed their treatment . Use of OTC statins by consumers needing more intensive statin therapy or facing the risk of potential drug-drug interactions remains an area of concern but occurred infrequently in CUSTOM . These data are important for making an informed risk-benefit decision concerning OTC statin availability OBJECTIVE To evaluate the effectiveness of the Nicotrol nicotine inhaler as an aid to smoking cessation in over-the-counter ( OTC ) versus health-care-provider ( HCP ) conditions . METHODS Five hundred twenty healthy smokers were r and omized to the treatment conditions and followed for a year . RESULTS At most follow-up visits , abstinence rates for the HCP group were 2 to 3 times those observed in the OTC group . Abstinence at 1 year was.77 % in the OTC condition versus 3.08 % in the HCP condition [ P<.01 ] . Inhaler use was low . CONCLUSIONS OTC nicotine inhaler appears to be ineffective , though quit rates are improved with HCP assistance PURPOSE To prospect ively compare magnetic resonance ( MR ) cholangiography with endoscopic retro grade cholangiography ( ERC ) in the diagnosis of choledocholithiasis . MATERIAL S AND METHODS Forty-seven patients with suspected choledocholithiasis underwent non-breath-hold , heavily T2-weighted , respiratory-triggered turbo spin-echo MR cholangiography . They then underwent ERC within 5 hours . The results of the two procedures were compared in 45 patients . RESULTS The absence of ductal dilatation was shown in 16 patients at MR cholangiography and at ERC . MR cholangiography showed common duct dilatation in 28 of the 29 patients with dilatation shown at ERC . MR cholangiography helped correctly identify 18 of the 19 patients with choledocholithiasis and 22 of the 26 patients without choledocholithiasis . Sensitivity with MR cholangiography was 95 % , specificity was 85 % , positive predictive value was 82 % , and negative predictive value was 96 % . Two of the false-positive findings were due to pneumobilia . CONCLUSION Non-breath-hold MR cholangiography is as accurate for the evaluation of choledocholithiasis as ERC PURPOSE To evaluate prospect ively a non-breath-hold magnetic resonance ( MR ) cholangiographic technique . MATERIAL S AND METHODS Twenty-nine non-breath-hold , heavily T2-weighted , turbo spin-echo MR cholangiograms were obtained in 28 patients and compared with 28 direct cholangiographic studies in 24 patients . RESULTS MR cholangiography showed the intrahepatic ducts ( IHDs ) within the peripheral third of the liver and within the four hepatic segments in 100 % of cases with dilated ducts . IHDs were seen in the peripheral third in 82 % of cases with nondilated ducts and within the four hepatic segments in 91 % . The extrahepatic duct ( EHD ) , dilated and nondilated , was visualized in 90 % of cases . Filling defects were identified in the EHD in 71 % of cases and in the gallbladder in 100 % . All obstructions were identified and their site and character accurately shown in most cases . The presence of IHD dilatation was accurately shown , and estimates of EHD and main pancreatic duct caliber correlated closely with those of direct cholangiography . CONCLUSION Non-breath-hold MR cholangiography is a reliable method for depiction of the biliary system
N-OTC is associated with shorter operative time and fewer peri-operative complications , and it is comparable to R-OTC in terms of CBD injury risk during cholecystectomy .
R-OTC is helpful for peri-operative CBD stone detection and there is therefore reduced readmission for retained CBD stones .
The N-OTC approach may be adopted routinely for patients undergoing laparoscopic cholecystectomy providing there are no clinical , biochemical or radiological features suggestive of CBD stones .
INTRODUCTION The aim of this review was to systemically analyse trials evaluating the efficacy of routine on-table cholangiography ( R-OTC ) versus no on-table cholangiography ( N-OTC ) in patients undergoing cholecystectomy .