A critical evaluation of cholangiography

U P to 1932 when Mirizzi’ first suggested choangiography during operation, post-operative choIangiography had ah-eady acquired some vogue. 2.3,4,6,6.7*9 In 1936, Robbins and Hermanson suggested the use of hippuran in pIace of IipiodoI for visualizing the ducts during operation and stressed the point that unnecessary choIedochostomy couId be avoided if a normal choIangiogram was obtained before opening the duct. Until recentIy the incidence of choIedochostomy in operations upon the biIiary tract has been between 8 and 16 per cent of a11 cases. Recogqition of the pitfaIIs resuIting from negIect to open the common duct has Ied to the performance of this procedure in 30 to 50 per cent of a11 cases in Iarge surgica1 clinics at the present time. Insofar as the greater number of negative expIorations of the common duct, which are necessariIy occasioned by this practice, contributes to a higher morbidity and mortality, they shouId be avoided. The use of a reIiabIe graphic method during the operation to check the criteria for choIedochostomy shouId heIp to achieve this objective. The purpose of this paper is to offer an appraisa1 of ChoIangiography on the basis of our experience with 105 cases. We propose to evaIuate the method when utiIized (I) during operation, and (2) post-operativeIy. Its advantages in the first instance are twofoId: (a) when appIied before opening the common duct it faciIitates a decision in doubtfu1 cases as to whether or not to open the duct; and (b) when applied after opening the duct, it acts as a check on the success or faiIure of the operator in the eradication of whatever pathoIogy may have been present. The technique of the procedure in the post-operative patient is simpIe enough and requires no specia1 comment. However, we shouId Iike to point out that aithough no serious sequeIae need be anticipated, a smaI1 percentage of patients may be disturbed for severa days by some fever and minor IocaI discomfort. Certain features of the technique during operation, however, are worth some notice. It is preferabIe, whenever possibIe, to inject the hippuran into the cystic rather than the common duct in order to avoid Ieakage through the needie hoIe. The escape of hippuran before or during exposure to the x-ray fiIm may obscure the picture, and the subsequent drainage of biIe may necessitate drainage when this might otherwise not have been necessary. The cystic duct is therefore Iigated, and through an opening beIow the tie, a cannuIa or a uretera catheter is inserted. This is tied in to prevent escape of the hippuran, which is then sIowIy introduced. If the cystic duct is occIuded, or must be preserved with the gaII-bIadder for sidetracking purposes, or if there is danger of forcing small stones present in its Iumen into the common duct, direct injection into the Iatter is the onIy aIternative. For this purpose a narrow gauge, short-beveIed, anguIated tonsi needIe is satisfactory, aIthough even if the duct is not opened subsequentIy, the wound may need to be drained because Ieakage wiI1 occur even from the tiny hoIe produced by this needle. The choIangiogram requires six minutes for compIetion, during which time the gaII-bIadder may be re-