Is Routine Cholangiography During Cholecystectomy a Good Idea?

Albert B. Lowenfels, MD


June 10, 2014

Association Between Cholecystectomy With vs Without Intraoperative Cholangiography and Risk of Common Duct Injury

Sheffield KM, Riall TS, Han Y, Kuo YF, Townsend CM Jr, Goodwin JS
JAMA. 2013;310:812-820


Does intraoperative cholangiography performed at the time of cholecystectomy reduce the risk for bile duct injury? To answer this question, Sheffield and colleagues looked at the frequency of common duct injuries in 92,932 Medicare patients undergoing cholecystectomy in Texas between 2000 and 2009. During this period, 280 common duct injuries were reported. The injury rate was 0.21% in patients who had cholangiography performed compared with 0.36% in patients without cholangiography, resulting in an adjusted odds ratio of 1.8. However, a more sophisticated adjustment procedure (ie, instrumental variable analysis) reduced the odds ratio to 1.3, which was no longer significant.


In this study, surgeons utilized cholangiography during cholecystectomy in about 40% of all patients. With traditional statistical methods, this additional radiologic procedure seemed to reduce the frequency of bile duct injury. The study authors pointed out that the apparent benefit of cholangiography is highly dependent on what statistical methods are used to analyze the data. It is also difficult to determine with the available administrative data whether cholangiography had been performed before or after bile duct injury. The accompanying editorial and letters criticized the conclusion, suggesting that cholangiography may indeed reduce the risk for a serious complication. In the absence of solid data from randomized trials, the decision about whether to use cholangiography routinely remains unclear.