A Meta-Analysis of the use of Intraoperative Cholangiography; Time to revisit our approach to Cholecystectomy?

Background: Despite some evidence of improved survival with intraoperative cholangiography (IOC) during cholecystectomy, debate has raged about its benefit, due in part to its questionable benefit, time and resources required to complete. Methods: A PROSPERO-registered (ID CRD42018102154) meta-analysis following PRISMA guidelines using PubMed, Scopus, Web of Science and Cochrane library from 2003 to 2018 was undertaken including search strategy “intraoperative AND cholangiogra* AND cholecystectomy”. Articles scoring ≥ 16 for comparative and ≥ 10 for non-comparative using the Methodological Index for Non-Randomised Studies (MINORS) criteria were included. A dichotomous random effects meta-analysis using the Mantel-Haenszel method performed on Review Manager Version 5.3 was carried out. Results: Of 2,059 articles reviewed, 62 met criteria for final analysis. The mean rate of IOC was 38.8% (range 1.6-96.4%).There was greater detection of bile duct stones during cholecystectomy with routine IOC compared with selective IOC (OR= 3.28, CI= 2.80-3.86, p-value <0.001). While bile duct injury (BDI) during cholecystectomy was less with IOC (0.39%) than without IOC (0.43%), it wasn’t statistically significant (OR=0.88, CI=0.65-1.19, p-value= 0.41). Readmission following cholecystectomy with IOC was 3.0% compared to 3.5% without IOC (OR= 0.91, CI= 0.78-1.06, p-value= 0.23). Conclusion: The use of IOC still has its place in cholecystectomy based on the detection of choledocholithiasis, and the potential reduction of unfavourable outcomes associated with common bile duct stones. This meta-analysis, the first to review IOC use, identified a marked variation in cholangiography use. Retrospective studies limit the ability to critically define association between IOC use and bile duct injury.