Optimal Utilisation of Cross-Sectional Imaging in Patients with Painful Jaundice Undergoing Bile Duct Exploration or Conservative Management for Suspected Bile Duct Stones on a Specialist Unit

Abstract Aim Laparoscopic management of bile duct stones relies on intraoperative cholangiography, optimising utilisation of preopertative imaging. This study aims to determine whether such a policy is justifiable in jaundiced patients over 50 years of age with no risk factors for malignancy. Methods Prospectively collected data of patients presenting with gall stones and painful jaundice undergoing biliary surgery or treated conservatively was analysed. The presentation, preoperative imaging, cholangiography/ choledochoscopy findings and postoperative outcomes were recorded. Patients with risk factors for malignancy were excluded. Results 1220 jaundiced patients over 50 years were referred over 24 years. 684 underwent surgery having had CT in 15.3%, MRCP 10% and ERCP 2.5%. 536 unfit patients were managed conservatively (CT 15.7%, MRCP 27.8% and ERCP 29.5%). Most had these investigations under the care of other departments prior to referral. 21/684 (3%) presenting with painful jaundice associated with acute cholecystitis or bile duct stones and no risk factors for malignancy were diagnosed with malignancy on IOC and choledochoscopy. 7 patients had preoperative cross sectional imaging, one with ERCP showing no evidence of malignancy. The remaining 14 patients underwent postoperative imaging; 7 had radiologically undetectable disease, 6 had advanced disease and only one was suitable for a “curative resection”. 21/536 (3.9%) cancers were diagnosed in patients who were treated conservatively. Conclusion Based on the little diagnostic yield of curable biliary malignancies, a policy of no cross sectional imaging in patients with obstructive jaundice and no risk of malignancy is justifiable in units adopting single session management of bile duct stones.