CHANGES IN THE PRACTICE OF BILIARY SURGERY AND ERCP DURING THE INTRODUCTION OF LAPAROSCOPIC CHOLECYSTECTOMY TO AUSTRALIA: THEIR POSSIBLE SIGNIFICANCE

Two and a half years after the introduction of laparoscopic cholecystectomy to Australia in February 1990, estimates from Medicare statistics suggest that by July 1992, 69% of cholecystectomies were being performed laparoscopically. There was a smaller decline in the numbers of open cholecystectomies performed. suggesting a 28% rise in the rate of cholecystectomy. This has been associated with a 66% decline in the use of intra‐operative cholangiography. Whereas 87% of cholecystectomies had an operative cholangiogram performed, now only 23% of all cholecystectomies do. It is suggested that in approximately half the patients, no attempt is made to exclude common duct stones. With those patients in whom an attempt is made, most surgeons rely on endoscopic retrograde cholangiopancreatography, as evidenced by a 43% increase in its use, or, more recently, a small proportion of surgeons have been using intravenous cholangiography, as evidenced by a 26% increase in its use. Once diagnosed, these stones are no longer being treated by open exploration of the bile duct, indicated by a 46% decrease in this procedure, but are being treated by endoscopic sphincterotomy, which has shown a 242% increase in its use. From the published results of the outcome of these treatments, the added risk, nationally, of these additional procedures in managing uncomplicated bile duct stones is predicted to increase mortality 1–3‐fold and morbidity 10–15‐fold. This risk can be reduced by the use of laparoscopic bile duct exploration. These techniques are already well established and can be learnt quickly if practice is achieved by performing routine intra‐operative cholangiography. The treatment of common duct calculi at the time of cholecystectomy still seems to be the most efficient strategy of management, even in the laparoscopic era.