Journal of Minimally Invasive Surgery Original Article Vol. 15. No. 3, 212 복강경담낭절제술에서수술전자기공명췌담관조영술의유용성 계명대학교의과대학외과학교실 백진오ㆍ김용훈ㆍ안근수ㆍ박태준ㆍ강구정ㆍ임태진 The Value of Preoperative Magnetic Resonance Cholangiopancreatography (MRCP) in Patients Who will be Performed Laparoscopic Cholecystectomy Jin O Baek, M.D., Yong Hoon Kim, M.D., Keun Soo Ahn, M.D., Tae Jun Park, M.D., Koo Jeong Kang, M.D., Tae Jin Lim, M.D. Department of Surgery, Keimyung University School of Medicine, Daegu, Korea Purpose: The aim of this study is to evaluate the value of preoperative MRCP prior to laparoscopic cholecystectomy by analysis of postoperative outcomes. Methods: Between 29.12 21.12, 283 patients underwent laparoscopic cholecystectomy for treatment of benign biliary disease. Among these patients, 125 underwent preoperative MRCP and were classified as the MRCP group. The remaining 158 patients who did not undergo MRCP were classified as the non MRCP group. We compared perioperative data, including the rate of bile duct injury, operative complication, conversion rate, hospital stay, and hospital cost between the two groups. In addition, we analyzed preoperative MRCP findings, including common bile duct (CBD) stones and bile duct anomaly. Results: Findings on pre-operative MRCP scan revealed silent CBD stones in five patients (4.%) and bile duct anomalies were identified in 17 patients (13.6%). Three cases of bile duct injury occurred in the non MRCP group, whereas, no bile duct injury occurred in the MRCP group. No significant statistical difference in postoperative complication was observed in either group. Mean duration of operation was 5.5 (±3.4) minutes in the MRCP group, and 52.2 (±29.9) minutes in the non MRCP group (p=.63). Post operative hospital stay was 2.1 (±1.4) days (mean) in the MRCP group, and 2.5 (±2.5) days in the non MRCP group. No statistical difference was observed between the two groups (p=.11). Conclusion: MRCP may be useful for evaluation of bile duct anomaly and identification of hidden bile duct stones. However, this modality did not show statistical benefits for postoperative outcomes in patients who underwent laparoscopic cholecystectomy. Key words: Gallbladder, Laparoscopic cholecystectomy, Bile ducts, Magnetic resonance cholangiopancreatography 서 198년대후반부터담석, 담낭염을비롯한양성담낭질환의수술에대한복강경적접근이치료의가장좋은방법이되어널리도입됨으로써이전의개복수술을대체하게되었다. 1 개복수술에비해복강경수술이큰장점을가짐에도불구하고복강경조작의기술적문제로인한총담관손상등의합병증이발생한경우재원기간이늘어나거나환자에게치명적인결과를초래할수있다. 자기공명췌담관조영술 (magnetic resonance cholangiopancreatography, MRCP) 이 Received June 3, 212, Revised 1st, July 24, 212; 2nd, August 14, 212; 3rd, August 24, 212, Accepted August 26, 212 Corresponding author:yong Hoon Kim Department of Surgery, Keimyung University School of Medicine, 56, Dalseong-ro, Jung-gu, Daegu 7-712, Korea Tel:+82-53-25-7387, Fax:+82-53-25-7322 E-mail:hbps@dsmc.or.kr http://dx.doi.org/1.762/jmis.212.15.3.68 론 복강경담낭절제수술전담관결석을진단하거나담도해부구조를파악하는데있어서내시경적역행성췌담관조영술 (endoscopic retrograde cholangiopancreatography, ERCP) 이나수술중담도조영술 (intraoperative cholangiography) 과비교해서비침습검사로서의우월성등많은장점들이보고되었다. 2-4 그러나복강경담낭절제술전진단목적과담관해부구조를파악하는데있어합리적이고경제적인가에대한논란이있다. 4-6 이연구는복강경담낭절제술전에시행한 MRCP가수술및수술후결과에유용한영향을미치는가에대하여알아보고자하였다. 대상및방법본연구는계명대학교의과대학외과학교실에서 29년 12월에서 21년 12월까지담석증, 담낭염, 담낭농양, 담낭용종, 담낭선근종증 (adenomyomatosis) 등의양성담낭질환으로복강경담낭절제술을시행받은 283명을대상으로하였다. 혈액학적검사나초음파, 컴퓨터단층촬영등다른 This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/ by-nc/3.) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Jin O Baek et al.: The Value of MRCP in Laparoscopic Cholecystectomy 69 영상의학적검사에서담관결석이의심되는환자는본연구에서제외하였다. MRCP 검사를시행하기전검사의목적, 필요성과유용성및검사비용에대해설명하고동의를한환자들에한해검사가실시되었다. 자기공명영상기기로 SIEMENS사의 MAGNETOM Avanto I-class 1.5 Tesla를이용했다. 자기공명영상검사의주요한금기로는검사기기에들어가지못할정도의고도비만, 폐쇄공포증, 인공심장박동기를장착한경우이고, 2,4,7 본연구에서검사에금기인환자는없었다. MRCP 전환자는위와소장영상의인공물로인한판독오류를방지하고담낭의팽만촉진을위해 4시간동안금식했다. 검사를위하여조영제를사용하지않았다. MRCP의판독은한명의복부영상의학전문의에의해이루어졌다. MRCP를시행한군 (MRCP) 과시행하지않은군 (non MRCP) 으로나누어다음에열거한인자들을의무기록을바탕으로후향적으로분석하였다. 환자의일반적인인구통계학적특성 ( 성별, 연령, 신장및체중을고려한체질량지수 ), 수술전진단명, 수술방법, 개복술로의전환율, 수술시간, 수술후재원기간, 총진료비, 담도손상을포함한수술합병증발생율등을비교하였다. MRCP 소견에서총담관결석유무, 간내담도결석, 담도계해부학적변이등을분석하였다. 복강경수술도중심한염증등으로칼롯삼각을확인하지못하고개복하여수술전계획했던시술을성공적으로마친경우또는담도손상에의해수술중개복한경우를개복으로의전환 (open conversion) 으로정의하였고, 수술후담도손상이있거나의심되어이차적으로개복을시행하여담낭절제술이외의술식이추가된경우는담도손상합병증에포함하였다. 자료저장과통계적분석을위해마이크로소프트사의 Excel (Microsoft, United States) 과 SPSS program (Statistical Package for Social Science version 18, IBM, United States) 을이용하였고 χ 2 검정및 student-t 검정을시행하였다. 유의수준 p<.5인경우를의미있는것으로하였다. 1) 수술방법복강경담낭절제술에많은경험을가진간담췌외과전문의가집도하였으며, 환자가응급실을경유하여입원하였더라도모든수술은계획수술 (elective surgery) 로이루어졌다. 복강경담낭절제수술의방법은전신마취하에서환자를수술대위에앙와위로눕히고복부전체를소독하였다. 복강내접근은 3공식법을사용했다. 배꼽및배꼽아래에 1 mm 트로카를위한절개를하고카메라사용을위한트로카를삽입하였다. 카메라로복강을관찰하고추가의트로카 2개를각각 (5 mm 또는 1 mm 트로카 ) 심와부의낫인대 (falciform ligament) 우측에, 우측쇄골중간선이배꼽과심와부중간선과만나는위치에마지막트로카를삽입하였다. 담낭의하트만파우치를복강경겸자로잡고우외측방 향으로견인하고하트만파우치와담낭관의경계부위를박리하여담낭관을확인한후클립 (5 mm 또는 1 mm) 으로결찰하고칼롯삼각 (Calot s triangle) 부위를확인하고담낭동맥의경로를확인한후결찰하였다. 담낭와, 간기저부부착부위를전기소작기를이용하여박리하였고제거된담낭을복강경용비닐주머니에담아서카메라포트를통하여복강외부로제거하였다. 투관침을제거하고복벽을봉합하여수술을마쳤다. 복강경수술중개복으로전환해야할때는수술시작후칼롯삼각을확인하지못하는경우, 염증이나출혈이심하여총담관및담낭관과의관계를확인하기힘든경우, 담관손상이의심되고담즙누출이있는경우등으로하였다. 결과 1) 일반적인인구통계학적특성, 수술전검사결과및비용분석복강경담낭절제술을시행받은 283명의환자중수술전 MRCP를시행한환자 (MRCP 군 ) 는 125명 ( 남자 63명, 여자 62명 ) 이었고, 시행하지않은환자 (non MRCP 군 ) 는 158명 ( 남자 83명, 여자 75명 ) 이었다. MRCP군의평균연령은 53.4 (23 82) 세이고 non MRCP군은평균 53.6 (19 89) 세였다. 모든환자들에게서자세한병력및투약력청취가이루어졌고, 복부를비롯한전신신체검사, 수술전후의 aspartate aminotransferase (AST), alanine aminotransferase (ALT), prothrombin time (PT), activated partial thromboplastin time (aptt), total, direct bilirubin, alkaline phosphatase (ALP) 를포함하는간기능검사, 혈당, 신기능평가를위한 blood urea nitrogen (BUN), creatinine (Cr) 수치를검사했다. 두군간의연령, 성별, 백혈구수치, 간기능검사수치, 체질량지수, 총진료비에서는유의한차이를보이지않았다. 특히체질량지수 (body mass index, BMI) 에서 Non MRCP 군이평균 24.8로 MRCP군의 24. 보다높은경향을보였으나통계적으로유의한차이를보이지는않았다 (Table 1). 2) MRCP를통한총담관결석의발견및담관변이의분석수술전 MRCP 군 125명의환자중총담관결석이발견된환자는 5명 (4.%) 이었다 (Fig. 1). 이중 2명은수술전 ERCP 및내시경적유두괄약근절개술 (endoscopic sphincterotomy, EST) 을시행하여총담관결석을제거하고이후복강경담낭절제술을시행했다. 한명은복강경담낭절제술후 ERCP 및 EST를시행하여결석을제거했다. 증상이없고황달이없던환자한명은수술하지않고퇴원하였으며, 복강경담낭절제술및담도절개술을계획했던환자는담낭농양으로주위염증이심하여개복수술로전환하였고총담관절개술및담관결석제거술, T자관 (T-tube) 삽입술을시행
7 Journal of Minimally Invasive Surgery Vol. 15. No. 3, 212 Table 1. Clinical characteristics of patients Characteristics MRCP (n=125) Non MRCP (n=158) p value Age (mean, yr) Sex (male/female) WBC ( 1 3 /μl) Bilirubin Total (mean, mg/dl) Direct (mean, mg/dl) ALP (mean, U/L) AST (mean, U/L) ALT (mean, U/L) Initial diagnosis Cholecystitis Polyp Adenomyomatosis Asymptomatic stone BMI (mean, kg/m 2 ) Admission via OPD (n, %) ER (n, %) 53.4 (±16.) 63/62 7.3 (±3.).86 (±1.2).31 (±.7) 256. (±167.6) 5.6 (±14.7) 46.8 (±112.2) 95 14 4 12 24. (±3.2) 11 (8.8) 24 (19.2) 53.6 (±15.7) 83/75 7.7 (±3.9).95 (±1.1).34 (±.6) 284.9 (±22.5) 41.1 (±47.) 5.4 (±94.7) 131 16 4 7 24.8 (±3.6) 112 (7.9) 46 (29.1).88.811.318.515.666.237.449.774.6.71 MRCP = magnetic resonance cholangiopancreatography; WBC = white blood cell count; ALP = alkaline phosphatase; AST = aspartate aminotransferase; ALT = alanine aminotransferase; BMI = body mass index; OPD = outpatient department; ER = emergency room. Fig. 1. 3D-MIP reconstruction MRCP image showing non-dilated CBD in diameter with signal void stones at the end. Fig. 2. 3D-MIP reconstruction MRCP image showing right posterior segmental duct inserts to the CBD. 하였다. 수술전판독소견에서간내담관결석이확인된경우는없었다. MRCP 소견으로여러가지담관의변이를확인할수있었다. 우측후엽간내담관이총담관으로삽입되는경우가 7예로 (5.6%) 가장많았다 (Fig. 2). 이외에담낭관이총담관의하부로삽입되는변이가 3예 (2.4%), 좌우간내담관분지가총담관합류부에서세갈래로나누어지는변이가 2예 (1.6%), 담낭관이총담관중간부위의후방내측으로삽입되는변이가 2예 (1.6%), 우측전엽간내담관이총담관으로삽입되는변이, 우측후엽간내담관이좌측간내담관으로삽입되는변이, 담관의제 1 분지와담낭관이매우가깝게위치한변이가각각 1예씩 (.8%) 확인되었다 (Table 2).
Jin O Baek et al.: The Value of MRCP in Laparoscopic Cholecystectomy 71 Table 2. Preoperative MRCP findings MRCP findings No. of case (n=125) Percentage (%) Right posterior segmental duct inserts to the CBD Right anterior segmental duct inserts to the CBD Right posterior segmental duct inserts to the LHD Low lying cystic duct insertion to the CBD Trifurcation of primary biliary confluence Posteromedial insertion of cystic duct in the middle extrahepatic duct Very close relation between biliary primary confluence and cystic duct insertion CBD stones identification IHD stones identification 7 1 1 3 2 2 1 5 5.6.8.8 2.4 1.6 1.6.8 4.. MRCP = magnetic resonance cholangiopancreatography; CBD = common bile duct; LHD = left hepatic duct; IHD = intra hepatic duct. Table 3. Peri-operative results Peri-operative results MRCP (n=125) Non MRCP (n=158) p value Surgical procedure (LC) Open conversion (n, %) Duration of operation (minutes) In hospital mortality Hospital stay (operation to discharge) (day) Hospital cost (mean, KRW) 124 1 (.8) 5.5 (±3.4) (.%) 2.1 (±1.4) 4,578,57.5 155 3 (1.9) 52.2 (±29.9) 1 (.6%) 2.5 (±2.5) 4,871,75.7 1..542.63 1..11.655 MRCP = magnetic resonance cholangiopancreatography; LC = laproscopic cholecystectomy; KRW = Korean won. 3) 수술성적연구기간중시행한복강경담낭절제술전체 283명중개복술로전환한예는 4예 (1.4%) 였고, MRCP군에서의 1예 (.8%), non MRCP군에서 3예 (1.9%) 로발생하여통계적으로유의한차이는없었다. MRCP군에서개복술로전환되었던환자는 74세남자로심한담낭농양으로주변염증및유착이심하였으며, 술전에총담관결석이확인되어복강경담낭절제술및담관절개술을계획하였으나심한염증으로칼롯삼각의확인이어려워개복술로전환하였고 T-tube 삽입술시행후 8일만에합병증없이퇴원하였다. non MRCP군에서개복술로전환되었던환자는염증이심하고짧은담낭관을가진 72세여자환자로개복하여담낭절제술로전환하고수술후 7일째합병증없이퇴원하였다. 수술에소요된시간비교에서 MRCP군이평균 5.5 (±3.4) 분, non MRCP군이평균 52.2 (±29.9) 분 (p=.63) 으로통계적으로유의한차이는없었고, 재원기간비교에서도 non MRCP군이 2.5 (±2.5) 일로 MRCP군 2.1 (±1.4) 일보다길었으나통계적으로유의한차이는보이지않았다 (Table 3). 수술합병증비교에서 MRCP군중 1예 (.8%) 에서합병증이발생하였고, 수술후 1일째상복부트로카삽입부위출혈로인한복강내혈종으로복강경을이용한복강내세척술후호전을보였다. non MRCP군중에서수술합병증은 Table 4. Peri-operative complication Complications Bile duct injury (n, %) Bleeding (n, %) Intra abdominal abscess (n, %) Hepatic failure (n, %) Total MRCP (n=125) 1 (.8) 1 (.8) Non MRCP (n=158) p value 3 (1.9) 1 (.6) 1 (.6) 5 (3.2).229 MRCP = magnetic resonance cholangiopancreatography. 5예 (3.2%) 에서발생했고, 2예는총담관손상이있어서개복술로전환하여 1예는손상받은담관을단순봉합하였고, 1 예는 Roux-en-Y식총수담관-공장문합술을시행하였다. 수술후 2일째담즙누출을보여개복한예는총담관손상에의한누출로 Roux-en-Y식총수담관-공장문합술을시행하였다. 이외에수술후담낭절제부위농양으로경피적배농술을실시한예가있었고, 알코올성간경변환자에서급성축농성 (empyema) 담낭염으로복강경담낭절제를무사히시행하였으나수술후대량의식도정맥류출혈로인한간부전으로사망한예가있었다 (Table 4).
72 Journal of Minimally Invasive Surgery Vol. 15. No. 3, 212 고 양성담낭질환에서복강경담낭절제술이표준술식이된것은개복술보다수술부위의출혈, 통증, 수술후장마비, 장폐색, 복강내감염이적고, 흉터가작아서미용적장점을가지며, 재원기간이짧아조기에일상생활로의복귀등장점이있기때문이다. 1,8 그러나복강경담낭절제술에서총담관의손상이나출혈등의여러합병증발생률이개복술과비교하여높게보고되고있으며 8,9 총담관분절의절단과같은중대한합병증으로사망에이를수도있으며재원기간의증가, 진료비의상승과함께복강경수술의장점을기대하였던환자들에게실망감을안겨줄수도있다. 1,11 이러한이유로복강경담낭수술전합병증을예방하기위한노력들은매우중요하다. 복강경담낭수술중총담관손상을유발하는원인으로심한담낭염에의한칼롯삼각주위의해부학적변형, 외과의사의경험부족에의한미숙한술기등이주요원인일수있으며, 특히전체손상의약 5 1% 는선천성담도계해부학적변이를인지하지못하여담관을담낭관으로오인하여전기적손상또는기계적절단에의해유발할수있다. 1,9-12 총담관손상을예방하기위해외과적경험과전문성, 수술전적절한영상검사, 조심스럽고정확한술기, 개복술로의적절한전환등이강조되고있으며, 6,9,13 특히수술중담도의해부학적구조를확인할수가없는경우선택적으로수술중담도조영술 (intraoperative cholangiography) 을시행할것을추천하고있으나실제임상현장에서시간적제약이나기술적인문제등으로시행하는것이쉽지않은것이현실이다. 14 이러한제한점을극복하기위해 MRCP를이용하는것이담도결석의진단이나해부학적구조를확인하는데도움을줄수있다. 15 Bahram과 Gaballa 4 는복강경담낭절제수술전 MRCP 유용성에관한논문에서담낭을포함한담도계해부에관한철저한이해와가능한선천성변이에대한지식이의인성담도손상의예방에매우중요하다고밝혔다. 복강경담낭절제술도중담도계해부의변이에의한담도손상은문헌에서약 5 1% 정도로보고되고있는데 MRCP를통하여수술전변이여부를알수있다면담도손상을줄이는데도움이될것이다. 담도손상을유발할수있는경우는담도를담낭관으로오인하는경우가될수있으며본연구에서는 trifurcation, right posterior segmental duct inserts to the LHD type (Table 2) 을제외한경우가이에해당되어약 11.2% 정도가복강경담낭절제술에영향을미칠수있는변이라고할수있겠다. 총담관결석은증상이있는담석증환자의 1 15% 에서발견되는흔한질환이고, 연령의증가에따라유병률은높아지며, 4-7 6세이상의담석증환자에서약 15 6% 에서동반된다. 6,16 복강경담낭절제술후총담관내잔여결석이 찰 있다면담관내압력증가로결찰된담낭관이열려담즙누출이있거나, 반복되는담도산통, 담도염, 팽대부폐쇄에의한반복되는췌장염등이나타날수있으며진단이지연되어곤란을겪는경우도있다. 4,6,17,18 이러한이유로 1998년 European Association for Endoscopic Surgery (EAES) 에서증상이있는담석증환자들에서총담관결석의유무를확인할것을권고하였다. 16 총담관결석의진단에복부초음파, 수술중담도조영술, 컴퓨터단층촬영, ERCP 등을이용할수있지만최근비침습적검사로 MRCP의장점들이보고되고있으나경제적인면에서또는진단율에서우월성에대하여서는논란이있다. 8,9 ERCP는총담관결석이발견되면시술중에바로제거할수있다는장점이있지만, 고도의전문화된기술을요할뿐만아니라, 십이지장천공, 출혈등의합병증발생이 3 1% 에서동반되고그로인한치사율도.1 3% 에이르기때문에표준검사로추천되지않는다. 2,4,6,19,2 반면, MRCP는비침습적검사로방사선피폭과조영제주입이없다는장점이있으며, 또한담낭의크기, 내용물, 담낭벽의두께를알수있고, 담도결석및담도의확장정도를파악할수있다. 이외에간, 췌장, 임파선의이상소견도함께볼수있으며, 3,4,6,21 수술전담관영상검사로서 ERCP와수술중담관조영술에버금가는정확도와민감도를보여주었다. 2,19,2,22 MRCP의단점중에가장큰걸림돌은비용문제일것이다. 본논문을기획하는단계에서도 MRCP 비용문제가대두되었다. 이를해결하기위해병원당국및방사선과와상의하여 Pre laparoscopic MRCP 라는코드를신설하고비용도기존 MRCP 대비 1/3 수준으로초음파수가와비슷한비보험수가를책정하여환자들의추가적인부담을최소화하였다. MRCP 촬영의적응증 (indication) 은설명후촬영에동의하는모든환자를포함시켰고, 비용문제때문에촬영에동의하지않은환자는없었다. 이번연구의총진료비비교분석에서통계적유의성은없으나오히려 non MRCP 군에서평균진료비가약 293,693 (6.4%) 원높게확인되었다. 이러한원인으로여러가지요인이있을수있겠으나 MRCP : non MRCP군사이에병리진단, BMI, 그리고동반질환 (comorbidity) 비교등에서통계적으로유의한차이는확인할수없었다 (Table 1). 다만 MRCP를촬영한환자중응급실을경유한경우가 24/125명 (19.2%) 로 non MRCP 중응급실을경유한 46/158명 (29.1%) 보다적었으므로통상응급실을경유하여입원한경우 ( 응급의료관리료등포함 ) 초기진료비가높아이러한결과가나왔으리라추측된다. 이러한부분을고려한향후추가적연구가필요하리라생각된다. 또한수술결과비교에서개복으로전환율, 수술시간, 그리고수술후재원기간등에서 MRCP군에서조금나은경향을보였지만통계적으로유의한결과는나타나지않았다. 수술후합병증발생률비교에서 MRCP군에서수술후복강내출혈이있었으나담관손상등의합병증발생
Jin O Baek et al.: The Value of MRCP in Laparoscopic Cholecystectomy 73 은없었으며 non MRCP군의 3예 (1.9%) 의담도계합병증발생률과비교하면고무적인결과이지만통계적으로유의한차이를보이지는않았다 (p=.229). 이번연구제한점으로대상군의숫자가적어상대적으로복강경담낭절제술의합병증발생율이낮아서소수의발생율로비교분석하기에는한계가있다는것과대상군의수술난이도를고려하지않고전체환자를대상으로시행한점은아쉬움이남는부분이며향후개복술로의전환율이나합병증발생률이높은것으로알려진군들, 예를들면, 심한담낭축농이발생한담낭염이나, 이전의수술과거력이있는환자, 또는체질량지수가높은환자군을따로대상군으로한대규모전향적연구가필요할것으로생각된다. 또한복강경담낭절제술에서담관손상같은합병증의발생이학습곡선 (learning curve) 이전증례에서다수보고되므로, 복강경담낭절제술을시작하고배우게되는초심자인경우수술전에 MRCP로담관해부구조를확인하고수술을진행한다면복강경담낭절제술도중담도계해부의변이에의한담도손상을 ( 약 5 1% 정도 ) 미연에방지하는데도움이될수도있을것이다. 결 복강경담낭절제술에서수술전시행하는 MRCP는수술후합병증예방에통계적으로유용하지는않지만잠재적인총담관결석의확인및담낭관을포함한담도계해부학적변이의관계를확인하는데일부도움이될것으로생각되며향후추가적인대규모전향적무작위다기관연구가필요할것으로사료된다. 론 참고문헌 1) Nuzzo G, Giuliante F, Giovannini I, et al. Bile duct injury during laparoscopic cholecystectomy: results of an Italian national survey on 56 591 cholecystectomies. Arch Surg 25;14: 986-992. 2) Hallal AH, Amortegui JD, Jeroukhimov IM, et al. Magnetic resonance cholangiopancreatography accurately detects common bile duct stones in resolving gallstone pancreatitis. J Am Coll Surg 25;2:869-875. 3) De Waele E, Op de Beeck B, De Waele B, Delvaux G. Magnetic resonance cholangiopancreatography in the preoperative assessment of patients with biliary pancreatitis. Pancreatology 27;7:347-351. 4) Bahram M, Gaballa G. The value of pre-operative magnetic resonance cholangiopancreatography (MRCP) in management of patients with gall stones. Int J Surg 21;8:342-345. 5) Shanmugam V, Beattie GC, Yule SR, Reid W, Loudon MA. Is magnetic resonance cholangiopancreatography the new gold standard in biliary imaging? Br J Radiol 25;78:888-893. 6) Nebiker CA, Baierlein SA, Beck S, von Flue M, Ackermann C, Peterli R. Is routine MR cholangiopancreatography (MRCP) justified prior to cholecystectomy? Langenbecks Arch Surg 29;394:15-11. 7) Shamiyeh A, Lindner E, Danis J, Schwarzenlander K, Wayand W. Short-versus long-sequence MRI cholangiography for the preoperative imaging of the common bile duct in patients with cholecystolithiasis. Surg Endosc 25;19:113-1134. 8) Ou ZB, Li SW, Liu CA, et al. Prevention of common bile duct injury during laparoscopic cholecystectomy. Hepatobiliary Pancreat Dis Int 29;8:414-417. 9) Al-Kubati WR. Bile duct injuries following laparoscopic cholecystectomy: a clinical study. Saudi J Gastroenterol 21;16: 1-14. 1) Deziel DJ, Millikan KW, Economou SG, Doolas A, Ko ST, Airan MC. Complications of laparoscopic cholecystectomy: a national survey of 4,292 hospitals and an analysis of 77,64 cases. Am J Surg 1993;165:9-14. 11) Fletcher DR, Hobbs MS, Tan P, et al. Complications of cholecystectomy: risks of the laparoscopic approach and protective effects of operative cholangiography: a population-based study. Ann Surg 1999;229:449-457. 12) Georgiades CP, Mavromatis TN, Kourlaba GC, et al. Is inflammation a significant predictor of bile duct injury during laparoscopic cholecystectomy? Surg Endosc 28;22:1959-1964. 13) Yoo SW, Bak SW, Bak YB, Jeong JH. Incidence of major surgical complications of laparoscopic cholecystectomy according to period. J Korean Soc Endsoc & Laparosc Surg 22;5:118-124. 14) Tantia O, Jain M, Khanna S, Sen B. Iatrogenic biliary injury: 13,35 cholecystectomies experienced by a single surgical team over more than 13 years. Surg Endosc 28;22:177-186. 15) Makary MA, Duncan MD, Harmon JW, et al. The role of magnetic resonance cholangiography in the management of patients with gallstone pancreatitis. Ann Surg 25;241:119-124. 16) Diagnosis and treatment of common bile duct stones (CBDS). Results of a consensus development conference. Scientific Committee of the European Association for Endoscopic Surgery (E.A.E.S.). Surg Endosc 1998;12:856-864. 17) Xu F, Xu CG, Xu DZ. A new method of preventing bile duct injury in laparoscopic cholecystectomy. World J Gastroenterol 24;1:2916-2918. 18) Notash AY, Salimi J, Golfam F, Habibi G, Alizadeh K. Preoperative clinical and paraclinical predictors of choledocholithiasis. Hepatobiliary Pancreat Dis Int 28;7:34-37. 19) Pavone P, Laghi A, Lomanto D, et al. MR cholangiography (MRC) in the evaluation of CBD stones before laparoscopic cholecystectomy. Surg Endosc 1997;11:982-985. 2) Mofidi R, Lee AC, Madhavan KK, Garden OJ, Parks RW. The selective use of magnetic resonance cholangiopancreatography in the imaging of the axial biliary tree in patients with
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