Intraoperative Cholangiography Use Variation Does Not Affect Bile Duct Injury Rates

Mullens CL, Sinamo JK, Levy SC, Sheetz KH, et al. Association Between Intraoperative Cholangiogram Use and Cholecystectomy Outcomes. J Am Coll Surg. July 2026.

Intraoperative cholangiography (IOC) is widely used during cholecystectomy to define biliary anatomy and potentially reduce bile duct injury (BDI), yet substantial surgeon-level variation in its use persists and its association with postoperative outcomes remains uncertain.

Mullens et al performed a retrospective cohort study of Medicare fee-for-service beneficiaries undergoing inpatient minimally invasive cholecystectomy from 2011 to 2023. Surgeons were classified by IOC utilization as never (0%), selective (>0% to <90%), or routine (≥90%). The primary outcome was BDI requiring operative repair within 1 year. Secondary outcomes included postoperative endoscopic retrograde cholangiopancreatography (ERCP), perioperative complications, length of stay, readmission, and mortality. Multivariable regression adjusted for patient characteristics and secular trends.

Among 434,696 beneficiaries (mean age 74.7 ± 9.8 years; 52.0% female), 81.0% were treated by selective IOC users, 11.4% by never users, and 7.6% by routine users. Adjusted BDI rates were low and did not differ significantly across IOC-use groups. In contrast, adjusted postoperative ERCP utilization increased progressively with greater IOC use (8.1% for never, 10.4% for selective, and 12.0% for routine users; all p<0.001).

Greater surgeon-level IOC utilization was associated with increased downstream ERCP use but not with measurable differences in BDI requiring operative repair. These findings suggest that variation in IOC practice may reflect differences in intervention thresholds rather than injury prevention and may have implications for operative decision-making, resource utilization, and surgical training.