Value and Consequences of Routine Intraoperative Cholangiography During Cholecystectomy Does routine intraoperative cholangiography prevent bile duct transection? Routine cholangiography is not warranted during laparoscopic cholecystectomy. Prospective evaluation of a selective approach to cholangiography for suspected common bile duct stones. Does selective peroperative cholangiography result in missed common bile duct stones? Bile duct leaks after laparoscopic cholecystectomy: value of contrast-enhanced MRCP Routine versus selective intra-operative cholangiography during laparoscopic cholecystectomy Evaluation of magnetic resonance cholangiography in the management of bile duct stones. [Intraoperative cholangiography as a routine method? A prospective, controlled, randomized study]. Over-the-Counter Supplement Interventions to Prevent Cognitive Decline, Mild Cognitive Impairment, and Clinical Alzheimer-Type Dementia Use of magnetic resonance cholangiography in the diagnosis of choledocholithiasis: prospective comparison with a reference imaging method Magnetic resonance cholangiography: comparison with endoscopic retrograde cholangiopancreatography.
Since the introduction of laparoscopic cholecystectomy ( LC ) , an increase in accidental  common bile duct ( CBD )  injuries of up to 1.2–1.6 % has been reported . In the present prospect i ve study of 1,710 patients undergoing cholecystectomy ( 1,241 LC procedures and 469 open cholecystectomies [ OC ] ) , we tested the predicative value of routine intraoperative cholangiography ( IOC ) . The IOC was feasible in 92.4 % of the cases in the LC group and in 83 % of cases in the OC group and presented a complete depiction of the extrahepatic bile system in 98.3 % . Anatomic variations of the bile duct system , which influenced the operative management , were found in 13.2 % of cases ( 13.4 % LC versus 12.8 % OC ) . In 2.5 % of the patients , preoperatively undetected CBD stones were also found . Method -specific complications did not occur in any of the patients . Additionally , in a controlled subgroup analysis of 163 patients , we evaluated preoperative intravenous cholangiography ( IVC ) and IOC . Intravenous cholangiography showed only 72.4 % of the operation-relevant anatomic variations ( vs. 100 % by IOC ) ; in 6.1 % of the cases , there were reactions to the dye ( vs. none in IOC ) , and in only 28.6 % of the patients , CBD stones were detected ( vs. 71.4 % IOC ) . There were four bile duct injuries ( 0.29 % ) during LC and two ( 0.4 % ) during OC . All injuries were detected intraoperatively and fixed in the same setting without postoperative complications . In conclusion , we recommend the use of routine IOC during cholecystectomy . By this technique , anatomic variations of the bile duct system will be visualized and therefore accidental injuries will be avoided Background The role of routine intraoperative cholangiography is controversial . The aim of this study was to assess the impact of routine intraoperative cholangiography on the incidence of common bile duct injuries , and to evaluate the operative outcome of laparoscopic cholecystectomy carried out in a major teaching hospital and review the literature . Methods Prospect ively collected data on 3,145 laparoscopic cholecystectomies performed mainly by surgical trainees in the period 1990 to 2002 using routine intraoperative cholangiography with fluoroscopy were review ed . Results The mean age of the study sample ( 65.6 % male , 34.4 % female ) was 54 years , and 16.9 % of the patients had clinical acute cholecystitis . The conversion rate to open cholecystectomy was 4.3 % . Intraoperative cholangiography was attempted for 90.7 % of the patients with a 95.9 % success rate . Five patients ( 0.16 % ) had common bile duct injuries . Four injuries had occurred in the first 5 years . One injury ( 0.06 % ) had occurred after 1995 . This injury was identified intraoperatively and repaired laparoscopically . Routine intraoperative cholangiography prevented one definite common bile duct transection . Conclusions In this series using routine intraoperative cholangiography , there was a low rate and severity of common bile duct injuries , with a high intraoperative recognition rate . There was no bile duct transection or major injury requiring common bile duct reconstruction . Although intraoperative cholangiography helped in the immediate identification of injuries and the institution of appropriate therapy , injury was not completely prevented The role of intraoperative cholangiography during laparoscopic cholecystectomy was prospect ively evaluated in 514 patients undergoing laparoscopic cholecystectomy .  Before surgery , all patients were assigned to one of three groups depending on the likelihood of their having common bile duct stones . Stratification was based on objective historical , laboratory , or radiologic criteria . In 453 patients deemed unlikely to have stones , laparoscopic cholecystectomy was performed without cholangiography . Of these patients , four had retained stones ( 0.9 % ) . In 25 patients likely to have stones , preoperative endoscopic retro grade cholangiopancreatography identified stones in six patients ( 24 % ) . In 36 patients whose likelihood of having stones was deemed indeterminate , intraoperative cholangiography was performed at laparoscopic cholecystectomy . A common bile duct stone was identified in one patient ( 2.8 % ) . One common bile duct injury occurred in the group deemed unlikely to have stones , and this injury would not have been prevented by intraoperative cholangiography . We conclude that preoperative assessment will identify common bile duct stones and that routine cholangiography is not warranted . Meticulous dissection of the cystic duct at its origin at the infundibulum will prevent common bile duct injury INTRODUCTION Common bile duct ( CBD ) stones can cause serious morbidity or mortality , and evidence for them should be sought in all patients with symptomatic gallstones undergoing cholecystectomy .  Routine intra-operative cholangiography ( IOC ) involves a large commitment of time and re sources , so a policy of selective cholangiography was adopted . This study prospect ively evaluated the policy of selective cholangiography for patients suspected of having choledocholithiasis , and aim ed to identify the factors most likely to predict the presence of CBD stones positively . PATIENTS AND METHODS Data from 501 consecutive patients undergoing laparoscopic cholecystectomy ( LC ) for symptomatic gallstones , of whom 166 underwent IOC for suspected CBD stones , were prospect ively collected . Suspicion of choledocholithiasis was based upon : ( i ) deranged liver function tests ( past or present ) ; ( ii ) history of jaundice ( past or present ) or acute pancreatitis ; ( iii ) a dilated CBD or demonstration of CBD stones on imaging ; or ( iv ) a combination of these factors . Patient demographics , intra-operative findings , complications and clinical outcomes were recorded . RESULTS Sixty-four cholangiograms were positive ( 39 % ) . All indications for cholangiogram yielded positive results . Current jaundice yielded the highest positive predictive value ( PPV ; 86 % ) . A dilated CBD on pre-operative imaging gave a PPV of 45 % for CBD calculi ; a history of pancreatitis produced a 26 % PPV for CBD calculi . Patients with the presence of several factors suggestive of CBD stones yielded higher numbers of positive cholangiograms . Of the 64 patients having a laparoscopic common bile duct exploration ( LCBDE ) , four ( 6 % ) required endoscopic retro grade cholangiopancreatography ( ERCP ) for retained stones ( 94 % successful surgical clearance of the common bile duct ) and one ( 2 % ) for a bile leak . Of the 335 patients undergoing LC alone , three ( 0.9 % ) re-presented with a retained stone , requiring intervention . There were 12 ( 7 % ) requiring conversion to open operation . CONCLUSIONS A selective policy for intra-operative cholangiography yields acceptably high positive results . Pre-operatively , asymptomatic bile duct stones rarely present following LC ; thus , routine imaging of the biliary tree for occult calculi can safely be avoided . Therefore , a rationing approach to the use of intra-operative imaging based on the pre-operative indicators presented in this paper , successfully identifies those patients with bile duct stones requiring exploration . Laparoscopic bile duct exploration , performed by an experienced laparoscopic surgeon , is a safe and effective method of clearing the bile duct of calculi  , with minimal complications , avoiding the necessity for an additional intervention and prolonged hospital stay A prospect i ve r and omized trial was undertaken to determine if selective peroperative cholangiography result ed in greater morbidity and mortality from missed common bile duct ( CBD ) stones . Five hundred and thirty-nine consecutive cholecystectomies were performed over a 3-year period . Two hundred and fifty-four had indications for m and atory peroperative cholangiography and were excluded from the trial . The remaining 285 patients , without a history of jaundice , pancreatitis or abnormal liver function tests , were r and omized blindly into two groups . Group 1 underwent peroperative cholangiography ( PC ) and group 2 did not . If the surgeon found a dilated CBD at surgery then these patients were also excluded from the trial . Selective peroperative cholangiography revealed an unsuspected CBD calculus in 16 of the 132 patients ( 12 % ) . Up to the time of review no patient from group 2 presented with symptoms or complications from retained CBD stones . One patient in group 1 had endoscopic removal of a retained CBD calculus 16 months after cholecystectomy . All patients were sent a question naire at least three years after surgery and 210 responded ( 74 % ) . One hundred and thirty ( 62 % ) of the respondents had  peroperative cholangiography .  There were 11 deaths from unrelated causes . No difference between the two groups was found for postoperative dietary habit , dyspepsia , pain , flatulence , diarrhoea or signs of biliary obstruction . It seems from these results that a policy of selective cholangiography in our h and s may miss a 12 % incidence of unsuspected stones but , importantly , this does not appear to influence postoperative morbidity or mortality . ( ABSTRACT TRUNCATED AT 250 WORDS Background We assessed the role of mangafodipir-enhanced magnetic resonance ( MR ) cholangiography in the detection and location of bile duct leaks after laparoscopic cholecystectomy . Methods In a prospect i ve study , 34 patients with clinical suspicion of bile duct leak after laparoscopic cholecystectomy underwent MR imaging .  Our protocol included conventional heavily T2-weighted MR cholangiography and three-dimensional T1-weighted MR cholangiography after an intravenous bolus injection of mangafodipir trisodium . All studies were performed on a 1.5-T or 1-T scanner . Contrast-enhanced MR cholangiograms were evaluated for the presence and location of bile duct leaks . Correlation was obtained in all cases with surgery ( n = 15 ) , endoscopic retro grade cholangiography ( n = 5 ) , percutaneous drainage ( n = 5 ) , and clinical follow-up ( n = 9 ) . Results In 20 of 34 patients , bile duct leakage was proved by surgery , endoscopic retro grade cholangiography , or drainage . Contrast enhancement displayed the leakage in 19 of 20 patients and ruled out leaks in the other 14 patients ( 95 % sensitivity , 100 % specificity ) . The leak site was depicted in 14 patients and contrast-enhanced MR cholangiography successfully located the origin of the leak in 11 patients . Conclusions Contrast-enhanced MR cholangiography with intravenous mangafodipir trisodium can accurately diagnose the presence and location of bile duct leaks in patients who have undergone laparoscopic cholecystectomy Opinion is divided whether intra-operative cholangiography should be performed routinely or on a selective basis during laparoscopic cholecystectomy . We therefore performed the first prospect i ve r and omized trial of static cholangiography in patients who did not have indications for cholangiograms .  Laparoscopic cholecystectomy  was attempted on 164 consecutive patients , of whom 49 ( 30 % ) patients were excluded from the trial due to indications for or against cholangiography .  In the remaining 115 ( 70 % ) patients , 56 were r and omized to the cholangiography group while 59 patients did not receive cholangiograms .  Duration of postoperative hospitalization and interval to return to full activity were identical in the two groups . Static cholangiograms added 16 ± 1 min ( mean ± SEM ) to the procedures ( p<0.01 ) . Cholangiography  increased the total charges for the operation by almost $ 700 ( p<0.01 ) . Cholangiograms were performed successfully in 94.6 % of the patients and changed the operative management in 4 ( 7.5 % ) patients . There was 1 ( 1.9 % ) false negative study . Intra-operative cholangiography did not reveal aberrant bile ducts at risk of injury from the operative dissection . There was no mortality or cholangiogram-related morbidity in either group . In follow-up ranging from 2–12 months , there has been no clinical evidence of bile duct injury or retained common bile duct stones . In summary , in patients without indications for cholangiography , the performance of static cholangiograms markedly increased the operative time and cost of laparoscopic cholecystectomy  . The operative management of a minority of patients was changed by the information obtained , but laparoscopic cholecystectomy may be performed safely in the absence of cholangiograms with little risk of injury to the major ductal system or retained calculi . RésuméLes avis sont partagés quant à la pratique systématique , ou seulement élective , d'une cholangiographie lors de la cholécystectomie coelioscopique . Nous avons mené le premier essai r and omisé prospect if de cholangiographie peropératoire chez des patients n'ayant pas d'indication formelle de cholangiographie . Dans une série de 164 cholécystectomies coelioscopiques consécutives , 49 patients ( 30 % ) ont été éliminés de l'étude parce qu'il existait une indication ou une contreindication formelles à la cholangiographie peropératoire . Les 115 patients restants ( 70 % ) ont été r and omisés ; 56 ont eu une cholangiographie alors que 59 n'ont pas eu de cholangiographie peropératoire . La durée de l'hospitalisation postopératoire et le délai entre l'intervention et la reprise de travail étaient similaires dans les deux groupes . La cholangiographie a prolongé l'intervention de 16 ± 1 min ( moyenne ± écart type de la moyenne ) ( p<0.01 ) . Le coût supplémentaire d'une cholangiographie peropératoire a été estimé à environ 700 $ US ( p<0.01 ) . La cholangiographie a pu être effectuée chez 94.6 % des patients , et celle-ci a changé la tactique opératoire chez 4 ( 7.5 % ) patients . Il y a eu un résultat faussement négatif ( 1.9 % ) . La cholangiographie peropératoire n'a pas montré d'anomalie anatomique des voies biliares pouvant les compromettre lors de la dissection . La mortalité a été nulle dans chaque groupe . De même , il n'y a eu aucune morbidité en rapport direct avec la cholangiographie . Dans la période du suivi allant de 2 à 12 mois , il n'y a eu acune lésion biliaire ni de lithiase résiduelle de la voie biliaire cliniquement évidentes . En conclusion , chez un patients ans indication formelle de cholangiographie , la réalisation d'une cholangiographie peropératoire augmente considérablement la durée et le coût de l'intervention . La tactique opératoire a été très peu influencée très peu par les donées de la cholangiographie . La cholécystectomie coelioscopique peut être réalisée sans cholangiographie peropératoire systématique sans augmenter pour autant le risque de lésions des voies biliaires ou de calcul résiduel . ResumenLas opiniones se encuentran divididas respecto a si se debe realizar colangiografía intraoperatoria en forma rutinaria o en forma selectiva en el curso de una colecistectomía laparoscópica . Por ello hemos realizado el primer estudio aleatorizado de colangiografía estática en pacientes que no tenían indicaciones para colangiograma . Se intentó la colecistectomía laparoscópica en 164 pacientes consecutivos ; 49 ( 30 % ) fueron excluidos debido a indicaciones en favor o en contra de colangiografía . Los otros 115 pacientes ( 70 % ) se repartieron al azar 56 a colangiografía y 59 al grupo de no colangiografía . La duración de la hospitalización postoperatoria y del tiempo de retorno a actividad normal fueron idénticos en los dos grupos . Los colangiogramas estáticos añadieron 16 ± 1 min . al procedimiento ( p<0.01 ) y elevaron el costo de la operación en $ 700 ( p<0.01 ) . Los colangiogramas fueron exitosamente realizados en 49.6 % de los pacientes y modificaron el manejo operatorio en 4 ( 7.5 % ) ; hubo un falso positivo ( 1.9 % ) . La colangiografía intraoperatoria no reveló la prescencia de canales biliares aberrantes en riesgo de lesión por la disección opeatoria . No hubo mortalidad o morbilidad relacionada con la colangiografía , y en un seguimiento de 2–12 meses no se registró evidencia clínica de lesión de canales biliares o de cálculos retenidos en el colédoco . En resumen , en pacientes sin indicaciones para colangiografía , la realización de colangiogramas estáticos aumentó notoriamente el tiempo operatorio y el costo de la colecistectomia laparoscópica . Aunque el manejo operatorio de una minoría de pacientes sí fue modificado por la información obtenida , se considera que la colecistectomía laparoscópica puede ser practicada en forma segura en ausencia de colangiogramas con mínimo riesgo de lesión del sistema biliar o de cálculos retenidos HYPOTHESIS Magnetic resonance cholangiography ( MRC ) offers the potential for accurate , noninvasive detection of  common bile duct stones ( CBDSs ) before cholecystectomy , and for a consequent reduction in the incidence of preoperative negative diagnoses associated with endoscopic retro grade cholangiography ( ERC ) . DESIGN Prospect i ve cohort study : MRC results were correlated with ERC ( high-risk patients ) or intraoperative cholangiography ( moderate-risk patients ) . SETTING A university hospital providing primary , secondary , and tertiary care . PATIENTS Seventy patients with suspected CBDSs scheduled to undergo elective cholecystectomy between April 15 , 1997 , and September 30 , 1998 . Forty patients were considered at high risk and 30 at moderate risk for CBDSs , according to results of liver function tests and sonograms of the upper abdomen . MAIN OUTCOME MEASURES Confirmation or exclusion of CBDSs by MRC  was assessed by a panel of radiologists who were unaware of the ERC results . Results of ERC and intraoperative cholangiography were analyzed by the investigating gastroenterologists or surgeon . RESULTS Results of MRC were positive for CBDSs in 21 ( 52 % ) of 40 high-risk patients , a finding confirmed by preoperative ERC in 19 ( 90 % ) of 21 patients . Results of MRC were positive for CBDSs in 6 ( 20 % ) of 30 moderate-risk patients , all of which were confirmed by intraoperative cholangiography . Finally , CBDSs were present in 19 ( 48 % ) of 40 high-risk patients and 6 ( 20 % ) of 30 moderate-risk patients ( P = .02 ) . Overall sensitivity and specificity of  MRC  were 100 % and 95.6 % , respectively ; the positive and negative predictive values were 92.6 % and 100 % , respectively . CONCLUSIONS Magnetic resonance cholangiography is a reliable , noninvasive method for the detection or exclusion of CBDSs , and seems to reduce the frequency of negative diagnoses associated with ERC . Magnetic resonance cholangiography revealed no CBDSs in 19 ( 48 % ) of 40 patients at high risk for CBDSs . Thus , MRC-based diagnosis has the potential to reduce the number of invasive preoperative diagnostic procedures and their associated risks and overall health care costs A prospect i ve , controlled , r and omized trial was conducted in 275 patients with symptomatic gall stone disease , whose history , laboratory data or sonographical findings did not suggest common bile duct stones . Of these patients , 137 did not undergo intraoperative fluoroscopic cholangiography ( IOC ) , but in the remaining 138 patients IOC was attempted . In 111 cases ( 80.4 % ) the biliary system was sufficiently visualized . In 3 patients ( 2.7 % ) calculi in the cystic or common bile duct were diagnosed , which would have been overlooked without IOC . IOC was false-positive in one case . One year after the operation the patients were asked to return for a follow-up examination . Three patients in the group without IOC had had symptomatic passage of a stone , and one had a common bile duct stone removed by endoscopic papillotomy . A retained stone was discussed as etiology for a pancreatitis in a fifth patient in this group . No patient sustained long-term sequelae from the retained common bile duct stones . None of the patients in the IOC group had evidence of cholangiolithiasis at follow-up . There was no difference between the study groups concerning the incidence of post-operative complications . The operations with IOC  lasted significantly longer ( 92 + /- 31 min vs 77 + /- 28 min ) . According to our data and those published earlier , the additional financial and logistic expenditure associated with routine IOC is not justified . Patients with the preoperative suspicion of a common bile duct stone should have endoscopic bile duct clearance ( ERCP and EPT ) prior to cholecystectomy Fear of losing cognitive ability to Alzheimer disease and related dementias drives a growing industry of over-the-counter ( OTC ) supplements intended to boost brain health and prevent or slow cognitive decline . The Alzheimer 's Research and Prevention Foundation recommends that people be sure to take [ their ] vitamins and memory-specific nutrients and suggests optimal dosages for an array of vitamins and nutrients ( 1 ) . An estimated 63 % of older adults use OTC supplements ( 2 ) . In 2015 , Americans spent $ 37 billion on OTC supplements and $ 91 million on ginkgo bilobajust one of a growing number of supplements marketed to boost memory ( 3 ) . Whether any dietary or herbal supplement or specific food can prevent or delay cognitive decline is unclear . This review summarizes the evidence on efficacy and harms of OTC supplements to prevent or delay cognitive decline , mild cognitive impairment ( MCI ) , or clinical Alzheimer-type dementia . Methods We developed and followed a st and ard protocol ( https://effectivehealthcare.ahrq.gov/topics/cognitive-decline/ research - protocol ) . Data Sources and Search es We search ed Ovid MEDLINE , PsycINFO , EMBASE , and the Cochrane Central Register of Controlled Trials for relevant literature published between 2009 and July 2017 ( see Part A of the Supplement for search strategies ) . We identified studies published before 2009 by search ing citations in systematic review s and pertinent studies ( 48 ) . Supplement . Supplementary Material Study Selection Two investigators independently review ed titles and abstract s and screened the full text of potentially eligible references . We included r and omized and nonr and omized controlled trials of any OTC supplements  that enrolled adults with normal cognition or MCI . Because the review focused on prevention , we excluded studies of adults with dementia . We included only studies that followed participants for at least 6 months , reported incident MCI or dementia ( our main outcome of interest ) or cognitive performance outcomes , and were published in English . There were no restrictions on sample size or comparator type . Disagreements about eligibility were resolved by consensus . Data Extraction and Quality Assessment One review er extracted information on study design , population , intervention , comparator , setting , and funding source from eligible studies . For each study , 2 review ers read the full text and independently rated risk of bias for the overall study and for each outcome and time point as low , medium , or high according to Agency for Healthcare Research and Quality ( AHRQ ) guidance ( 9 ) . Outcomes and adverse events were extracted from studies with low to medium risk of bias . A second review er checked the quality of all data . Data Synthesis and Analysis We summarized results for studies with low to medium risk of bias by intervention , baseline cognitive status ( presumed normal cognition or MCI ) , and outcome . Because studies used highly variable outcome measures , neuropsychological tests were categorized according to the following 4 specific cognitive domains to facilitate analysis : executive function , attention , and processing speed ; memory ; language ; and visuospatial abilities ( see Supplement Table A1 for the list of cognitive outcomes that were used and Supplement Table A2 for measurement properties , including change indices , of neuropsychological tests that were used ) . We grouped executive function , attention , and processing speed because a large number of cognitive tests frequently measure all 3 of these related domains . Our preliminary work found that studies analyzed and reported cognitive test results in widely varying ways , frequently making it impossible to determine effect size or assess whether between-group differences in scores or subscores were clinical ly meaningful . We instead analyzed and report cognitive test results by direction of effect and statistical significance . When there were at least 2 studies or 1 large study ( > 500 participants ) for a treatment comparison , 2 review ers grade d strength of evidence for each outcome on the basis of study limitations , directness , consistency , and precision ; otherwise , strength of evidence was grade d as insufficient ( 10 ) . Assessment s were confirmed by consensus . Role of the Funding Source This review was funded by the National Institute on Aging and the AHRQ . These agencies and members of the National Academies Committee on Preventing Dementia and Cognitive Impairment helped refine the scope and review ed a draft report of findings . The authors are solely responsible for the content , preparation , and writing of the manuscript and the decision to su bmi t it for publication . Results We identified 63 publications of 56 unique studies covering 13 categories of OTC treatments ( Appendix Figure ) . A third of the studies were at least partially funded by industry . Eighteen were assessed as having high risk of bias and were not further analyzed . Table 1 depicts the interventions and population s of the 38 studies judged as having low or medium risk of bias . Detailed evidence tables and risk-of-bias assessment s are presented for studies involving adults with normal cognition in Part B of the Supplement and for studies involving adults with MCI in Part C of the Supplement ; these tables are also available in the parent technical report ( 11 ) . Table 2 summarizes the strength of evidence for the findings . Appendix Figure . Evidence search and selection . Table 1 . Number of Studies With Low or Moderate Risk of Bias , by Intervention Type and Population Table 2 . Effect of OTC Supplement Interventions Versus Control on Cognitive Outcomes in Adults With Normal Cognition and MCI * Table . Continued . -3 Fatty Acids Normal Cognition Seven r and omized trials with low to medium risk of bias ( n= 21027 ) that enrolled adults with presumed normal cognition compared -3 fatty acids with placebo ( 1218 ) . Interventions lasted from 6 months to more than 6 years . Five trials reported cognitive exclusion criteria , including a Mini-Mental State Examination ( MMSE ) score less than 22 ( 14 , 15 ) , less than 24 ( 13 ) , or less than 26 ( 16 , 17 ) out of a possible 30 points . One study used only docosahexaenoic acid ( DHA ) ( 17 ) ; all others used some combination of eicosapentaenoic acid ( EPA ) plus DHA . The largest study ( n= 15077 ) allowed participation of adults who were already using -3 supplementation  ( 18 ) . Population s varied in baseline health and risk for cognitive decline . Participants included patients with diabetes or impaired glucose tolerance ( 18 ) , patients with a history of ischemic heart disease ( 12 ) or coronary artery disease ( 14 ) , and healthy adults ( 13 , 1517 ) . None of the studies reported on incident Alzheimer-type dementia or MCI . A large multinational study of adults with diabetes or impaired glucose tolerance ( n= 15077 ) used a combination of clinical diagnosis or an MMSE score less than 24 and found no difference in probable dementia incidence between the EPA/DHA group and the placebo group at a median follow-up of 6.2 years ( hazard ratio [ HR ] , 0.93 [ 95 % CI , 0.86 to 1.0 ] ) ( 18 ) . Overall , studies provided low-strength evidence suggesting that -3 fatty acids do not improve cognitive performance in adults with normal cognition compared with placebo . Of 67 reported cognitive testsincluding 9 brief cognitive tests ( 12 , 14 , 17 , 18 ) ; 1 test of multidomain neuropsychological performance ( 13 ) ; 32 tests of executive function , attention , and processing speed ( 13 , 1518 ) ; and 25 memory tests ( 13 , 1517)only 5 showed scores that were statistically significantly better in -3treated groups than in control groups . These 5 tests were administered in 2 studies that had relatively short follow-up ( 6 months ) and included fewer than 5 % of the total participants in the 7 studies ( 16 , 17 ) . Four studies did not report adverse events , and no studies reported statistically significant differences in adverse events between the -3 and placebo groups . The parent technical report provides details on adverse events ( 11 ) . Subgroups were examined in 4 studies . No statistically significant differences in effect were found by age ( 12 , 14 , 15 , 18 ) , sex ( 14 , 15 , 18 ) , time since myocardial infa rct ion ( 14 ) , or diabetes status ( 18 ) . One study ( n= 884 ) with 4-year follow-up examined the comparative effectiveness of -3 fatty acids and B vitamins on cognition ( 12 ) . No between-group differences were found for any cognitive outcome between -3 fatty acids ( alone or in combination with B vitamins ) and B vitamins alone . Adverse events were not reported . MCI Evidence was insufficient for benefits of -3 fatty acids on cognitive outcomes compared with placebo after 1 year in the single small study of adults with MCI that we identified ( n= 36 ) ( 19 ) . No serious adverse events were reported . Soy Normal Cognition  Five r and omized trials with low to medium risk of bias that enrolled 35 to 350 participants ( n= 829 ) and lasted 6 months to 2.5 years compared soy supplementation with placebo ( 2025 ) . Population s included older adults without dementia ( 20 ) and generally healthy postmenopausal women ( 21 , 2325 ) . Baseline testing excluded persons with cognitive impairment in 2 of the studies ( 20 , 21 ) . Mean reported baseline MMSE scores  ranged from 28 to 29 ( 2023 ) . None of the trials reported MCI or Alzheimer-type dementia outcomes . Evidence was deemed insufficient to determine soy 's effect on brief cognitive test performance ( 21 , 25 ) and multidomain neuropsychological test performance ( 21 , 24 ) and low-strength for soy having no effect on executive function , attention , and processing speed ( 20 , 21 , 2325 ) or memory ( 2025 ) for up to 2.5 years . Two studies reported no serious adverse events and no statistically significant differences in adverse events between the soy and placebo groups ( 21 , 25 ) . MCI Evidence was insufficient to determine any beneficial effect on cognitive outcomes from soybean-derived phosphatidylserine at 2 doses ( 100 and 300 mg daily ) compared with placebo after 9 months in a single small study of adults Background Magnetic resonance cholangiography ( MRC ) is a new technique for non-invasive imaging of the biliary tract . Aim To assess the results of MRC in patients with suspected bile duct stones as compared with those obtained with reference imaging methods . Patients / Methods 70 patients ( 34 men and 36 women , mean ( SD ) age 71 ( 15.5 ) years ; median 75 ) with suspected bile duct stones were included ( cholangitis , 33 ; pancreatitis , three ; suspected post-cholecystectomy choledocholithiasis , nine ; cholestasis , six ; stones suspected on ultrasound or computed tomography scan , 19 ) . MR cholangiograms with two dimensional turbo spin echo sequences were acquired . Endoscopic retro grade cholangiography with or without sphincterotomy ( n = 63 ) , endosonography ( n = 5 ) , or intraoperative cho- langiography ( n = 2 ) were the reference imaging techniques used for the study and were performed within 12 hours of MRC . Radiologists were blinded to the results of endoscopic retro grade cholangiography and previous investigations . Results 49 patients ( 70 % ) had bile duct stones on reference imaging ( common bile duct , 44 , six of which impacted in the papilla ; intrahepatic , four ; cystic duct stump , one ) . Stone size ranged from 1 to 20 mm ( mean 6.1 , median 5.5 ) . Twenty seven patients ( 55 % ) had bile duct stones smaller than 6 mm . MRC diagnostic accuracy for bile duct lithiasis was : sensitivity , 57.1 % ; specificity , 100 % ; positive predictive value , 100 % ; negative predictive value , 50 % . Conclusions Stones smaller than 6 mm are still often missed by MRC when st and ard equipment is used . The general introduction of new technical improvements is needed before this method can be considered reliable for the diagnosis of bile duct stones BACKGROUND & AIMS Magnetic resonance cholangiography ( MRC ) is a noninvasive diagnostic modality capable of producing high- quality images of the biliary tree . The purpose of this study was to determine in a prospect i ve , blinded fashion the sensitivity and specificity of three-dimensional fast spin-echo ( 3D FSE ) MRC for the evaluation of biliary tract abnormalities . METHODS Forty-six patients referred for elective direct cholangiography ( 45 endoscopic retro grade cholangiopancreatography and 1 percutaneous transhepatic cholangiography )  were studied prospect ively with 3D FSE MRC during a 1-year period . All images were interpreted blindly by two radiologists . The presence of dilatation , strictures , and intraductal abnormalities was recorded . Sensitivity and specificity of 3D FSE MRC were determined using findings on direct cholangiography as the gold st and ard . RESULTS MRC images of diagnostic quality were obtained in 44 ( 95.7 % ) of the patients . Sensitivity for the detection of bile duct dilatation ( n = 27 ) , biliary strictures ( n = 10 ) , and intraductal abnormalities ( n = 7 ) was 96.3 % , 90 % , and 100 % , respectively . In addition , the MRC showed 16 of 17 patients with normal bile ducts ( specificity , 94.1 % ) . CONCLUSIONS MRC has a very high sensitivity and specificity in the evaluation of the biliary tract . Based on these data , we believe that the efficacy of MRC using 3D FSE is sufficient to warrant its use in the routine diagnosis of biliary tract disease
N-OTC is associated with shorter operative time and fewer peri-operative complications , and it is comparable to R-OTC in terms of CBD injury risk during cholecystectomy .
R-OTC is helpful for peri-operative CBD stone detection and there is therefore reduced readmission for retained CBD stones .
The N-OTC approach may be adopted routinely for patients undergoing laparoscopic cholecystectomy providing there are no clinical , biochemical or radiological features suggestive of CBD stones .
INTRODUCTION The aim of this review was to systemically analyse trials evaluating the efficacy of routine on-table cholangiography ( R-OTC ) versus no on-table cholangiography ( N-OTC ) in patients undergoing cholecystectomy .