{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2025,10,11]],"date-time":"2025-10-11T01:15:02Z","timestamp":1760145302824,"version":"build-2065373602"},"reference-count":35,"publisher":"MDPI AG","issue":"13","license":[{"start":{"date-parts":[[2024,7,1]],"date-time":"2024-07-01T00:00:00Z","timestamp":1719792000000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Diagnostics"],"abstract":"<jats:p>A proportion of patients who undergo intraoperative cholangiogram (IOC) do not have bile duct stones at the time of endoscopic retrograde cholangiopancreatography (ERCP), either due to the spontaneous passage of stones or a false-positive IOC. Glucagon has been utilized as an inexpensive tool to allow the passage of micro-choledocholithiasis to the duodenum and resolve filling defects caused by stones or air bubbles. The purpose of our study is to understand the change in diagnostic accuracy of IOC to detect choledocholithiasis with intraoperative glucagon. We conducted a retrospective study at a tertiary care center on adult patients who underwent laparoscopic cholecystectomy with IOC. The diagnostic accuracy of IOC was assessed before and after the administration of intravenous glucagon. Of 1455 patients, 374 (25.7%) received intraoperative glucagon, and 103 of these 374 patients (27.5%) showed resolution of the filling defect with the passage of contrast to the duodenum. Pre- and post-glucagon administration comparison showed enhancement in specificity from 78% to 83%, an increase in positive predictive value from 67.3% to 72.4%, and an improvement in the diagnostic accuracy of IOC from 81.5% to 84.3%. Our findings suggest that intraoperative glucagon administration carries the potential to reduce the rate of false-positive IOCs, thereby reducing the performance of unnecessary ERCPs.<\/jats:p>","DOI":"10.3390\/diagnostics14131405","type":"journal-article","created":{"date-parts":[[2024,7,1]],"date-time":"2024-07-01T09:06:07Z","timestamp":1719824767000},"page":"1405","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["The Impact of Intraoperative Glucagon on the Diagnostic Accuracy of Intraoperative Cholangiogram for the Diagnosis of Choledocholithiasis: Experience from a Large Tertiary Care Center"],"prefix":"10.3390","volume":"14","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-7168-2550","authenticated-orcid":false,"given":"Nitish","family":"Mittal","sequence":"first","affiliation":[{"name":"Department of Internal Medicine, The University of Texas Health Sciences Center, Houston, TX 77054, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Faisal S.","family":"Ali","sequence":"additional","affiliation":[{"name":"Department of Gastroenterology, Hepatology, and Nutrition, The University of Texas Health Sciences Center, Houston, TX 77054, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Antonio Pizuorno","family":"Machado","sequence":"additional","affiliation":[{"name":"Department of Internal Medicine, The University of Texas Health Sciences Center, Houston, TX 77054, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-7298-2662","authenticated-orcid":false,"given":"Sean","family":"Ngo","sequence":"additional","affiliation":[{"name":"School of Medicine, McGovern Medical School, Houston, TX 77054, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-8503-7811","authenticated-orcid":false,"given":"Malek","family":"Shatila","sequence":"additional","affiliation":[{"name":"Department of Gastroenterology, University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Tomas","family":"DaVee","sequence":"additional","affiliation":[{"name":"Department of Gastroenterology, Hepatology, and Nutrition, The University of Texas Health Sciences Center, Houston, TX 77054, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4607-6241","authenticated-orcid":false,"given":"Nirav","family":"Thosani","sequence":"additional","affiliation":[{"name":"Department of Surgery, Section of Endoluminal Surgery and Interventional Gastroenterology, McGovern Medical School at UTHealth, Houston, TX 77054, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Vaibhav","family":"Wadhwa","sequence":"additional","affiliation":[{"name":"Department of Surgery, Section of Endoluminal Surgery and Interventional Gastroenterology, McGovern Medical School at UTHealth, Houston, TX 77054, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1968","published-online":{"date-parts":[[2024,7,1]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"117","DOI":"10.1016\/j.igie.2023.04.011","article-title":"Accuracy of intraoperative cholangiography and outcomes of ERCP in hospitalized patients with suspected choledocholithiasis","volume":"2","author":"Syed","year":"2023","journal-title":"iGIE"},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"186","DOI":"10.1016\/S1590-8658(03)00027-6","article-title":"Prospective evaluation of magnetic resonance cholangiopancreatography in patients with biliary disease: Comparative study with conventional ultrasonography and endoscopic retrograde cholangiopancreatography: Diagnostic algorithm","volume":"35","author":"Pamos","year":"2003","journal-title":"Dig. Liver Dis."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"486","DOI":"10.5946\/ce.2016.159","article-title":"Sensitivity and specificity of magnetic resonance cholangiopancreatography versus endoscopic ultrasonography against endoscopic retrograde cholangiopancreatography in diagnosing choledocholithiasis: The Indonesian experience","volume":"50","author":"Makmun","year":"2017","journal-title":"Clin. Endosc."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"139","DOI":"10.1016\/S0016-5107(97)70061-0","article-title":"A prospective, double-blind trial of L-hyoscyamine versus glucagon for the inhibition of small intestinal motility during ERCP","volume":"46","author":"Lahoti","year":"1997","journal-title":"Gastrointest. Endosc."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"E558","DOI":"10.1055\/a-1747-3242","article-title":"Clinical safety and outcomes of glucagon use during endoscopic retrograde cholangiopancreatography (ERCP)","volume":"10","author":"Perisetti","year":"2022","journal-title":"Endosc. Int. Open"},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"312","DOI":"10.1007\/BF01324947","article-title":"Effects of exogenous glucagon on pancreatic and biliary ductal and sphincteric pressures in man demonstrated by endoscopic manometry and correlation with plasma glucagon","volume":"28","author":"Gregg","year":"1983","journal-title":"Dig. Dis. Sci."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"258","DOI":"10.1016\/S0720-048X(03)00084-6","article-title":"Does intravenous glucagon improve common bile duct visualisation during magnetic resonance cholangiopancreatography? Results in 42 patients","volume":"49","author":"Dalal","year":"2004","journal-title":"Eur. J. Radiol."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"400","DOI":"10.1016\/S0016-5085(71)80119-1","article-title":"Effect of glucagon on hepatic bile secretion in man","volume":"60","author":"Dyck","year":"1971","journal-title":"Gastroenterology"},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"50","DOI":"10.1080\/00365521.2016.1228117","article-title":"Impact of nitroglycerin and glucagon administration on selective common bile duct cannulation and prevention of post-ERCP pancreatitis","volume":"52","author":"Katsinelos","year":"2017","journal-title":"Scand. J. Gastroenterol."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"663","DOI":"10.1016\/S0009-9260(80)80015-8","article-title":"Further experience with glucagon enhanced cholangiography","volume":"31","author":"Evans","year":"1980","journal-title":"Clin. Radiol."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"833","DOI":"10.1001\/archsurg.1987.01400190099022","article-title":"Intraoperative cardiovascular crisis caused by glucagon","volume":"122","author":"Schorr","year":"1987","journal-title":"Arch. Surg."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"AB298","DOI":"10.1016\/j.gie.2022.04.763","article-title":"Accuracy of intraoperative cholangiogram in hospitalized patients with suspected choledocholithiasis","volume":"95","author":"Syed","year":"2022","journal-title":"Gastrointest. Endosc."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"101906","DOI":"10.1016\/j.bpg.2024.101906","article-title":"Prevention of post-ERCP complications","volume":"69","author":"Triki","year":"2024","journal-title":"Best Pract. Res. Clin. Gastroenterol."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"4019","DOI":"10.3748\/wjg.v25.i29.4019","article-title":"Post-endoscopic retrograde cholangiopancreatography pancreatitis: A systematic review for prevention and treatment","volume":"25","year":"2019","journal-title":"World J. Gastroenterol."},{"key":"ref_15","doi-asserted-by":"crossref","unstructured":"Boicean, A., Birlutiu, V., Ichim, C., Todor, S.B., Hasegan, A., Bacila, C., Solomon, A., Cristian, A., and Dura, H. (2023). Predictors of post-ERCP pancreatitis (PEP) in choledochal lithiasis extraction. J. Pers. Med., 13.","DOI":"10.3390\/jpm13091356"},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"425","DOI":"10.1067\/mge.2001.117550","article-title":"Risk factors for post-ERCP pancreatitis: A prospective, multicenter study","volume":"54","author":"Freeman","year":"2001","journal-title":"Gastrointest. Endosc."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"E952","DOI":"10.1055\/a-1793-9508","article-title":"Early prediction of post-ERCP pancreatitis by post-procedure amylase and lipase levels: A systematic review and meta-analysis","volume":"10","author":"Goyal","year":"2022","journal-title":"Endosc. Int. Open"},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"446","DOI":"10.1016\/j.gie.2009.10.027","article-title":"A lexicon for endoscopic adverse events: Report of an ASGE workshop","volume":"71","author":"Cotton","year":"2010","journal-title":"Gastrointest. Endosc."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"1576","DOI":"10.4254\/wjh.v8.i35.1576","article-title":"Intrahepatic pancreatic pseudocyst: A review of the world literature","volume":"8","author":"Demeusy","year":"2016","journal-title":"World J. Hepatol."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"e00507","DOI":"10.1016\/j.idcr.2019.e00507","article-title":"ERCP-associated infected intrahepatic pancreatic pseudocyst","volume":"15","author":"Angsubhakorn","year":"2019","journal-title":"IDCases"},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"304","DOI":"10.1007\/s00464-008-9883-2","article-title":"How reliable is intraoperative cholangiography as a method for detecting common bile duct stones? A prospective population-based study on 1171 patients","volume":"23","author":"Videhult","year":"2009","journal-title":"Surg. Endosc."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"244","DOI":"10.1308\/rcsann.2016.0068","article-title":"Meta-analysis of the diagnostic accuracy of laparoscopic ultrasonography and intraoperative cholangiography in detection of common bile duct stones","volume":"98","author":"Jamal","year":"2016","journal-title":"Ann. R. Coll. Surg. Engl."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"139","DOI":"10.1111\/ans.18215","article-title":"Incidence and management of choledocholithiasis on routine intraoperative cholangiogram: A 5-year tertiary centre experience","volume":"93","author":"Ng","year":"2023","journal-title":"ANZ J. Surg."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"319","DOI":"10.1007\/BF00187380","article-title":"One hundred consecutive laparoscopic cholangiograms: Results and conclusions","volume":"10","author":"Carroll","year":"1996","journal-title":"Surg. Endosc."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"84","DOI":"10.1001\/archsurg.1983.01390010060014","article-title":"Glucagon Enhancement of Cholangiography: A Preliminary Report","volume":"118","author":"Tabak","year":"1983","journal-title":"Arch. Surg."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"455","DOI":"10.1097\/00007611-198804000-00011","article-title":"Effect of intravenous glucagon on intraoperative cholangiography","volume":"81","author":"Cofer","year":"1988","journal-title":"South. Med. J."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"510","DOI":"10.1067\/mge.2003.149","article-title":"EUS for suspected choledocholithiasis: Do benefits outweigh costs? A prospective, controlled study","volume":"57","author":"Buscarini","year":"2003","journal-title":"Gastrointest. Endosc."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"2900","DOI":"10.1111\/j.1572-0241.2001.04245.x","article-title":"Can endoscopic ultrasound or magnetic resonance cholangiopancreatography replace ERCP in patients with suspected biliary disease? A prospective trial and cost analysis","volume":"96","author":"Scheiman","year":"2001","journal-title":"Off. J. Am. Coll. Gastroenterol."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"86","DOI":"10.1016\/S0016-5107(04)02472-1","article-title":"Noninvasive vs. selective invasive biliary imaging for acute biliary pancreatitis: An economic evaluation by using decision tree analysis","volume":"61","author":"Romagnuolo","year":"2005","journal-title":"Gastrointest. Endosc."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"620","DOI":"10.1016\/S1076-6332(03)80080-6","article-title":"Making cost-effectiveness analyses clinically relevant: The effect of provider expertise and biliary disease prevalence on the economic comparison of alternative diagnostic strategies","volume":"10","author":"Carlos","year":"2003","journal-title":"Acad. Radiol."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"960","DOI":"10.1016\/j.gie.2006.07.031","article-title":"Pancreatic-stent placement for prevention of post-ERCP pancreatitis: A cost-effectiveness analysis","volume":"65","author":"Das","year":"2007","journal-title":"Gastrointest. Endosc."},{"key":"ref_32","doi-asserted-by":"crossref","unstructured":"Hope, W., Fanelli, R., Walsh, D.S., Price, R., Stefanidis, D., and Richardson, W.S. (2017). Clinical Spotlight Review: Intra-Operative Cholangiography, Society of American Gastrointestinal and Endoscopic Surgeons.","DOI":"10.1007\/s00464-016-5320-0"},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"160","DOI":"10.1002\/bjs.7809","article-title":"Systematic review of intraoperative cholangiography in cholecystectomy","volume":"99","author":"Ford","year":"2012","journal-title":"J. Br. Surg."},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"957","DOI":"10.1007\/s00464-012-2540-9","article-title":"Kumar versus Olsen cannulation technique for intraoperative cholangiography: A randomized trial","volume":"27","author":"Buddingh","year":"2013","journal-title":"Surg. Endosc."},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"243","DOI":"10.1016\/j.jsurg.2012.09.011","article-title":"Teaching cholangiography in a surgical residency program","volume":"70","author":"Hope","year":"2013","journal-title":"J. Surg. Educ."}],"container-title":["Diagnostics"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2075-4418\/14\/13\/1405\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,10]],"date-time":"2025-10-10T15:08:44Z","timestamp":1760108924000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2075-4418\/14\/13\/1405"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2024,7,1]]},"references-count":35,"journal-issue":{"issue":"13","published-online":{"date-parts":[[2024,7]]}},"alternative-id":["diagnostics14131405"],"URL":"https:\/\/doi.org\/10.3390\/diagnostics14131405","relation":{},"ISSN":["2075-4418"],"issn-type":[{"type":"electronic","value":"2075-4418"}],"subject":[],"published":{"date-parts":[[2024,7,1]]}}}