Ezra N Teitelbaum, MD, MEd1, Nathaniel J Soper, MD1, Pratik Patel, BS1, Byron F Santos, MD2, Eric S Hungness, MD1. 1Northwestern University, 2Dartmouth-Hitchcock Medical Center
Introduction: Laparoscopic common bile duct exploration (LCBDE) at the time of cholecystectomy remains an underutilized treatment for choledocholithiasis, despite demonstrated clinical advantages over the two-stage approach of ERCP plus laparoscopic cholecystectomy. In order to better understand the etiology of this underutilization, we surveyed surgeons regarding their experience with LCBDE and barriers that prevent them from performing the procedure.
Methods: Attending surgeons were surveyed at two academic conferences (American College of Surgeons and SAGES) prior to participating in LCBDE courses or visiting the SAGES “learning-center”. Participants received no LCBDE teaching prior to completing the survey. Subjects were queried regarding their prior experience with LCBDE and Likert-type questions were used to assess their confidence in performing the procedure, their evaluation of LCBDE in relation to ERCP, and barriers that currently prevent them from performing LCBDE. Surgeon factors that were associated with increased utilization of LCBDE were analyzed using a Spearman’s correlation test.
Results: 117 surgeons were surveyed. Participants had a median of 8 years in practice (range 1-40 years) and a mix of practice settings (20% university, 21% university-affiliated, 53% community, 6% other). 35% had completed a minimally-invasive fellowship. During their residencies, participants had performed a median of 0 LCBDEs (mean 1, range 0-10) and those who had completed a minimally-invasive fellowship had also performed a median of 0 LCBDEs during fellowship (mean 2, range 0-20). In the entirety of their post-training practice, those surveyed had performed a median of 2 LCBDEs (range 0-600) and a median of 0 in the last year (range 0-20). 77% stated they employed ERCP more often than LCBDE for initial treatment of choledocholithiasis. Regarding their technical ability, 45% of surgeons indicated they “agree” or “strongly agree” with the statement, “I can effectively and safely perform a transcystic LCBDE”, and that proportion was only 27% for transcholedochal LCBDE. When comparing LCBDE and ERCP, participants indicated that LCBDE was superior with respect to hospital length of stay and cost, whereas the two approaches were equivalent in terms of stone clearance and safety. The most significant barriers to performing LCBDE in the surgeons’ current practice were inadequate OR staff familiarity with the procedure (mean 3.1, scale 1-5), not having the necessary instruments available (mean 3.0), and their own limited technical ability (mean 2.8). Less significant barriers were added procedure time (mean 2.3) and poor financial compensation (1.7). Surgeons with more years in practice had higher confidence in their ability to perform LCBDE (r=.28, p<.01), as did those who had completed a fellowship (r=.18, p=.06), but those factors were not associated with actually performing more LCBDEs in the past year. However, more frequent use of intraoperative cholangiogram was associated with performing more LCBDEs (r=.22, p<.05).
Conclusions: In this cohort, surgeons had little experience with LCBDE during either training or practice and were not confident in their ability perform the procedure. Lack of surgeon and OR staff training, as well as instrument availability, were the main barriers to utilization. These results can be used to guide future LCBDE-specific curricula and training.