Rebeccah B Baucom, MD1, Irene D Feurer, PhD1, Julia S Shelton, MD, MPH2, Kristy L Kummerow, MD1, Michael D Holzman, MD, MPH1, Benjamin K Poulose, MD, MPH1. 1Vanderbilt University Medical Center, 2University of Louisville
Background Management of choledocholithiasis (CDL) remains challenging. This study aimed to evaluate associations between demographic and practice-related characteristics and CDL management.
Methods A 22 item, web-based survey was administered to U.S. general surgeons. Respondents were classified into metropolitan or non-metropolitan groups by zip code. Univariate tests and multivariable regression were used to determine factors associated with CDL management preferences.
Results The survey was sent to 33,331 surgeons; 9,902 performed laparoscopic cholecystectomy in last year; 750 of 771 respondents had a valid U.S. zip code and were included in the analysis. Mean practice time was 18±10 years, 87% were male, and 83% practiced in a metropolitan area. For CDL discovered preoperatively, 86% chose preoperative endoscopic retrograde cholangiopancreatography (ERCP) and 7% laparoscopic common bile duct exploration (LCBDE). Those in metropolitan areas were more likely to select preoperative ERCP than those in non-metropolitan areas (88% vs. 79%, p<0.001). The top reasons for not performing LCBDE were: having a reliable ERCP proceduralist available, lack of equipment, and lack of comfort performing LCBDE (Figure). Factors associated with preoperative ERCP were: metropolitan status, selective intraoperative cholangiography (IOC), and availability of a reliable ERCP proceduralist (Table). Those who perform selective IOC were 70% less likely to prefer LCBDE (OR 0.32, 95% CI 0.18-0.57, p<0.001). Those with a reliable ERCP proceduralist available were 90% less likely to prefer LCBDE (0R 0.10, 95% CI 0.04-0.26, p<0.001).
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| Variable | Odds Ratio | 95% Confidence Interval | p-value |
|---|---|---|---|
| Metropolitan (ref: non-metropolitan) | 2.50 | 1.30-4.82 | 0.006 |
| Years in practice (ref: >30) | |||
| ≤5 | 1.06 | 0.40-2.86 | 0.905 |
| 6-10 | 0.76 | 0.31-1.86 | 0.549 |
| 11-20 | 0.87 | 0.42-1.77 | 0.691 |
| 21-30 | 0.87 | 0.43-1.75 | 0.687 |
| Male | 1.12 | 0.58-2.16 | 0.747 |
| ERCP at primary institution (ref: requires referral) | 0.50 | 0.23-1.06 | 0.068 |
| Selective IOC (ref: routine) | 2.73 | 1.75-4.27 | <0.001 |
| Residency type (ref: community) | |||
| Community hospital, university affiliated | 1.40 | 0.65-3.03 | 0.395 |
| University hospital/VA | 0.89 | 0.45-1.77 | 0.734 |
| Practice type (ref: community) | |||
| Community hospital, university affiliated | 1.75 | 0.90-3.39 | 0.098 |
| University hospital/VA | 0.91 | 0.49-1.69 | 0.764 |
| Reliable ERCP proceduralist available (ref: none available) | 2.25 | 1.41-3.59 | 0.001 |
| Time constraints limit LCBDE (ref: not a limitation) | 0.76 | 0.47-1.24 | 0.275 |
Conclusions The majority of respondents preferred pre-operative ERCP for CDL management. Having a reliable ERCP proceduralist available and selective IOC were independently associated with ERCP, regardless of metropolitan status. Many surgeons are uncomfortable performing LCBDE, and increased training is needed.
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