Surgeons, ERCP, and Laparoscopic Common Bile Duct Exploration: Do We Need a Standard Approach for Common Bile Duct Stones?

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).

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.