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).
|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)|
|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|
|Practice type (ref: community)|
|Community hospital, university affiliated||1.75||0.90-3.39||0.098|
|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.