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).


Multivariable Model Predicting Preference for Preoperative ERCP
VariableOdds Ratio95% Confidence Intervalp-value
Metropolitan (ref: non-metropolitan)2.501.30-4.820.006
Years in practice (ref: >30)
ERCP at primary institution (ref: requires referral)0.500.23-1.060.068
Selective IOC (ref: routine)2.731.75-4.27<0.001
Residency type (ref: community)
Community hospital, university affiliated1.400.65-3.030.395
University hospital/VA0.890.45-1.770.734
Practice type (ref: community)
Community hospital, university affiliated1.750.90-3.390.098
University hospital/VA0.910.49-1.690.764
Reliable ERCP proceduralist available (ref: none available)2.251.41-3.590.001
Time constraints limit LCBDE (ref: not a limitation)0.760.47-1.240.275

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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