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).

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Multivariable Model Predicting Preference for Preoperative ERCP
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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