The Evolution of Management of CBD stones in Scotland

K Knight, MBChB, MRCS, Z Ahmed, MBChB, MRCS, Ahm Nassar, FRCS, M Alwahid

Monklands District General Hospital, Lanarkshire, Scotland; University of Glasgow, Scotland

Introduction: The management of common bile duct stones in surgically fit patients continues to vary between a single session approach with LCDBE at the time of LC, to those preferring a staged procedure utilising LC and ERCP. Recent published work tend to favour laparoscopic bile duct exploration as the index procedure. It is not clear, however, if such evidence has permeated into a change of practice amongst surgeons who generally care for such patients.

Method: We therefore canvassed the opinion of all Scottish General Surgeons during 1997 and repeated the process in 2010 using the same standardised postal questionnaire. Data analysis was carried out using Microsoft access and SPSS 15 for windows. Continuous variables were parametric and were assessed with analysis of variance and binary outcomes were assessed using chi squared test of association.

Results: A total of 158/165 replies were received in 1997 and 77/120 surgeons replied in 2010.

In 1997, 122 surgeons treated gallstone disease and 39 (32%) declared an upper GI subspecialty interest. 59 surgeons treated gallstones disease in 2010 of whom 23 (39%) declared an upper GI interest. In 1997 CBD stones were exclusively diagnosed with ERCP while in 2010 71% were diagnosed by MRCP. ERCP availability in the same hospital was unchanged (82%). Waiting times for ERCP also remained unchanged with the majority waiting 3-7 days (51 v 57% p>0.05).

Laparoscopic CBD exploration appeared to be more widely practiced. 35% of respondents declared that they offered LCBDE in 2010 compared to 19% in 1997. Nonetheless, of these? Said that they never performed LCBDE or performed it occasionally. In those that did not personally offer the service 41% had access to LCBDE in their own hospital compared to 33% in 1997. Only 10% performed LCBDE in all comers in 2010 compared to 2% in 1997.

When asked what their preferred choice of managing CBD stones was; the majority (66%) still preferred ERCP+/-LC in 2010 (82% in 1997). More surgeons now (38%) believe that the future first choice would be LCBDE (21% in 1997 p<0.05).

Conclusion: Our follow up study demonstrates that LCBDE has become a more accepted form of managing ductal stones and its practice has become more widespread in the 13 year period. However, it is still not a first choice procedure for the majority of surgeons even those with expertise to perform it. The lack of uptake of LCDBE as an index procedure for CBD stone management is likely to be multifactorial and requires further investigation and analysis.

Session: Poster Presentation

Program Number: P365

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