Declining use of CBD exploration in choledocholithiasis

Last Updated: 2016-09-02

By Will Boggs MD

NEW YORK (Reuters Health) - Over the past 15 years, the use of open and laparoscopic common bile duct exploration in patients with choledocholithiasis has declined markedly, according to data from the National Inpatient Sample (NIS).

"The use of laparoscopic common bile duct exploration (LCBDE) in the management of choledocholithiasis has been steadily declining since 1998, despite it being a potentially beneficial, and at times necessary, minimally invasive alternative to ERCP (endoscopic retrograde cholangiopancreatography)," Dr. Michael W. Wandling from Northwestern University Feinberg School of Medicine in Chicago told Reuters Health by email.

LCBDE has been shown to be safe and effective in treating choledocholithiasis and can be performed concurrently with cholecystectomy in a 1-stage management approach.

Using data on 87,859 operations, Dr. Wandling's team reviewed trends in the management of choledocholithiasis as well as differences in hospital length of stay when laparoscopic cholecystectomy (LC) was done with LCBDE or with ERCP.

The percentage of patients with choledocholithiasis whose treatment included CBDE declined steadily, from 39.8% in 1998 to 8.5% in 2013.

There were significant declines in both open CBDE (from 30.6% to 5.5%) and LCBDE (from 9.2% to 3.0%), according to the August 24th JAMA Surgery online report.

During the same interval, the use of LCBDE+LC decreased from 5.3% to 1.5%, while the use of ERCP+LC increased from 52.8% to 85.7%.

The median length of stay was significantly shorter for patients managed with LCBDE+LC (3.5 days) rather than ERCP+LC (4.0 days).

Dr. Wandling laments the decline in CBDE.

"There continues to be a need for surgical common bile duct exploration, particularly in the setting of failed ERCP or altered foregut anatomy not amenable to ERCP," he said. "Unless efforts are made to train surgeons in laparoscopic common bile duct exploration, it is at risk of disappearing from the surgical armamentarium."

"The establishment of laparoscopic cholecystectomy and ERCP as less invasive treatment modalities for choledocholithiasis than traditional open surgical approaches have likely been key contributors to the declining use of open common bile duct exploration," Dr. Wandling explained. "The reasons behind the declining use of laparoscopic common bile duct exploration are perhaps less clear. However, we suspect that the technical challenges of laparoscopic common bile duct exploration and a lack of experience and comfort with the procedure have made ERCP a more preferable alternative for many surgeons."

"Laparoscopic common bile duct with laparoscopic cholecystectomy is associated with a shorter hospital length of stay than ERCP with laparoscopic cholecystectomy," he concluded. "However, further research evaluating the clinical outcomes of laparoscopic cholecystectomy with laparoscopic common bile duct exploration is needed before widely advocating for this approach over ERCP with laparoscopic cholecystectomy."

Dr. Timothy M. Pawlik from The Ohio State University in Columbus, who co-authored an invited commentary related to this report, told Reuters Health by email, "As surgical common bile duct exploration becomes more uncommon, more and more surgeons are less comfortable with this technique - and therefore patients are referred for endoscopic management. The modest decrease in length of stay was also not surprising, as ERCP+LC are two procedures rather than one surgical procedure (i.e., LCBDE+LC), so a slight increase in length of stay would be anticipated."

"I am not so sure that we need to be that 'concerned,'" Dr. Pawlik said. "While some surgeons advocate for surgical clearance of the bile duct in the setting of choledocholithiasis, endoscopic clearance is very effective and well-tolerated."

"While the authors comment on the 0.5 (day) increased length of stay associated with endoscopic rather than laparoscopic clearance of the common bile duct, a more formal cost analysis would also be interesting," he said. "One reason to be 'concerned' may be that in an era of rising health care costs, LCBDE+LC may not only reduce stay but also be more cost effective - however, more data are needed since the current study does not address this point."

Dr. David Burnett and Dr. Jon Gani from John Hunter Hospital, Newcastle, New South Wales, Australia, who recently evaluated the feasibility of single-stage laparoscopic cholecystectomy and intraoperative ERCP, told Reuters Health by email, "There should be no guilt with a general surgeon utilizing ERCP for common duct stones rather than attempting laparoscopic choledochotomy, as the volume of experience in LCBDE is ever decreasing. The development of hybrid operating theatres will encourage the uptake of single stage LC+ERCP, which is likely to completely obviate the length-of-stay differences seen in this study."

SOURCE: http://bit.ly/2c7OuAW and http://bit.ly/2bQV2S1

JAMA Surg 2016.