Presenting Author:

Ben Schwab, M.D.

Principal Investigator:

Eric Hungness, M.D.

Department:

Surgery

Keywords:

Laparoscopic common bile duct exploration, choledocholithiasis, endoscopic retrograde cholangiopancreatography

Location:

Ryan Family Atrium, Robert H. Lurie Medical Research Center

C133 - Clinical

SINGLE STAGE LAPAROSCOPIC MANAGEMENT OF CHOLEDOCHOLITHIASIS: AN ANALYSIS OF OUTCOMES

Introduction: The optimal management of choledocholithiasis remains controversial with the majority of patients currently undergoing two-stage management with laparoscopic cholecystectomy (LC) and endoscopic retrograde cholangiopancreatography (ERCP). In contrast, the utilization of laparoscopic common bile duct exploration (LCBDE) continues to decline despite evidence demonstrating equivalent efficacy and reduced duration of hospitalization for patients who undergo single-stage management with LCBDE performed at the time of LC. In this study, we sought to compare outcomes for patients presenting to our institution with choledocholithiasis who underwent single-stage management with LC+LCBDE compared to two-stage management with LC+ERCP, either pre- or post-operatively. Methods and Procedures: After IRB-exempt determination, we performed a retrospective chart review of all patients admitted to our teaching hospital from June 2008 to June 2015 with an ICD-9 code for choledocholithiasis requiring intervention (surgical or endoscopic) during their index hospitalization. After application of exclusion criteria, 155 patients were included in the analysis. Cost data was representative of all hospital charges incurred over the patient’s hospital stay. Continuous variables were reported as means, standard deviations, medians and ranges and differences between groups were assessed via the Wilcoxon rank-sum test.  Categorical variables were reported as frequencies and percentages and differences between groups were assessed via Fisher’s exact test.  Analyses were conducted using SAS v9.4 (SAS Institute, Cary, NC). Results: 31 patients underwent LC+LCBDE (7 males, 24 females) and 124 patients had LC+ERCP (33 males, 91 females). No significant differences were noted in the patient demographics, ASA class, or preoperative laboratory values with the exception of total bilirubin, which was higher in the ERCP cohort (2.73 ± 2.55 vs. 1.66 ± 1.15, p = 0.02). Use of a single stage approach (LC+LCBDE) compared with the two- stage approach (LC+ERCP) resulted in a statistically significant reduction in hospital length of stay (2.52 ± 1.81 vs. 4.32 ± 2.18, p <0.0001) and average patient costs ($12987 ± 3286 vs. $15022 ± 4613, p = 0.01). There were no identified deaths among the study population and morbidity was equivalent across groups as measured by rate of readmission and/or need for re-operation within 30 days. Conclusion: Single-stage management of choledocholithiasis with LC+LCBDE was shown to be cost effective and resulted in a significantly shorter hospital stay when compared to the use of ERCP to obtain clearance of the common bile duct prior to, or after, cholecystectomy. We propose that LC+LCBDE should be considered the first line treatment for appropriately selected patients who present with choledocholithiasis.