A O02 Few patients with bile duct stones are managed with a one-stage approach: Results from a prospective multicentre cohort study
Authors: Russell Thomas , Tanase Andrei , Platt Timothy , Griffiths Ewen , Aroori Somaiah 
Published: December 2022

Abstract

Background
Bile duct stones (BDS) are present in 10–20% of patients with symptomatic gallstones. They require treatment to reduce the risk of further morbidity. There are two accepted treatment methods. A two-stage approach is most common where preoperative magnetic resonance cholangiopancreatography (MRCP) and endoscopic retrograde cholangiopancreatography (ERCP) are followed by laparoscopic cholecystectomy (LC). Less commonly, upfront LC is performed with laparoscopic bile duct exploration (LBDE). Recent evidence suggests patients who undergo ERCP+LC have higher stone clearance rates and a lower rate of bile leakage compared to those who undergo LC+LBDE. However, the latter have lower rates of postoperative pancreatitis and reduced length of stay. Overall morbidity and mortality rates are similar. Although the literature supports the single-stage approach, it is not commonly used across the United Kingdom (UK) or Republic of Ireland (RoI). The reasons for this are not clear. The lack of data on LDBE outcomes from large multicentre studies may be a contributing factor. Most published series are from single institutions and the outcomes of these are difficult to generalise to low-volume centres. This study aimed to analyse the CholeS study dataset to examine LBDE hospital volumes, LBDE-to-LC rates and LBDE outcomes.

Methods
The CholeS study was a multicentre, prospective population-based cohort study which investigated the variations in practice and outcomes of cholecystectomy. Data were collected from 166 UK/RoI hospitals from the months of March and April 2014. The hospitals were divided into high- and low-volume centres based on the number of LBDEs performed. High-volume centres performed at least two LBDEs per month during the study period and low-volume centres performed less than two per month. Most data were analysed and presented descriptively, using tables, graphs, and percentages for distribution. Where possible, we compared clinically relevant groups using the Chi-squared test to detect differences. A p value of less than 0.05 was considered statistically significant.

Results
In total, 8820 LCs were performed and 2.9% of patients underwent LBDE. Seventy-seven centres (46.1%) performed at least one LBDE. In these units, 5.4% of patients who underwent LC also underwent LBDE. Almost 90% of the hospitals that performed LBDE carried out less than or equal to five. In contrast, 10.6% of patients underwent ERCP and sphincterotomy. Of the 256 LBDEs, 28.5% underwent preoperative ERCP and 43.8% underwent preoperative MRCP. Eighty seven percent of LBDEs were performed by consultants and 13% by trainees. The laparoscopic-to-open conversion rate was 12.5% and the median operation time was 111 minutes (IQR: 75–155). Among the LBDE cases, the overall postoperative morbidity rate was 21.5% and the bile leak rate was 4.7%. 30-day readmission and 30-day mortality rates were 12.1% and 0.4%, respectively.
Bile leak, acute pancreatitis, retained stone and overall morbidity rates following LBDE were compared between the low- and high-volume centres. Bile leak (OR 8.62, 95% CI: 2.26–32.84, p=0.0016) and 30-day morbidity (OR 1.90, 95% CI: 1.05–3.44, p=0.035) were significantly higher in the low-volume units. There was no difference in the rate of postoperative pancreatitis (OR 0.85, 95% CI:0.09–8.3, p=0.8887) or retained stone rate (OR 0.76, 95% CI:0.16–3.68, p=0.7376).

Conclusions
During the study period, just 2.9% of patients underwent LBDE. The majority of hospitals did not perform this procedure at all and very few were “high-volume” units. Our results suggest that the single-stage management of BDS was underutilised despite the recent evidence which suggests it is a safe and reasonable approach. Our results do not provide any insight into why uptake was low and we suspect the reasons for this are multiple. We argue large retrospective/prospective studies are required to investigate this and hope this information will further guide patient management.