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Chan KS, Teo ZHT, Oo AM, Junnarkar SP, Shelat VG. Learning Curve of Laparoscopic Common Bile Duct Exploration: A Systematic Review. J Laparoendosc Adv Surg Tech A 2023; 33:241-252. [PMID: 36161969 DOI: 10.1089/lap.2022.0382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Background: Single-stage laparoscopic common bile duct exploration (LCBDE) with cholecystectomy has superior outcomes over two-stage endoscopic retrograde cholangiopancreatogram with interval cholecystectomy. With decreasing trend of LCBDE, this study aims to summarize the literature on learning curve (LC) in LCBDE. Materials and Methods: PubMed, Embase, Scopus, and the Cochrane Library were systematically searched for articles from inception to June 3, 2022 (PROSPERO Ref No: CRD42022328451). Basic clinical demographics were collected. Poisson means (95% confidence interval [95% CI]) was used to determine the number of cases required to surmount the LC (NLC). Results: Eight articles (n = 2071 patients) reported LC outcomes in LCBDE with mean study period of 5.9 ± 2.8 years. Majority of studies (62.5%) used arbitrary methods of LC analysis. Most common outcomes reported were complications (any or major) (75%), open conversion (75%), length of stay (62.5%), and operating time (50%). Mean CBD diameter was 11.3 ± 4.8 mm (n = 1122 patients). Incidence of acute cholecystitis, acute cholangitis, and acute pancreatitis were 13.9% (n = 232/1668), 7.8% (n = 128/1629), and 13.7% (n = 229/1668), respectively. Pooled analysis of all the included studies showed NLC of 78.8 cases (95% CI: 71.9-86.3). Studies that used cumulative sum control chart analysis, nonarbitrary methods, and arbitrary-based LC had NLC of 152.0 (95% CI: 135.4-170.1), 108.0 (95% CI: 96.6-120.4), and 49.7 (95% CI: 42.0-58.3) cases, respectively. NLC was 37.0 cases (95% CI: 29.1-46.5) for single surgeon LC, and 99.8 cases (95% CI: 90.2-110.0) for institutional LC. Conclusion: Studies reporting NLC in LCBDE are heterogeneous. Further studies should use nonarbitrary methods of analysis for patient-reported outcome measures and procedure-specific morbidity.
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Affiliation(s)
- Kai Siang Chan
- Department of General Surgery, Tan Tock Seng Hospital, Singapore, Singapore
| | | | - Aung Myint Oo
- Department of General Surgery, Tan Tock Seng Hospital, Singapore, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
| | - Sameer P Junnarkar
- Department of General Surgery, Tan Tock Seng Hospital, Singapore, Singapore
| | - Vishal G Shelat
- Department of General Surgery, Tan Tock Seng Hospital, Singapore, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
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Hodgson R, Heathcock D, Kao CT, Seagar R, Tacey M, Lai JM, Yong TL, Houli N, Bird D. Should Common Bile Duct Exploration for Choledocholithiasis Be a Specialist-Only Procedure? J Laparoendosc Adv Surg Tech A 2021; 31:743-748. [PMID: 33913756 DOI: 10.1089/lap.2021.0156] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Background: Common bile duct exploration (CBDE) is performed uncommonly. Issues surrounding its uptake in the laparoscopic era include perceived difficulty and lack of training. We aim to determine the success of CBDE performed by "specialist" and "nonspecialist" common bile duct (CBD) surgeons to determine whether there is a substantial difference in success and safety. Methods: A 10-year retrospective audit was performed of patients undergoing CBD exploration for choledocholithiasis. Northern Health maintains an on-call available "specialist" CBD surgeon roster to aid with CBDE. Results: Five hundred fifty-one patients were identified, of which 489/551 (88.7%) patients had stones successfully cleared. Specialists had a higher success rate (90.8% versus 82.6%, P = .008), associated with a longer surgical time. Method (transcystic or transductal), approach (laparoscopic or open), and indication for operation were similar between groups. There was no significant difference in complications. To be confident of a surgeon having an 80% success rate, 70 procedures over 10 years were required, however, an "in-control" 50% success rate may only require 1 procedure per year. Conclusion: While specialist CBDE surgeons have improved success rates, nonspecialist general surgeons also have a good and comparable success rate with an equivalent complication rate. With realistic annual targets, nonspecialist CBD surgeons should be encouraged to perform CBDE in centers without specialist support.
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Affiliation(s)
- Russell Hodgson
- Division of Surgery, Northern Health, Epping, Australia
- Department of Surgery, University of Melbourne, Epping, Australia
| | | | - Chien-Tse Kao
- Division of Surgery, Northern Health, Epping, Australia
| | | | - Mark Tacey
- Department of Medicine, Dentistry and Health Sciences, University of Melbourne, Parkville, Australia
| | - Jiun Miin Lai
- Division of Surgery, Northern Health, Epping, Australia
| | | | - Nezor Houli
- Division of Surgery, Northern Health, Epping, Australia
- Department of Surgery, Western Health, Footscray, Australia
| | - David Bird
- Division of Surgery, Northern Health, Epping, Australia
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Quaresima S, Balla A, Guerrieri M, Campagnacci R, Lezoche E, Paganini AM. A 23 year experience with laparoscopic common bile duct exploration. HPB (Oxford) 2017; 19:29-35. [PMID: 27890483 DOI: 10.1016/j.hpb.2016.10.011] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Revised: 10/14/2016] [Accepted: 10/28/2016] [Indexed: 12/12/2022]
Abstract
BACKGROUND Laparoscopic common bile duct exploration (LCBDE) during laparoscopic cholecystectomy (LC) is as effective as two-stage endo-laparoscopic treatment, but with shorter hospital stay, lower cost and recurrent stone rate. Aim of this paper was to report the authors' experience with LCBDE during LC. METHODS A retrospective analysis of patients who underwent LCBDE for ductal stones was performed. Recurrent stones were defined as CBD stones detected beyond 6 months from the procedure. Postoperative biliary stricture was defined as a symptomatic reduction of CBD diameter. RESULTS Out of 3444 patients who underwent LC, 384 (11%) had CBD stones treated by trans-cystic duct exploration [214 (6%) patients, TCD-CBDE] or choledochotomy [170 (5%) patients, C-CBDE]. For TCD-CBDE and C-CBDE, mean operative time was 127 ± 69 and 191 ± 74 min, respectively. Major morbidity rate was 3% (n = 6) in TCD-CBDE and 6% (n = 11) in C-CBDE. The incidence of residual stones was 5% (n = 20) and complete ductal clearance rate was 95% (n = 364). After long-term follow-up (mean 189 ± 105 months) the recurrent stone rate was 2%. DISCUSSION In expert centers, LCBDE during LC is safe and effective with low short and long term morbidity rates.
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Affiliation(s)
- Silvia Quaresima
- Department of General Surgery and Surgical Specialties "Paride Stefanini", Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy.
| | - Andrea Balla
- Department of General Surgery and Surgical Specialties "Paride Stefanini", Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy
| | - Mario Guerrieri
- Department of General Surgery, Università Politecnica delle Marche, Piazza Roma 22, 60121 Ancona, Italy
| | - Roberto Campagnacci
- Department of General Surgery, Università Politecnica delle Marche, Piazza Roma 22, 60121 Ancona, Italy
| | - Emanuele Lezoche
- Department of General Surgery and Surgical Specialties "Paride Stefanini", Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy
| | - Alessandro M Paganini
- Department of General Surgery and Surgical Specialties "Paride Stefanini", Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy
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Vannijvel M, Lesurtel M, Bouckaert W, Houben B, Knol J, Vangertruyden G, Sergeant G. A survey of European-African surgeons' management of common bile duct stones. HPB (Oxford) 2016; 18:959-964. [PMID: 27838253 PMCID: PMC5144544 DOI: 10.1016/j.hpb.2016.10.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2016] [Revised: 09/25/2016] [Accepted: 10/12/2016] [Indexed: 12/12/2022]
Abstract
BACKGROUND Common bile duct (CBD) stones can be managed by either endoscopic retrograde cholangiopancreatography (ERCP) or laparoscopic common bile duct exploration (LCBDE). The aim of this survey was to document the management of CBD stones by European-African HPB Association (E-AHPBA) members. METHODS All 331 members of the E-AHPBA were invited by personal email to participate to an online survey. RESULTS Ninety-three (28%) surgeons replied within 2 months. Responding surgeons were attending surgeons (84%), working as HPB surgeons (75%) in academic hospitals (73%). In patients with clinically suspected CBD stones, MRCP was the preferred diagnostic test for 61% of respondents. LCBDE was the preferred therapeutic strategy for 11 (12%) respondents only. Previous gastric surgery was an absolute contraindication to ERCP for 47% of respondents. Absence of CBD dilation was considered an absolute contraindication for LCBDE in 24% of respondents. Yearly caseload exceeded 10 patients for only 30% of 56 centers performing LCBDE. The transcystic approach was preferred by 39% of surgeons performing LCBDE. There was considerable variation amongst respondents with regard to type and duration of drainage, bile duct closure technique and follow-up after LCBDE. CONCLUSION Indications for single-stage LCBDE are not standardized and do not appear well established across E-AHPBA members.
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Affiliation(s)
- Marie Vannijvel
- Department of Abdominal Surgery, Jessa Ziekenhuis, Hasselt, Belgium
| | - Mickael Lesurtel
- Swiss HPB Center, Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland; Department of General Surgery and Liver Transplantation, Croix-Rousse University Hospital, Hospices Civils de Lyon, University of Lyon I, Lyon, France
| | - Wim Bouckaert
- Department of Abdominal Surgery, Jessa Ziekenhuis, Hasselt, Belgium
| | - Bert Houben
- Department of Abdominal Surgery, Jessa Ziekenhuis, Hasselt, Belgium
| | - Joep Knol
- Department of Abdominal Surgery, Jessa Ziekenhuis, Hasselt, Belgium
| | | | - Gregory Sergeant
- Department of Abdominal Surgery, Jessa Ziekenhuis, Hasselt, Belgium; Faculty of Medicine and Life Sciences, Universiteit Hasselt, Hasselt, Belgium.
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Results of Medium Seventeen Years' Follow-Up after Laparoscopic Choledochotomy for Ductal Stones. Gastroenterol Res Pract 2016; 2016:9506406. [PMID: 26880900 PMCID: PMC4735927 DOI: 10.1155/2016/9506406] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2015] [Revised: 09/14/2015] [Accepted: 09/15/2015] [Indexed: 02/07/2023] Open
Abstract
Introduction. In a previously published article the authors reported the long-term follow-up results in 138 consecutive patients with gallstones and common bile duct (CBD) stones who underwent laparoscopic transverse choledochotomy (TC) with T-tube biliary drainage and laparoscopic cholecystectomy (LC). Aim of this study is to evaluate the results at up to 23 years of follow-up in the same series. Methods. One hundred twenty-one patients are the object of the present study. Patients were evaluated by clinical visit, blood assay, and abdominal ultrasound. Symptomatic patients underwent cholangio-MRI, followed by endoscopic retrograde cholangiopancreatography (ERCP) as required. Results. Out of 121 patients, 61 elderly patients died from unrelated causes. Fourteen patients were lost to follow-up. In the 46 remaining patients, ductal stone recurrence occurred in one case (2,1%) successfully managed by ERCP with endoscopic sphincterotomy. At a mean follow-up of 17.1 years no other patients showed signs of bile stasis and no patient showed any imaging evidence of CBD stricture at the site of choledochotomy. Conclusions. Laparoscopic transverse choledochotomy with routine T-tube biliary drainage during LC has proven to be safe and effective at up to 23 years of follow-up, with no evidence of CBD stricture when the procedure is performed with a correct technique.
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Chan DSY, Jain PA, Khalifa A, Hughes R, Baker AL. Laparoscopic common bile duct exploration. Br J Surg 2014; 101:1448-52. [PMID: 25123479 DOI: 10.1002/bjs.9604] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2014] [Revised: 04/28/2014] [Accepted: 06/06/2014] [Indexed: 01/19/2023]
Abstract
BACKGROUND Laparoscopic common bile duct exploration (LCBDE) is a safe and effective single-stage treatment for choledocholithiasis in the elective setting. The outcomes after LCBDE in the emergency setting are unknown. The aim of this study was to compare the outcomes following elective and emergency LCBDE for choledocholithiasis. METHODS Details of all patients who underwent LCBDE for choledocholithiasis between August 2003 and August 2013 were analysed retrospectively. The primary outcome measure was common bile duct (CBD) stone clearance rate. Secondary outcome measures were conversion rate, morbidity, mortality and length of hospital stay. RESULTS Some 215 consecutive patients (57 male; median age 65 (range 14-92) years) underwent LCBDE. Some 121 procedures were performed electively and 94 as an emergency. Forty-five patients (48 per cent) presented with obstructive jaundice or cholangitis in the emergency LCBDE group compared with 15 (12·4 per cent) in the elective group (P < 0·001). The CBD stone clearance rate was similarly high in both groups (96 versus 96·7 per cent respectively; P = 0·557). There were no significant differences in conversion rate (6 versus 4·1 per cent), morbidity (5 versus 6·6 per cent), mortality (2 versus 0 per cent) or median length of stay (3 days) between groups. Two patients died, both following emergency LCBDE. CONCLUSION LCBDE can be performed safely and effectively in both elective and emergency settings.
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Affiliation(s)
- D S Y Chan
- Department of Surgery, Wrexham Maelor Hospital, Wrexham, LL13 7TD, UK
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Herrero A, Philippe C, Guillon F, Millat B, Borie F. Does the surgeon’s experience influence the outcome of laparoscopic treatment of common bile duct stones? Surg Endosc 2012; 27:176-80. [DOI: 10.1007/s00464-012-2416-z] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2012] [Accepted: 05/18/2012] [Indexed: 12/21/2022]
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Pekolj J. [Laparoscopic treatment of common bile duct calculi. Is there still controversy?]. Cir Esp 2012; 90:144-6. [PMID: 22230749 DOI: 10.1016/j.ciresp.2011.12.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2011] [Revised: 12/07/2011] [Indexed: 11/27/2022]
Affiliation(s)
- Juan Pekolj
- Servicio de Cirugía General, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
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Abstract
BACKGROUND To meet Australia's future demands, surgical training in the private sector will be required. The aim of this study was to estimate the time and lost opportunity cost of training in the private sector. METHODS A literature search identified studies that compared the operation time required by a supervised trainee with a consultant. This time was costed using a business model. RESULTS In 22 studies (34 operations), the median operation duration of a supervised trainee was 34% longer than the consultant. To complete a private training list in the same time as a consultant list, one major case would have to be dropped. A consultant's average lost opportunity cost was $1186 per list ($106,698 per year). Training in rooms and administration requirements increased this to $155,618 per year. To train 400 trainees in the private sector to college standards would require 54,000 training lists per year. The consultants' national lost opportunity cost would be $137 million per year. The average lost hospital case payment was $5894 per list, or $330 million per year nationally. The total lost opportunity cost of surgical training in the private sector would be about $467 million per year. When trainee salaries, other specialties and indirect expenses are included, the total cost will be substantially greater. CONCLUSION It is unlikely that surgeons or hospitals will be prepared to absorb these costs. There needs to be a public debate about the funding implications of surgical training in the private sector.
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Affiliation(s)
- R James Aitken
- Hollywood Medical Centre, Nedlands, Western Australia, Australia.
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