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Original Investigation | Pacific Coast Surgical Association

Nationwide Assessment of Trends in Choledocholithiasis Management in the United States From 1998 to 2013 ONLINE FIRST

Michael W. Wandling, MD, MS1,2,3,4; Eric S. Hungness, MD1; Emily S. Pavey, MA1,2; Jonah J. Stulberg, MD, PhD, MPH1,2,3; Ben Schwab, MD1; Anthony D. Yang, MD1,2,3; Michael B. Shapiro, MD1; Karl Y. Bilimoria, MD, MS1,2,3,4; Clifford Y. Ko, MD, MS, MSHS4,5,6; Avery B. Nathens, MD, PhD7
[+] Author Affiliations
1Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
2Surgical Outcomes and Quality Improvement Center, Northwestern University Feinberg School of Medicine, Chicago, Illinois
3Center for Healthcare Studies, Northwestern University Feinberg School of Medicine, Chicago, Illinois
4Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, Illinois
5Department of Surgery, University of California, Los Angeles
6Department of Surgery, VA Greater Los Angeles Healthcare System, Los Angeles, California
7Department of Surgery, Sunnybrook Health Sciences Centre, the University of Toronto, Toronto, Ontario, Canada
JAMA Surg. Published online August 24, 2016. doi:10.1001/jamasurg.2016.2059
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Importance  There are currently 2 widely accepted treatment strategies for patients presenting to the hospital with choledocholithiasis. However, the rate of use for each strategy in the United States has not been evaluated, and their trends over time have not been described. Furthermore, an optimal management strategy for choledocholithiasis has yet to be defined.

Objective  To evaluate secular trends in the management of choledocholithiasis in the United States and to compare hospital length of stay between patients with choledocholithiasis treated with endoscopic retrograde cholangiopancreatography with laparoscopic cholecystectomy (ERCP+LC) vs laparoscopic common bile duct exploration with laparoscopic cholecystectomy (LCBDE+LC).

Design, Setting, and Participants  In this cohort study, we studied patients with a primary diagnosis of choledocholithiasis that were included in the National Inpatient Sample between 1998 and 2013 from a representative sample of acute care hospitals in the United States. Patients with cholangitis or pancreatitis were excluded.

Main Outcomes and Measures  Unadjusted and risk-adjusted median hospital length of stay.

Results  Of the 37 207 patients included in our analysis, 36 048 (96.9%) were treated with ERCP+LC and 1159 (3.1%) were treated with LCBDE+LC. The mean (SD) age of patients treated with ERCP+LC was 50.7 (21.1) years and was 51.9 (20.9) years for those treated with LCBDE+LC; 25 788 (69.3%) were female. Analysis of the National Inpatient Sample data indicates that there are an average of 26 158 patients with choledocholithiasis admitted in the United States each year. The overall use of CBDE for patients with choledocholithiasis decreased from 39.8% of admissions in 1998 to 8.5% in 2013 (P < .001). A decrease was also seen for open CBDE (30.6% vs 5.5%; P < .001) and laparoscopic CBDE (9.2% vs 3.0%; P < .001) independently. Rates of management with LCBDE+LC decreased from 5.3% to 1.5% (P < .001), while rates of ERCP+LC increased from 52.8% to 85.7% (P < .001). The unadjusted median hospital length of stay was shorter for patients treated with LCBDE+LC than for those treated with ERCP+LC (3.0 vs 4.0 days; P < .001). After risk-adjustment, the median length of stay remained 0.5 days shorter for patients treated with LCBDE+LC than with ERCP+LC (3.5 vs 4.0 days; P < .001).

Conclusions and Relevance  This study highlights the marked decline in the use of both open and laparoscopic CBDE in the United States as well as the benefit to the length of stay LCBDE+LC has over ERCP+LC. Despite a persistent need for CBDE and the potential benefits of LCBDE+LC over ERCP+LC for managing choledocholithiasis, if current trends continue, CBDE may be at risk of disappearing from the surgical armamentarium.

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Figure 1.
CONSORT Diagram for Study Sample

CBDE indicates common bile duct exploration; ERCP, endoscopic retrograde cholangiopancreatography; LC, laparoscopic cholecystectomy.

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Figure 2.
National Trends in Common Bile Duct Exploration for Choledocholithiasis From 1998 to 2013

Annual national estimates of the number of hospitalizations for choledocholithiasis were calculated from 1998 to 2013 using NIS discharge weights and SAS survey sampling and analysis procedures. All trends were assessed using logistic regression and were significant at P < .001. CBDE indicates common bile duct exploration.

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