Cholecystectomy Outcomes in the Veterans Affairs Surgical Quality Improvement Program (2006-2017).

Background: Cholecystectomy trends and outcomes have been reported extensively in the private sector. Despite being one of the most common procedures performed in the United States, there is a paucity of reports on the trends and outcomes of laparoscopic and open cholecystectomy in the veteran population. Materials and Methods: Veterans who underwent laparoscopic or open cholecystectomy from 2006 to 2017 were identified using current procedural terminology codes from the Veterans Affairs Surgical Quality Improvement Program (VASQIP) database. Multivariable analyses were used to compare laparoscopic and open outcomes. The primary outcome was mortality, and secondary outcomes were postoperative complications and length of stay (LOS). Results: In the VASQIP database, 53,901 patients underwent laparoscopic cholecystectomy and 8011 patients underwent open cholecystectomy during the study period. The laparoscopic approach increased from 82.0% (2006-2008) to 91.9% (2015-2017). Postoperatively, the open group had a significantly higher morbidity rate (15.4% versus 3.8%, P < .001). The 30-day mortality rate and mean LOS were also significantly higher in the open cholecystectomy group (P < .001). Earlier year of operation, diabetes diagnosis, and open approach significantly increased the likelihood of postoperative morbidity (P < .05). Conclusions: Similar to the private sector, minimally invasive cholecystectomy in the Veterans Health Administration (VHA) has increased over the last two decades. Diabetes was present in a significant percentage of the veteran population and was a predictor of all postoperative complications. Finally, the clinical outcomes in the VHA are comparable with those documented in the private sector.

National trends and outcomes of inpatient robotic-assisted versus laparoscopic cholecystectomy.

BACKGROUND: Laparoscopic cholecystectomy has reached nearly universal adoption in the management of gallstone-related disease. With advances in operative technology, robotic-assisted cholecystectomy has been used increasingly in many practices, but few studies have examined the adoption of robotic assistance for inpatient cholecystectomy and the temporal outcomes on a national scale. The present study aimed to identify trends in utilization, as well as outcomes and factors associated with the use of robotic-assisted cholecystectomy. METHODS: The 2008 to 2017 database of the National Inpatient Sample was used to identify patients undergoing inpatient cholecystectomy. Independent predictors of the use of robotic assistance for cholecystectomy were identified using multivariable logistic regression adjusting for patient and hospital characteristics. RESULTS: Of an estimated 3,193,697 patients undergoing cholecystectomy, 98.7% underwent laparoscopic cholecystectomy and 1.3% robotic-assisted cholecystectomy. Rates of robotic-assisted cholecystectomy increased from 0.02% in 2008 to 3.2% in 2017 (nptrend < .001). Compared with laparoscopic cholecystectomy, patients undergoing robotic-assisted cholecystectomy had a greater burden of comorbidities as measured by the Elixhauser index (2.2 vs 1.9, P < .001). Although mortality rates were similar, robotic-assisted cholecystectomy was associated with greater complication rates (15.5% vs 11.7%, P < .001), most notably gastrointestinal-related complications (3.7% vs 1.5%, P < .001). On multivariable regression, robotic-assisted cholecystectomy was associated with increased costs of hospitalization (ß: $2,398, P < .001). CONCLUSION: Using the largest national database available, we found a dramatic increase in the use of robotic-assisted cholecystectomy with no difference in mortality or duration of hospital stay, but there was a statistically significant increase in complications and costs. These findings warrant further investigation.

Neuromuscular blockade reversal with sugammadex versus pyridostigmine/glycopyrrolate in laparoscopic cholecystectomy: a randomized trial of effects on postoperative gastrointestinal motility.

BACKGROUND: Acetylcholinesterase inhibitors (e.g., pyridostigmine bromide) are used for neuromuscular blockade (NMB) reversal in patients undergoing surgery under general anesthesia (GA). Concurrent use of anticholinergic agents (e.g., glycopyrrolate) decreases cholinergic side effects but can impede bowel movements. Sugammadex has no cholinergic effects; its use modifies recovery of gastrointestinal (GI) motility following laparoscopic cholecystectomy compared to pyridostigmine/glycopyrrolate. This study evaluated the contribution of sugammadex to the recovery of GI motility compared with pyridostigmine and glycopyrrolate. METHODS: We conducted a prospective study of patients who underwent laparoscopic cholecystectomy. Patients were randomly allocated to the experimental group (sugammadex, Group S) or control group (pyridostigmine-glycopyrrolate, Group P). After anesthesia (propofol and rocuronium, and 2% sevoflurane), recovery was induced by injection of sugammadex or a pyridostigmine-glycopyrrolate mixture. As a primary outcome, patients recorded the time of their first passage of flatus ('gas-out time') and defecation. The secondary outcome was stool types. RESULTS: One-hundred and two patients participated (Group S, 49; Group P, 53). Mean time from injection of NMB reversal agents to gas-out time was 15.03 (6.36-20.25) h in Group S and 20.85 (16.34-25.86) h in Group P (P = 0.001). Inter-group differences were significant. Time until the first defecation as well as types of stools was not significantly different. CONCLUSIONS: Sugammadex after laparoscopic cholecystectomy under GA resulted in an earlier first postoperative passage of flatus compared with the use of a mixture of pyridostigmine and glycopyrrolate. These findings suggest that the use of sugammadex has positive effects on the recovery of GI motility.

Nationwide trends in the use of subtotal cholecystectomy for acute cholecystitis.

BACKGROUND: Subtotal cholecystectomy is a viable alternative approach to the proverbial "difficult" gallbladder. To date, only a few studies have observed the establishment of those bail-out procedures as an increasingly common surgical practice. The purpose of this study is to assess nationwide trends of subtotal cholecystectomy through evaluation of operative variables and patient- and institution-level characteristics in procedure preference. METHODS: Data were obtained from the National Inpatient Sample for the years between 2003 and 2014. Patients with acute cholecystitis were categorized based on the ninth revision International Classification of Disease Clinical Modification procedure codes for open total, laparoscopic total, open subtotal, or laparoscopic subtotal cholecystectomy. Any patient younger than 18 years of age or with a preoperative stay >1 week was excluded. Logistic regression analysis was performed to evaluate significant patient- and institution-level characteristics associated with the performance of subtotal cholecystectomy. RESULTS: A total of 290,855 patients were evaluated. During the study period, the rate of open and laparoscopic subtotal cholecystectomy sharply increased (0.10% of all cholecystectomy procedures to 0.52% and 0.12% to 0.28%, respectively). The conversion rate from laparoscopic to open total cholecystectomy decreased from 10.5% to 7.6%. Subtotal cholecystectomies were performed at significantly higher rates in men (odds ratio: 1.95, P < .001), Asian Americans (odds ratio: 2.21, P = .037), and patients with alcohol abuse (odds ratio: 2.23, P < .001). Teaching hospitals (odds ratio: 2.41, P < .001) and those in rural areas (odds ratio: 2.26, P < .001) were more likely to perform subtotal cholecystectomies. CONCLUSION: Growing trends in the use of subtotal cholecystectomy suggest evolving surgical practices for acute cholecystitis. Our data suggests that several patient- and hospital-level characteristics might play a deciding role in procedure preference.

Changing trends in surgical management for acute cholecystitis, in light of Tokyo guidelines - 14 year experience.

OBJECTIVE: To look for trends in surgical management of acute cholecystitis and compare the outcomes of patients with severe condition. METHODS: The retrospective study was conducted at Aga Khan University Hospital, Karachi, from January to December 2016, and comprised data of adult patients who underwent cholecystectomy for acute cholecystitis from January 1, 2001, to December 31, 2014. Record of patients from 2001 to 2007 was designated in Group-1 while Group-II covered period between 2008 and 2014. Severe cases of acute cholecystitis were divided into similar period-based Group-A and Group-B. Data was analysed using SPSS 20. RESULTS: Of the 1153 patients, 521(45.2%) were males. The overall mean age was 49.3+14 years. There were 309(36.2%) patents in Group-I and 844(73.2%) in Group-II. Early laparoscopic-cholecystectomy was performed in 907(78%) patients. Postoperative morbidity was observed in 73(6.3%) patients. In Group-II, there was significant increase in early cholecystectomy, decrease in conversion rates and use of percutaneous cholecystostomy tube placement (p<0.05 each). In patients with severe acute cholecystitis, higher rate of early cholecystectomy was found in Group-A but it was not significant, and the same was the case in terms of conversion rate, postoperative morbidity and hospital stay (p>0.05 each). CONCLUSIONS: Over the years, the institutional experience of managing acute cholecystitis has changed dramatically which has helped improve the level of care for the patients.

Preemptive oxycodone is superior to equal dose of sufentanil to reduce visceral pain and inflammatory markers after surgery: a randomized controlled trail.

BACKGROUND: Postoperative visceral pain is common after surgery and previous studies have demonstrated that oxycodone is an effective treatment. In this study, we compared the effects of preemptive oxycodone to equal dose of sufentanil on postoperative pain and serum level of inflammatory factors (TNF-α, IL-6, IL-10) after laparoscopic cholecystectomy. METHODS: Forty patients undergoing laparoscopic cholecystectomy were randomized into preemptive oxycodone group or preemptive sufentanil group. Patients were given either oxycodone 0.1 mg/kg (oxycodone group, n = 20) or sufentanil 0.1 µg/kg (sufentanil group, n = 20) for preemptive analgesia. We evaluated pain/sedation scores at 0 h, 0.5 h, 2 h, 4 h, 6 h, 8 h and 24 h after surgery and measured serum concentrations of TNF-α, IL-6 and IL-10 before surgery and at 0 h, 6 h and 24 h after surgery. RESULTS: Twenty patients were recruited in each group. Numerical rating scale (NRS) of visceral pain in the oxycodone group at 2 h when resting (0.5(0,2.75) vs 3(2,4), P = 0.008) and moving (0.5(0,3) vs 3(2.25,4), P = 0.015) and 4 h when moving (2(0,3) vs 3(0,4.75), P = 0.043) after surgery were significantly lower than the sufentanil group. Serum concentrations of TNF-α at 6 h (38.68 ± 10.49 vs 73.02 ± 16.27, P<0.001) and 24 h (43.12 ± 8.40 vs 74.00 ± 21.30, P<0.001) in the oxycodone group were lower than the sufentanil group. CONCLUSIONS: Preemptive oxycodone 0.1 mg/kg administration could effectively suppress visceral pain at 2 h and 4 h after surgery and had lower inflammatory marker, serum TNF-α, level when compared to equal dose of sufentanil. TRIAL REGISTRATION: Clinical trials registration number: ChiCTR-IOR-17013738 http://www.chictr.org.cn/showproj.aspx?proj=17346 . Date of registration: 6th December 2017.

Selective Trans-Catheter Coil Embolization of Cystic Duct Stump in Post-Cholecystectomy Bile Leak.

BACKGROUND: Percutaneous drainage is a first-line treatment for bilomas developed post-cholecystectomy in the setting of bile leak from the cystic duct stump. Percutaneous drainage is usually followed by surgical or endoscopic treatment to address the leak. AIMS: This study aimed to evaluate outcome of selective coil embolization of the cystic duct stump via the percutaneously placed drainage catheters in patients with post-cholecystectomy bile leak. METHODS: Seven patients with persistent bile leak after laparoscopic cholecystectomy who underwent percutaneous catheter placement for biloma/abscess formation in the region of the gallbladder fossa were followed. These patients underwent selective trans-catheter cystic duct stump coil embolization from Feb 2013 to Feb 2019. Procedural management, complications, and success rates were analyzed. RESULTS: All patients underwent placement of a percutaneous catheter for drainage of biloma formation in the gallbladder fossa post-cholecystectomy. Selective coil embolization of the cystic duct was performed through the existing percutaneous tract on average 3.5 weeks after percutaneous catheter placement, resulting in resolution of the biloma. All bile leaks were immediately closed. None of the patients showed recurrent bile leak or further clinical symptoms. Coil migration to the common bile duct was diagnosed in a single case, after 2.5 years, with no bile leak reported. CONCLUSIONS: Selective trans-catheter coil embolization of the cystic stump is a feasible and safe procedure, which successfully seals leaking cystic duct stumps and can circumvent the need for repeat surgical or endoscopic intervention in selected patient populations.

Gallbladder Disease in Children: A 20-year Single-center Experience.

OBJECTIVE: Aim of this study was to examine the changes in incidence of pediatric cholecystectomies. METHODS: Based on a review of hospital-records, children were divided into two groups regarding year of surgery (Group I: 1998-2007; Group II: 2008-2017) and their characteristics were compared. RESULTS: Number of cholecystecomies increased from 11 to 34. Median age increased from 11 to 15.5 years and mean BMI increased from 19.2 cm/m2 to 23.0 cm/m2. Hereditary spherocytosis decreased from 63.6% to 11.8% (P=0.001) of indications for cholecystectomy, while proportion of cholesterol stones increased from 27.3% to 70.6% (P=0.006). Frequency of laparoscopic cholecystectomy increased from 36.4% to 85.3% (P=0.001). Duration of hospital stay shortened from 8 to 4 days (P=0.008). CONCLUSIONS: Number of pediatric cholecystectomies has significantly increased in the last 20 years, as well as average BMI of the observed population This probably signifies a correlation between rising obesity rates and increase in frequency of symptomatic cholelithiasis in children.

Needleless Transcutaneous Neuromodulation Accelerates Postoperative Recovery Mediated via Autonomic and Immuno-Cytokine Mechanisms in Patients With Cholecystolithiasis.

BACKGROUND: Postsurgical gastrointestinal disturbance is clinically characterized by the delayed passage of flatus and stool, delayed resumption of oral feeding, dyspepsia symptoms, and postsurgical pain. This study was designed 1) to evaluate the effects of needleless transcutaneous neuromodulation (TN) on postoperative recovery; 2) to investigate mechanisms of the TN involving autonomic functions in postoperative patients after removal of the gallbladder. METHODS: Sixty patients scheduled for laparoscopic cholecystectomy (LC) were randomized to TN (n = 30) and sham-TN (n = 30). TN was performed via acupoints ST36 and PC6 for 30 min twice daily from 24 hours before surgery to 72 hours after surgery. Sham-TN was performed using the same parameters at nonacupoints. RESULTS: 1) Compared to sham-TN, TN shortened time to first flatulence (38.9 ± 4.0 vs. 24.9 ± 2.4 hour, p = 0.004) and time to defecation (63.1 ± 4.5 vs. 42.5 ± 3.1 hour, p < 0.001). 2) Compared to sham-TN, TN increased the percentage of normal pace-making activity (66.2 ± 2.2 vs. 73.8 ± 2.3%, p = 0.018). 3) TN enhanced vagal activity. Compared to that 24 hours before surgery, surgery decreased vagal activity (HF) (0.41 ± 0.02 vs. 0.34 ± 0.02, p = 0.043) 3 hours after the operation. Compared to sham-TN, TN increased HF (0.45 ± 0.02 vs. 0.52 ± 0.02, p = 0.045) 72 hours after the operation. Further, HF was negatively correlated with time to defecation and serum norepinephrine. 4) Surgery increased serum IL-6 (1.1 ± 0.1 before surgery vs. 2.9 ± 0.7 pg/mL, p = 0.041) 72 hours after the operation, which was reduced to baseline by TN (0.9 ± 0.1). CONCLUSIONS: In conclusion, the proposed needleless TN accelerates postoperative recovery after LC, possibly mediated via the autonomic and immune-cytokine mechanisms. Needleless and self-administrable TN may be an easy-to-implement and low-cost complementary therapy for postoperative recovery.

Colecistectomía: resultados de una década de experiencia / Cholecystectomy: results. a decade of experience

Introducción: La colecistectomía, sea a través de una incisión subcostal o videolaparoscópica es la intervención quirúrgica por excelencia para remover la vesícula biliar. El objetivo del estudio es presentar la experiencia acumulada en este tipo de cirugía a través de diez años, sus indicaciones, sus modalidades quirúrgicas, la relación con otras patologías así como las complicaciones de las técnicas empleadas. Metodología: Se incluyen todos los casos quirúrgicos de pacientes con enfermedad de la vesícula y vías biliares ingresados del 01 de enero del 2006 al 31 de diciembre del 2016 en el Departamento de Cirugía del Hospital San Vicente. Resultados: Del 2006 al 2016 se intervinieron 985 pacientes de los cuales, 888 (90.15%) corresponden al sexo femenino. La edad promedio fue de 41 años para ambos sexos, no mostrando diferencias 40.78 vs. 40.95. La colecistitis crónica fue la indicación pre operatoria en el 98.7% y su relación con hernia umbilical fue del 2.23%. La técnica quirúrgica abierta se realizó en 702 (70.27%) y la vía laparoscópica en 260 (26.40%). La tasa global de complicaciones fue del 2.33% (23 / 985 pacientes) siendo el sangrado el más observado en 12 pacientes (1.21%) y la lesión de la vía biliar en 5 (0.50%). Conclusiones: La afección de la vesícula sigue afectando principalmente al sexo femenino, su resolución es esencialmente quirúrgica y en la actualidad la colecistectomía video laparoscópica se considera la cirugía por excelencia, sin que ésta anule la vía abierta por múltiples factores. Es un procedimiento de baja morbilidad y en nuestra serie no se acompañó de mortalidad.

Background: Cholecystectomy, performed with open incision or laparoscopically, by excellence it is the surgery to remove the pathological gallbladder. The aim of this study is to present the experience gained in this type of surgery within ten years, showing indicatons, surgical modalites, and the relaton with other pathologies as well as complicatons of the techniques employed. Methods: All surgical cases of patents with diseased gallbladder and bile ducts are admited from January 01, 2006 to December 31, 2016 in the Department of Surgery of San Vicente Hospital. Results: 985 patents were included, 888 (90.15%) are female. Average age was 41 years old for both sexes, showing no diferences 40.78 vs. 40.95. Chronic Cholecystts was the main preoperatve diagnosis in 98.7%, and its relaton with an umbilical hernia was 2.23%. The open technique was performed on 702 patents (70.27%) and laparoscopic approach on 260 patents (26.40%). The overall complicaton rate was 2.33%. Hemorrhage was the most common in 12 patents (1.21%), and bile duct injury in 5 patents (0.50%). Conclusion: Gallbladder disease is stll more common in women. Treatment is essentally surgical and currently laparoscopic cholecystectomy is considered the standard of care. Cholecystectomy has a low incidence of morbidity and in this study there was no mortality

Cholecystectomy in Emilia-Romagna region (Italy): A retrospective cohort study based on a large administrative database.

BACKGROUND: The aim of this study was to ascertain the variability and to identify a trend for the outcome of cholecystectomy surgery when used to treat cholelithiasis and acute cholecystitis. METHODS: This was a large retrospective cohort study following patients up to 11 years post surgery, based on administrative data collected from 2002 to 2012 in the Emilia-Romagna Region (Northern Italy) and comparing the effectiveness and efficiency of surgical activity (laparoscopic (LC) and open cholecystectomy (OC)). Analyses included patient characteristics, length of hospital stay, type of admission and mortality risk. Outcomes considered were death from all causes (during the index hospital admission or thereafter), hospital readmissions with cholecystitis or cholelithiasis as principal diagnosis and time to surgery. RESULTS: A total of 84,628 cholecystomies were performed from 2002 to 2012 out of 123,061 admissions with primary diagnostic category of cholecystitis or cholelitiasis. Laparoscopic procedure was used in 69,842 patients. Over time there was a rising linear statistically significant trend in the use of LC. Mortality rate at 1 year of OC treated patients showed a statistically significant difference compared to LC treated patients (using a cohorts match with propensity score). Only a small number of patients with acute cholecystitis was operated according guidelines within 72 hours. CONCLUSIONS: The analysis of aggregate administrative data is a powerful tool to support regional health management, improve the quality of medical care, and assess the appropriateness of therapeutic or diagnostic approaches. It is important to stress a short hospital stay for laparoscopic cholecystectomy patients (50% less than open surgery): this shorter hospital stay leads to a significant economic advantage. Moreover, mortality is significantly higher in open surgery for acute cholecystitis. Interestingly, the same finding was confirmed after 30 days and 1 year, probably due to comorbidities that are more evident in open surgery. KEY WORDS: Cholecystitis, Cholelithiasis, Delivery of health care, Disease management, Surgical.

Pulse photoplethysmographic amplitude and heart rate variability during laparoscopic cholecystectomy: A prospective observational study.

BACKGROUND: Surgical stress affects the autonomic nervous system by increasing sympathetic outflow. One method of monitoring sympathetic activity is pulse photoplethysmographic analysis. From this two indices can be derived - autonomic nervous system state (ANSS) and ANSS index (ANSSi). It has recently been claimed that these indices can be used to measure sympathetic activity in anaesthetised patients, but their validity has not yet been demonstrated. OBJECTIVE: To measure changes in pulse photoplethysmographic indices and determine any agreement with autonomic nervous system modulation of the cardiovascular system in healthy study participants during surgery under general anaesthesia. DESIGN: Prospective observational study. SETTING: Single-centre study based at a tertiary care centre in Milan, Italy. PATIENTS: Healthy patients undergoing general anaesthesia for elective laparoscopic cholecystectomy. INTERVENTIONS: ANSS, ANSSi, and heart rate variability (HRV) were analysed at three main times: baseline, after induction of general anaesthesia, and after pneumoperitoneum insufflation. MAIN OUTCOME MEASURES: The magnitude of changes in photoplethysmographic and HRV indices was measured. The agreement between pulse photoplethysmographic and HRV-derived indices was assessed by Bland-Altman plots. RESULTS: In total, 52 patients were enrolled and their data analysed. Both pulse photoplethysmographic and HRV indices changed during the study phases. An agreement was found between ANSSi and low frequency spectral components of HRV [bias 10.2nu, 95% confidence interval (CI) -13 to 33.4], high frequency spectral components of HRV (bias 6.1 nu, 95% CI -16.3 to 28.6), and low frequency/high frequency ratio (bias 16.1nu, 95% CI -1.4 to 33.5). The agreement was weaker between ANSSI and HRV indices. CONCLUSION: The study endorses the use of pulse photoplethysmographic indices ANSS and ANSSi as surrogates to estimate changes of autonomic modulation of the cardiovascular system in healthy adults during surgery under general anaesthesia.Orcid ID: orcid.org/0000-0002-9616-803X.

A survey of European-African surgeons' management of common bile duct stones.

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.

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

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.

Who Will Be Able to Perform Open Biliary Surgery in 2025?

BACKGROUND: Although laparoscopic cholecystectomy (LC) is the gold standard, some patients still require an open cholecystectomy (OC). This study evaluates the mean number of OCs performed by each graduating general surgery resident during each of 3 decades. STUDY DESIGN: Data were obtained from all patients undergoing a cholecystectomy during 3 decades: prelaparoscopic era (1981 to 1990), first decade of LC (1991 to 2001), and recent decade of LC (2004 to 2013). Data were prospectively collected and retrospectively reviewed and analyzed by chi-square or Fisher's exact test. RESULTS: Compared with the prelaparoscopic decade, the number of patients undergoing an OC decreased considerably, by 67%, during the first decade of LC, and by 92% during the most recent decade at the 2 core teaching hospitals. Mean number of OCs performed per graduating chief general surgery resident decreased significantly for both laparoscopic decades compared with the prelaparoscopic decade (70.4, 22.4, and 3.6, respectively). In the last decade at the core institutions, 683 (8.8%) patients also underwent an intraoperative cholangiogram (IOC) and 36 (0.5%) underwent common bile duct exploration (CBDE). When biliary cases done at affiliated institutions during the last decade were included, the mean number of OCs (from 3.6 to 10.2), IOCs (from 683 to 2,098), and CBDEs (from 36 to 116) all increased (p < 0.001) per graduating chief general surgery resident. CONCLUSIONS: There has been a considerable decline in the number of OCs, IOCs, and CBDEs available to our trainees during the past 30 years. New training paradigms should include renewed focus on performing an IOC and/or CBDE as clinically indicated during LC; high-quality simulation programs for OC, IOC, and CBDE; and the availability of an advanced video library depicting complicated open biliary procedures.