Missed opportunities for laparoscopic common bile duct exploration (LCBDE): we can do better

Laparoscopic common bile duct exploration (LCBDE) is a safe and effective alternative to endoscopic retrograde cholangiopancreatography (ERCP) plus laparoscopic cholecystectomy (LC), but with a shorter length of stay (LOS). Nevertheless, LCBDE remains highly underutilized. Since 2021, our institution has conducted simulation-based LCBDE training for surgeons and residents. We sought to determine our current LCBDE utilization rate and potential utilization rate by identifying "missed opportunities" for LCBDE.

We reviewed LCBDE or ERCP plus LC cases from 2023 to 2024 at a single institution. We excluded LC for hepatobiliary cancer and ERCP for non-gallstone disease. Contraindications to LCBDE were severe cholangitis, severe pancreatitis, malignancy concern, or significant comorbidities. We defined "missed opportunities" as cases eligible for LCBDE wherein ERCP was chosen instead. Median LOS (days) was compared between groups.

A total of 87 patients underwent LC plus LCBDE or ERCP. LCBDE was performed in 38% (n = 33, LOS = 2). ERCP with appropriate justification was performed in 25% (n = 22, LOS = 4.5) due to severe acute cholangitis (15%, n = 13), concern for malignancy (6%, n = 5), surgeon judgment (3%, n = 3), severe pancreatitis (1%, n = 1), severe comorbidities (1%, n = 1), patient preference (1%, n = 1), and diagnostic uncertainty (2%, n = 2). "Missed opportunities" represented the remaining 37% (n = 32, LOS = 3) due to: surgeon consulted after ERCP (18%, n = 16), patient transferred for ERCP only (5%, n = 4), surgeon not LCBDE trained (2%, n = 2), unavailable operating room (1%, n = 1), and unclear reasons (10%, n = 9).

Our potential LCBDE utilization rate was 75%. Most ERCP cases represented "missed opportunities" for LCBDE despite our robust LCBDE adoption. "Missed opportunities" had a significantly longer median LOS than LCBDE (3 vs. 2 days, p = 0.048). Efforts to optimize LCBDE utilization could significantly reduce LOS. The highest yield quality improvement opportunity may be to optimize ERCP/LC referral patterns. The 10% of unclear "missed opportunities" cases require additional investigation.