NEW ORLEANS — Over the past decade, there has been a sixfold decline in open common bile duct explorations, said Edward Livingston, M.D., FACS, at the annual clinical congress of the American College of Surgeons.
This decrease may signal a loss of skill and experience in doing all open procedures, said Dr. Livingston. After learning that one of his residents had never performed an open procedure, Dr. Livingston investigated common bile duct explorations (CBDEs) to see whether the resident's situation was unusual.
Bile duct exploration typically is performed when there's a suspected blockage or obstruction. It requires general anesthesia, the injection of contrast dye and use of x-ray to highlight obstructions, and a 1- to 4-day hospital stay. Increasingly, however, patients with gallstones or other suspected blockages are undergoing endoscopic retrograde cholangiopancreatography (ERCP), a less invasive procedure that also allows imaging of stones.
Dr. Livingston, chair of the gastrointestinal and endocrine surgery division at the University of Texas, Dallas, wanted to see whether ERCP was supplanting CBDE and whether healthier patients were being referred to the endoscopic procedure while sicker patients were undergoing the open procedure. Using the federal government's National Hospital Discharge Summary, he flagged procedures performed in the biliary tract from 1979 to 2001, the most recent year for which information was available.
There were 47,000 CBDEs in 1979, but by 2001, only 7,700 were performed. The number of ERCPs rose steeply in 1989, when a billing code was added, and continued to increase throughout the 1990s, Dr. Livingston said.
He found that as the number of open explorations declined, complication rates increased. Most occurred in the operating room and usually involved technical errors by the surgeon, such as accidental lacerations, he said.
“There are probably too few common bile duct explorations now to [ensure] adequate training and experience,” said Dr. Livingston, adding that CBDEs should perhaps be done only by more experienced surgeons.
“As bad as these results are for CBDE now, the worse may be yet to come,” said Keith Lillimoe, M.D., FACS. He said the trends seen with CBDEs could be viewed as a harbinger for all surgeries. “Imagine what it will be like in 10 years, when few residents are trained in open procedures,” said Dr. Lillimoe, chair of the department of surgery at Indiana University.
Citing data from the American Council of Graduate Medical Education, Dr. Lillimoe said that in 1989–1990, chief surgical residents performed an average of 57 open cholecystectomies. In 2002–2003, that number dropped to 12.8. Chief residents performed 9.8 open CBDEs on average in 1989–1990 and only 3 by 2002–2003.
Dr. Lillimoe also said he's concerned that a growing number of patients may become ineligible for ERCP—in particular, those who have had the Roux-en-Y gastric bypass.