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Is Routine Intraoperative Cholangiogram Necessary in the Twenty-First Century? A National View

  • 2012 SSAT Plenary Presentation
  • Published:
Journal of Gastrointestinal Surgery Aims and scope

Abstract

Introduction

Intraoperative cholangiogram (IOC) can define biliary ductal anatomy. Routine IOC has been proposed previously. However, current surgeon IOC utilization practice patterns and outcomes are unclear.

Methods

Nationwide Inpatient Sample 2004–2009 was queried for patients with acute biliary disease undergoing cholecystectomy (CCY). Analyses only included surgeons performing ≥10 CCY/year. We dichotomized surgeons into a routine IOC group vs. selective. Outcomes included bile duct injury, complications, mortality, length of stay, and cost.

Results

Of the nonweighted patients, 111,815 underwent CCY. A total of 4,740 actual surgeon yearly volumes were examined. On average, each surgeon performed 23.6 CCYs and 7.9 IOCs annually, using IOC in 33 % of cases. The routine IOC group used IOC for 96 % of cases, whereas selective IOC group used IOC ∼25 % of the time. Routine IOC surgeons had no difference in mortality (0.4 %) or rate of bile duct injury (0.25 vs. 0.26 %), but higher overall complications (7.3 vs. 6.8 %, p = 0.04). Patients of routine IOC surgeons received more additional procedures and incurred higher costs.

Conclusion

Routine IOC does not decrease the rate of bile duct injury, but is associated with significant added cost. Surgeons’ routine use of IOC is correlated with increased rates of postsurgical procedures, and is associated with increased overall complications. These data suggest routine IOC may not improve outcomes.

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Grant Support/Funding

NIH/NCRR Clinical and Translational Science Award Pilot, American Cancer Society MRSG-10-003-01, Howard Hughes Medical Institute Early Career Award (all to JFT), the Linda J. Verville Foundation and Clinical Scholar Award (ERC).

Author information

Authors and Affiliations

  1. Department of Surgery, Surgical Outcomes Analysis & Research (SOAR), University of Massachusetts Medical School, Room S3-752, 55 Lake Avenue North, Worcester, MA, 01655, USA

    Elizaveta Ragulin-Coyne, Elan R. Witkowski, Zeling Chau, Sing Chau Ng MS, Heena P. Santry & Shimul A. Shah

  2. Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Ave, Stoneman 9, Boston, MA, 02215, USA

    Mark P. Callery & Jennifer F. Tseng

Authors
  1. Elizaveta Ragulin-Coyne
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  2. Elan R. Witkowski
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  3. Zeling Chau
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  4. Sing Chau Ng MS
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  5. Heena P. Santry
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  6. Mark P. Callery
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  7. Shimul A. Shah
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  8. Jennifer F. Tseng
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Corresponding author

Correspondence to Jennifer F. Tseng.

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Discussant

Dr. Nicholas J. Zyromski (Indianapolis, IN, USA): Using a typically innovative study question and lucid analysis, Dr. Ragulin-Coyne and the Sports Orthopedic and Rehabilitation group argue strongly against the routine use of intraoperative cholangiography. Their contemporary analysis of the Nationwide Inpatient Sample (NIS) database found that 11 % of surgeons performed routine intraoperative cholangiogram (IOC), that 33 % of all patients had IOC, and that selective cholangiographers performed IOC 25 % of the time. Surgeons performing routine IOC had similar rates of bile duct injury (0.2 %) and mortality, but higher rates of in-hospital morbidity, specifically infection and cardiopulmonary complications.

Questions:

1. Additional procedures including endoscopic retrograde cholangiopancreatography (ERCP) and common bile duct exploration (CBDE) were performed more commonly in routine cholangiographers’ patients, suggesting perhaps intervention in some cases that may not be clinically significant. Is it possible to determine from this NIS the incidence of readmission for ERCP/CBDE (in both groups)—I do not think so intuitively from this administrative database, but obviously these numbers would strengthen your argument considerably.

2. I can understand increased infection rates with routine IOC, but can you speculate WHY the increased rates of cardiovascular (CV)/pulmonary morbidity? Increased operative time? Was there correlation between increased complication rate and those patients undergoing additional procedure (ERCP/CBDE)?

2. You acknowledge challenges of interpreting cost data, and indeed I was not sure how you arrived at the figure of $881 extra per cholangiogram—defining the derivation of this number is important.

3. An argument for routine cholangiography lies in education. I was surprised (as I am sure you were) to see that only 23 % of routine cholangiographers practiced in teaching centers. What are your thoughts on this subject and what is your practice?

Closing Discussant

Dr. Elizaveta Ragulin-Coyne: I would like to thank the SSAT for the privilege of presenting our work. Just this morning, Dr. John Hunter stated in his presidential address that “meetings matter.” Our project is proof this concept, as it was inspired by a question posed by a community surgeon to Michael Sarr and Jennifer Tseng, who were leading a Postgraduate Course at the American College of Surgeons Clinical Congress last fall. The surgeon asked, “shouldn't everyone perform routine intraoperative cholangiogram to reduce bile duct injury?” In this work, we attempt to answer his question.

1. Regarding your first question, currently, NIS does not have readmission data. However, this information is available in the NIS state database, and currently more studies are underway to see if there is a difference in the number of readmissions after cholecystectomy done by selective or routine IOC surgeons. However, as the incidence of unsuspected retained stones is about 10 %, and clinical problems are seen in less than 1 % of all retained stones cases, the practice of routine IOC to catch one in a 100 cases is likely not cost-effective.

2. Actually, after multivariable analysis with stringent criteria, the increase in pulmonary/CV complications is not statistically significant.

3. The cost per case was calculated for routine IOC providers ($10,425) and selective IOC providers ($9495). The routine IOC providers spent an additional $930 per case ($10,425–9,495). The proportion of cases done by the routine IOC group was 11.6 % of all cases (13,025/111,815). Assuming that routine IOC providers use IOC unnecessarily for 71 % of the cases (comparing 96 % use to 25 % use for selective IOC surgeons), projected additional cost for our cohort was calculated as $930 × 111,815 × 0.116 × 0.71 = $8,546,447.

4. It was surprising to see that routine cholangiography is less commonly used in teaching hospitals. We found that only 7 % of surgeons practicing in teaching hospitals use IOC routinely, whereas 14 % of surgeons in nonteaching hospitals are routine IOC users. It does intuitively make sense, as a higher proportion of the attending surgeons in teaching hospitals, due to possibly additional laparoscopic training, feel more comfortable with a critical view of safety approach that perhaps replaces cholangiography to some extent. At our institution, about 5–10 % of surgeons use routine IOC. Dr Jennifer Tseng, my mentor, is a selective IOC surgeon. Selective cholangiography is still an important skill. However, as cholecystectomy is one of the most common general surgery procedures, even if it is done only for a quarter of cases, there are still plenty of opportunities for residents to learn.

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Ragulin-Coyne, E., Witkowski, E.R., Chau, Z. et al. Is Routine Intraoperative Cholangiogram Necessary in the Twenty-First Century? A National View. J Gastrointest Surg 17, 434–442 (2013). https://doi.org/10.1007/s11605-012-2119-8

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  • DOI: https://doi.org/10.1007/s11605-012-2119-8

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