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The Laparoscopy in Biliary Exploration Research and Training Initiative (LIBERTI) trial: simulator-based training for laparoscopic management of choledocholithiasis

  • 2023 SAGES Oral
  • Published:
Surgical Endoscopy Aims and scope Submit manuscript

Abstract

Background

Laparoscopic cholecystectomy with common bile duct exploration (LCBDE) is equivalent in safety and efficacy to endoscopic retrograde cholangiopancreatography (ERCP) plus laparoscopic cholecystectomy (LC) while decreasing number of procedures and length of stay (LOS). Despite these advantages LCBDE is infrequently utilized. We hypothesized that formal, simulation-based training in LCBDE would result in increased utilization and improve patient outcomes across participating institutions.

Methods

Data was obtained from an on-going multi-center study in which simulator-based transcystic LCBDE training curricula were instituted for attending surgeons and residents. A 2-year retrospective review of LCBDE utilization prior to LCBDE training was compared to utilization up to 2 years after initiation of training. Patient outcomes were analyzed between LCBDE strategy and ERCP strategy groups using χ2, t tests, and Wilcoxon rank tests.

Results

A total of 50 attendings and 70 residents trained in LCBDE since November 2020. Initial LCBDE utilization rate ranged from 0.74 to 4.5%, and increased among all institutions after training, ranging from 9.3 to 41.4% of cases. There were 393 choledocholithiasis patients analyzed using LCBDE (N = 129) and ERCP (N = 264) strategies. The LCBDE group had shorter median LOS (3 days vs. 4 days, p < 0.0001). No significant differences in readmission rates between LCBDE and ERCP groups (4.7% vs. 7.2%, p = 0.33), or in post-procedure pancreatitis (0.8% v 0.8%, p > 0.98). In comparison to LCBDE, the ERCP group had higher rates of bile duct injury (0% v 3.8%, p = 0.034) and fluid collections requiring intervention (0.8% v 6.8%, p < 0.009) secondary to cholecystectomy complications. Laparoscopic antegrade balloon sphincteroplasty had the highest technical success rate (87%), followed by choledochoscopic techniques (64%).

Conclusion

Simulator-based training in LCBDE results in higher utilization rates, shorter LOS, and comparable safety to ERCP plus cholecystectomy. Therefore, implementation of LCBDE training is strongly recommended to optimize healthcare utilization and management of patients with choledocholithiasis.

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Funding

Boston Scientific provided grant funding and educational equipment for teaching LCBDE [ISREND00116].

Author information

Authors and Affiliations

  1. Department of Minimally Invasive Surgery, NorthShore University HealthSystem, 2650 Ridge Avenue, GCSI Suite B665, Evanston, IL, 60201, USA

    Vanessa N. VanDruff, Kristine Kuchta, Abigail J. Uyrga, Julia R. Amundson, Stephanie Joseph, H. Mason Hedberg, Michael McCormack & Michael B. Ujiki

  2. Department of Surgery, University of Chicago, Chicago, IL, USA

    Vanessa N. VanDruff & Julia R. Amundson

  3. Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA

    B. Fernando Santos, Robin Cotter, Jenaya Goldwag, Ming Cai, Xavier Fowler & Casey R. Lamb

  4. Veterans Affairs Medical Center, White River Junction, VT, USA

    B. Fernando Santos, Robin Cotter, Jenaya Goldwag, Ming Cai, Xavier Fowler & Casey R. Lamb

  5. Department of Minimally Invasive Surgery, University of New Mexico Hospital, Albuquerque, NM, USA

    Roxann A. Lerma & Edward D. Auyang

  6. Department of Surgery, Indiana University Health Hospital, Indianapolis, IN, USA

    Wendy Li & Eugene P. Ceppa

  7. Department of Surgery, Texas Tech University Health Sciences Center, El Paso, TX, USA

    Michael Cutshall & Brian R. Davis

  8. Department of Surgery, Wayne State University, Detroit, MI, USA

    Stephanie Joseph

  9. Department of Surgery, University of Colorado, Denver, CO, USA

    Edward Jones & Danielle Abbitt

Authors
  1. Vanessa N. VanDruff
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  2. B. Fernando Santos
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  9. Abigail J. Uyrga
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  10. Michael Cutshall
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  12. Roxann A. Lerma
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  13. Edward D. Auyang
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  14. Wendy Li
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  15. Eugene P. Ceppa
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  16. Edward Jones
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  18. Julia R. Amundson
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  19. Stephanie Joseph
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  20. H. Mason Hedberg
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  21. Michael McCormack
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  22. Michael B. Ujiki
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Corresponding author

Correspondence to Vanessa N. VanDruff.

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Disclosures

Dr Michael Ujiki is a scientific advisory board member of Boston Scientific and Apollo, and receives payment lectures from Medtronic, and Gore. Dr. B. Fernando Santos is a consultant for Boston Scientific and is entitled to shared royalties as a co-inventor of the 3D-Med LCBDE simulator. Dr. Edward Auyang is a consultant for Boston Scientific. Dr. Edward Jones is a consultant for Boston Scientfic. Drs. Vanesa N. VanDruff, Eugene P. Ceppa, Wendy Li, Brian Davis, Danielle Abbitt, Michael Cutshall, Casey Lamb, Robin Cotter, Xavier Fowler, Ming Cai, Jenaya Goldwag, Julia R. Amundson, Stephanie Joseph, Simon Che, Michael McCormack, H. Mason Hedberg, and Kristine Kuchta have no financial interests or conflicts of interest to disclose.

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This manuscript was accepted for an oral presentation at the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) in Montreal, Quebec, Canada on March 29-April 2, 2023.

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VanDruff, V.N., Santos, B.F., Kuchta, K. et al. The Laparoscopy in Biliary Exploration Research and Training Initiative (LIBERTI) trial: simulator-based training for laparoscopic management of choledocholithiasis. Surg Endosc 38, 931–941 (2024). https://doi.org/10.1007/s00464-023-10480-5

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