Laparoscopic Common Bile Duct Exploration Utilization Within the VA: A Needs Assessment Survey

Author(s):
Heather Evans; Maggie Bosley; MACELYN BATTEN; Byran Santos-Aleman

Background:

Introduction

Laparoscopic common bile duct exploration (LCBDE) for choledocholithiasis treatment is safe, effective, and associated with shorter hospital length of stay compared to laparoscopic cholecystectomy (LC) plus endoscopic retrograde cholangiopancreatography (ERCP). There are many barriers to LCBDE adoption, which are likely unique to practice settings and health systems. Increasing utilization of LCBDE may improve patient and system-level outcomes and serve as an important quality improvement (QI) target. We conducted a needs assessment to evaluate utilization patterns and potential barriers within the Department of Veterans Affairs (VA).

Methods:

Methods and Procedures

An IRB-exempt, REDCap survey was designed by content experts on the subjects of cholecystectomy and common bile duct exploration. The survey was distributed by email to all VA surgeons who perform cholecystectomy at a VA medical center. Descriptive statistics were used to analyze the survey results.

Results:

Results

87 practicing surgeons across 18 of 23 Veterans Integrated Service Networks (VISNs) who perform cholecystectomy in their facilities responded to the survey. Most (n=74, 85.1%) surgeons preferred to manage choledocholithiasis with ERCP plus LC (rather than LCBDE), despite 39% of respondents having very limited access to ERCP. Over a third of respondents reported that ERCP always requires patient transfer to a separate facility. Only 29 (33.3%) respondents reported performing LCBDE in their practice at all. Most of the respondents (n=68, 78.2%) know that using LCBDE is more efficient, and 60 (69%) respondents believe that ERCP is not safer than LCBDE.  Over half (58.6%) of the respondents reported interest in participating in a simulation based LCBDE course.

Conclusions:

Conclusions

In the largest survey of VA surgeons regarding the use of LCBDE to date, only a third of VA surgeons who perform cholecystectomy also perform LCBDE. Most VA surgeons who perform cholecystectomy utilize ERCP plus LC rather than LCBDE for biliary duct clearance, even though a significant percentage have limited access to ERCP at their hospitals or need to routinely transfer patients for treatment. Understanding access to care for patients with choledocholithiasis and barriers faced by physicians interested in performing LCBDE can provide targeted opportunities to improve overall quality of care received in the VA.