Peninsula HPB Unit, Derriford Hospital, University Hospitals Plymouth NHS Trust, Plymouth, UK.
Peninsula Medical School (Faculty of Health), University of Plymouth, Plymouth, UK.
Surg Endosc. 2022 Aug;36(8):5882-5896. doi: 10.1007/s00464-021-08983-0. Epub 2022 Feb 10.
The practice of managing suspected/confirmed common bile duct stones (CBDS) can vary significantly in the UK. We aimed to assess this variability in practice and challenges to form a basis for future consensus.
An electronic survey containing 40 questions on various aspects of management of CBDS was sent to surgeons who perform cholecystectomies via five surgical associations.
A total of 132 surgeons responded to the survey. The speciality of surgeons includes upper gastro-intestinal (68%), general (18%), colorectal (12%), and others (2%). For patients with suspected CBD stones, 80% would choose magnetic resonance cholangio-pancreatography, and 14.4% would proceed to intra-operative imaging. Most surgeons preferred intra-operative cholangiogram over intra-operative ultrasound (83% vs 17%). For the treatment, 62.1% preferred a two-stage approach [endoscopic retrograde cholangio-pancreatography (ERCP) followed by laparoscopic cholecystectomy (LC)] and 33.4% chose a single-stage approach [LC + laparoscopic common bile duct exploration (LCBDE)]. Eighty (60.6%) responders performed LCBDE, and 19 (23.8%) of them performed > 10 LCBDEs in a year. Two third of surgeons (62.5%) preferred a trans-choledochal approach to CBDS. Half of the surgeons that perform LCBDE use a T-tube selectively and 1.6% routinely. The "availability of very good ERCP service" and "lack of formal training" were the two main reasons for surgeons not performing LCBDE. Both surgeons' speciality and whether they perform other complex laparoscopic surgery were significantly associated with choosing a two-stage approach over a one-stage approach (χ test, speciality p = 0.033, complex surgery p = 0.011).
Our survey confirms the significant variability in the diagnosis and management of CBDS. The two-stage approach is still the most common way of managing CBDS in the UK. The main reasons for the low uptake of the single-stage approach are the availability of good ERCP service, lack of equipment and lack of formal training in the technique of LCBDE.
英国在诊治疑似/确诊胆总管结石（CBDS）的实践中存在显著差异。我们旨在评估实践中的这种变异性，并为未来的共识奠定基础。
我们向通过五个外科协会行胆囊切除术的外科医生发送了一份包含 40 个问题的电子调查问卷，内容涉及 CBDS 管理的各个方面。
共有 132 名外科医生对调查做出了回应。外科医生的专业包括上消化道（68%）、普通外科（18%）、结直肠外科（12%）和其他（2%）。对于疑似 CBD 结石的患者，80%的外科医生会选择磁共振胰胆管成像，14.4%的外科医生会选择术中影像学检查。大多数外科医生更喜欢术中胆管造影而不是术中超声（83%比 17%）。在治疗方面，62.1%的外科医生首选两阶段方法[内镜逆行胰胆管造影（ERCP）后腹腔镜胆囊切除术（LC）]，33.4%的外科医生选择单阶段方法[LC+腹腔镜胆总管探查术（LCBDE）]。80 名（60.6%）应答者进行了 LCBDE，其中 19 名（23.8%）在一年内进行了>10 次 LCBDE。62.5%的外科医生倾向于采用经胆总管途径治疗 CBDS。一半的行 LCBDE 的外科医生选择性地使用 T 管，1.6%的外科医生常规使用 T 管。外科医生不进行 LCBDE 的两个主要原因是“非常好的 ERCP 服务的可用性”和“缺乏正规培训”。外科医生的专业和是否进行其他复杂的腹腔镜手术与选择两阶段方法而非单阶段方法显著相关（卡方检验，专业 p=0.033，复杂手术 p=0.011）。
我们的调查证实了 CBDS 的诊断和治疗存在显著差异。在英国，两阶段方法仍然是治疗 CBDS 的最常见方法。单阶段方法使用率低的主要原因是良好的 ERCP 服务的可用性、设备缺乏以及 LCBDE 技术的正规培训缺乏。
