腹腔镜胆总管探查术（LCBDE）的错失良机：我们可以做得更好。
Missed opportunities for laparoscopic common bile duct exploration (LCBDE): we can do better.
作者信息
Johnston Tawni M, Lamb Casey R, Jo Alice, Rodriguez Christina L Sierra, Mancini David Joshua, Martinez-Camblor Pablo, Santos Byron Fernando
机构信息
Department of Surgery, Dartmouth Hitchcock Medical Center (DHMC), Lebanon, NH, USA.
Department of Surgery, Bassett Medical Center, Cooperstown, NY, USA.
出版信息
Surg Endosc. 2025 Sep 11. doi: 10.1007/s00464-025-12159-5.
BACKGROUND
Laparoscopic common bile duct exploration (LCBDE) is a safe and effective alternative to endoscopic retrograde cholangiopancreatography (ERCP) plus laparoscopic cholecystectomy (LC), but with a shorter length of stay (LOS). Nevertheless, LCBDE remains highly underutilized. Since 2021, our institution has conducted simulation-based LCBDE training for surgeons and residents. We sought to determine our current LCBDE utilization rate and potential utilization rate by identifying "missed opportunities" for LCBDE.
METHODS
We reviewed LCBDE or ERCP plus LC cases from 2023 to 2024 at a single institution. We excluded LC for hepatobiliary cancer and ERCP for non-gallstone disease. Contraindications to LCBDE were severe cholangitis, severe pancreatitis, malignancy concern, or significant comorbidities. We defined "missed opportunities" as cases eligible for LCBDE wherein ERCP was chosen instead. Median LOS (days) was compared between groups.
RESULTS
A total of 87 patients underwent LC plus LCBDE or ERCP. LCBDE was performed in 38% (n = 33, LOS = 2). ERCP with appropriate justification was performed in 25% (n = 22, LOS = 4.5) due to severe acute cholangitis (15%, n = 13), concern for malignancy (6%, n = 5), surgeon judgment (3%, n = 3), severe pancreatitis (1%, n = 1), severe comorbidities (1%, n = 1), patient preference (1%, n = 1), and diagnostic uncertainty (2%, n = 2). "Missed opportunities" represented the remaining 37% (n = 32, LOS = 3) due to: surgeon consulted after ERCP (18%, n = 16), patient transferred for ERCP only (5%, n = 4), surgeon not LCBDE trained (2%, n = 2), unavailable operating room (1%, n = 1), and unclear reasons (10%, n = 9).
CONCLUSIONS
Our potential LCBDE utilization rate was 75%. Most ERCP cases represented "missed opportunities" for LCBDE despite our robust LCBDE adoption. "Missed opportunities" had a significantly longer median LOS than LCBDE (3 vs. 2 days, p = 0.048). Efforts to optimize LCBDE utilization could significantly reduce LOS. The highest yield quality improvement opportunity may be to optimize ERCP/LC referral patterns. The 10% of unclear "missed opportunities" cases require additional investigation.
背景
腹腔镜胆总管探查术（LCBDE）是内镜逆行胰胆管造影术（ERCP）联合腹腔镜胆囊切除术（LC）的一种安全有效的替代方法，且住院时间更短。然而，LCBDE的使用率仍然很低。自2021年以来，我们机构为外科医生和住院医师开展了基于模拟的LCBDE培训。我们试图通过识别LCBDE的“错失机会”来确定我们目前的LCBDE使用率和潜在使用率。
方法
我们回顾了2023年至2024年在单一机构进行的LCBDE或ERCP联合LC的病例。我们排除了因肝胆癌行LC的病例和因非胆结石疾病行ERCP的病例。LCBDE的禁忌证包括严重胆管炎、严重胰腺炎、恶性肿瘤疑虑或严重合并症。我们将“错失机会”定义为符合LCBDE条件但选择了ERCP的病例。比较两组的中位住院时间（天数）。
结果
共有87例患者接受了LC联合LCBDE或ERCP。38%（n = 33，住院时间 = 2天）的患者接受了LCBDE。由于严重急性胆管炎（15%，n = 13）、恶性肿瘤疑虑（6%，n = 5）、外科医生判断（3%，n = 3）、严重胰腺炎（1%，n = 1）、严重合并症（1%，n = 1）、患者偏好（1%，n = 1）和诊断不确定性（2%，n = 2），25%（n = 22，住院时间 = 4.5天）的患者因合理理由接受了ERCP。“错失机会”占其余37%（n = 32，住院时间 = 3天），原因包括：ERCP后咨询外科医生（18%，n = 16）、仅因ERCP转诊患者（5%，n = 4）、外科医生未接受LCBDE培训（2%，n = 2）、手术室不可用（1%，n = 1）以及原因不明（10%，n = 9）。
结论
我们的潜在LCBDE使用率为75%。尽管我们大力采用LCBDE，但大多数ERCP病例代表了LCBDE的“错失机会”。“错失机会”的中位住院时间明显长于LCBDE（3天对2天，p = 0.048）。优化LCBDE使用率的努力可显著缩短住院时间。最高收益的质量改进机会可能是优化ERCP/LC转诊模式。10%原因不明的“错失机会”病例需要进一步调查。
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