Lessons learned from implementing laparoscopic common bile duct exploration at a safety net hospital

Background: Mounting evidence favors one-stage laparoscopic cholecystectomy with common bile duct exploration over endoscopic retrograde cholangiopancreatography with cholecystectomy for choledocholithiasis. However, laparoscopic cholecystectomy with common bile duct exploration remains underused. In 2020, our center initiated a laparoscopic cholecystectomy with common bile duct exploration program for choledocholithiasis. This study compares the experience and outcomes of laparoscopic cholecystectomy with common bile duct exploration compared with endoscopic retrograde cholangiopancreatography with cholecystectomy at a safety net hospital.

Methods: This single-center, retrospective study analyzed data from 179 patients admitted with choledocholithiasis from 2019 to 2023. Demographics, preoperative investigations, intraoperative details, and postoperative outcomes were evaluated.

Results: The study included 179 patients (55.6 ± 21.0 years, 66% female) with American Society of Anesthesiologists Physical Status Classification System score III (II-III) and body mass index 29 kg/m² (25.8-35.5 kg/m²). Of these, 148 underwent endoscopic retrograde cholangiopancreatography with cholecystectomy and 31 underwent laparoscopic cholecystectomy with common bile duct exploration. Demographic and preoperative data were similar between groups. Laparoscopic cholecystectomy with common bile duct exploration achieved a 74.2% success rate. Laparoscopic cholecystectomy with common bile duct exploration's average operative time was 180 (139-213) minutes, with a 3.2% postoperative bile leak and 35.4% requiring postoperative ERCP. Median lengths of stay were 3 (1-4) for laparoscopic cholecystectomy with common bile duct exploration and 4 days (3-7) for endoscopic retrograde cholangiopancreatography with cholecystectomy (Z = -3.16, P = .002). The number of readmissions were 1.2 ± 0.4 for laparoscopic cholecystectomy with common bile duct exploration and 1.9 ± 1.3 for endoscopic retrograde cholangiopancreatography with cholecystectomy (t = 1.43, P = .08). Additional procedures for choledocholithiasis were performed in 36% of laparoscopic cholecystectomy with common bile duct exploration and 79% of ERCP + LC cases (χ² = 21.7, P < .0001).

Conclusion: The study highlights challenges in implementing laparoscopic cholecystectomy with common bile duct exploration at a safety net hospital. Results support laparoscopic cholecystectomy with common bile duct exploration over endoscopic retrograde cholangiopancreatography, with cholecystectomy, with shorter stays, fewer readmissions, and fewer additional procedures reported. Laparoscopic cholecystectomy with common bile duct exploration remains underused, with only 17.3% of patients who underwent one-stage laparoscopic cholecystectomy with common bile duct exploration. Further research is needed for laparoscopic cholecystectomy with common bile duct exploration's expansion as the superior choledocholithiasis treatment.