TY - JOUR
T1 - National adherence to the ASGE-SAGES guidelines for managing suspected choledocholithiasis
T2 - An EAST multicenter study
AU - EAST Retained Common Bile Duct Stones Study Group
AU - Tracy, Brett M.
AU - Poulose, Benjamin K.
AU - Paterson, Cameron W.
AU - Mendoza, April E.
AU - Gaitanidis, Apostolos
AU - Saxe, Jonathan M.
AU - Young, Andrew J.
AU - Zielinski, Martin D.
AU - Sims, Carrie A.
AU - Gelbard, Rondi B.
N1 - Publisher Copyright:
Copyright © 2021 American Association for the Surgery of Trauma
PY - 2022/2/1
Y1 - 2022/2/1
N2 - BACKGROUND: The American Society for Gastrointestinal Endoscopy and Society of American Gastrointestinal and Endoscopic Surgeons provide guidelines for managing suspected common bile duct (CBD) stones. We sought to evaluate adherence to the guidelines among patients with choledocholithiasis and/or acute biliary pancreatitis (ABP) and to evaluate the ability of these guidelines to predict choledocholithiasis. METHODS: We prospectively identified patients undergoing same-admission cholecystectomy for choledocholithiasis and/or ABP from 2016 to 2019 at 12 United States medical centers. Predictors of suspected CBD stones were very strong (CBD stone on ultrasound; bilirubin >4 mg/dL), strong (CBD > 6 mm; bilirubin ≥1.8 to ≤4 mg/dL), or moderate (abnormal liver function tests other than bilirubin; age >55 years; ABP). Patients were grouped by probability of CBD stones: high (any very strong or both strong predictors), low (no predictors), or intermediate (any other predictor combination). The management of each probability group was compared with the recommended management in the guidelines. RESULTS: The cohort was comprised of 844 patients. High-probability patients had 64.3% (n = 238/370) deviation from guidelines, intermediate-probability patients had 29% (n = 132/455) deviation, and low-probability patients had 78.9% (n = 15/19) deviation. Acute biliary pancreatitis increased the odds of deviation for the high- (odds ratio [OR], 1.71; 95% confidence interval [CI], 1.06–2.8; p = 0.03) and intermediate-probability groups (OR, 1.6; 95% CI, 1.07–2.42; p = 0.02). Age older than 55 years (OR, 2.19; 95% CI, 1.4–3.43; p < 0.001) also increased the odds of deviation for the intermediate group. A CBD greater than 6 mm predicted choledocholithiasis in the high (adjusted OR (aOR), 2.16; 95% CI, 1.17–3.97; p = 0.01) and intermediate group (aOR, 2.78; 95% CI, 1.59–4.86; p < 0.001). Any very strong predictor (aOR, 2.43; 95% CI, 1.76–3.37; p < 0.0001) and both strong predictors predicted choledocholithiasis (aOR, 2; 95% CI, 1.35–2.96; p < 0.001). CONCLUSION: Almost 45% of patients with suspected CBD stones were managed discordantly from the American Society for Gastrointestinal Endoscopy and Society of American Gastrointestinal and Endoscopic Surgeons guidelines. We believe these guidelines warrant revision to better reflect the ability of the clinical variables at predicting choledocholithiasis. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.
AB - BACKGROUND: The American Society for Gastrointestinal Endoscopy and Society of American Gastrointestinal and Endoscopic Surgeons provide guidelines for managing suspected common bile duct (CBD) stones. We sought to evaluate adherence to the guidelines among patients with choledocholithiasis and/or acute biliary pancreatitis (ABP) and to evaluate the ability of these guidelines to predict choledocholithiasis. METHODS: We prospectively identified patients undergoing same-admission cholecystectomy for choledocholithiasis and/or ABP from 2016 to 2019 at 12 United States medical centers. Predictors of suspected CBD stones were very strong (CBD stone on ultrasound; bilirubin >4 mg/dL), strong (CBD > 6 mm; bilirubin ≥1.8 to ≤4 mg/dL), or moderate (abnormal liver function tests other than bilirubin; age >55 years; ABP). Patients were grouped by probability of CBD stones: high (any very strong or both strong predictors), low (no predictors), or intermediate (any other predictor combination). The management of each probability group was compared with the recommended management in the guidelines. RESULTS: The cohort was comprised of 844 patients. High-probability patients had 64.3% (n = 238/370) deviation from guidelines, intermediate-probability patients had 29% (n = 132/455) deviation, and low-probability patients had 78.9% (n = 15/19) deviation. Acute biliary pancreatitis increased the odds of deviation for the high- (odds ratio [OR], 1.71; 95% confidence interval [CI], 1.06–2.8; p = 0.03) and intermediate-probability groups (OR, 1.6; 95% CI, 1.07–2.42; p = 0.02). Age older than 55 years (OR, 2.19; 95% CI, 1.4–3.43; p < 0.001) also increased the odds of deviation for the intermediate group. A CBD greater than 6 mm predicted choledocholithiasis in the high (adjusted OR (aOR), 2.16; 95% CI, 1.17–3.97; p = 0.01) and intermediate group (aOR, 2.78; 95% CI, 1.59–4.86; p < 0.001). Any very strong predictor (aOR, 2.43; 95% CI, 1.76–3.37; p < 0.0001) and both strong predictors predicted choledocholithiasis (aOR, 2; 95% CI, 1.35–2.96; p < 0.001). CONCLUSION: Almost 45% of patients with suspected CBD stones were managed discordantly from the American Society for Gastrointestinal Endoscopy and Society of American Gastrointestinal and Endoscopic Surgeons guidelines. We believe these guidelines warrant revision to better reflect the ability of the clinical variables at predicting choledocholithiasis. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.
KW - ASGE
KW - Acute biliary pancreatitis
KW - Choledocholithiasis
KW - Guidelines
KW - SAGES
UR - http://www.scopus.com/inward/record.url?scp=85123878932&partnerID=8YFLogxK
U2 - 10.1097/TA.0000000000003466
DO - 10.1097/TA.0000000000003466
M3 - Article
C2 - 34813581
AN - SCOPUS:85123878932
SN - 2163-0755
VL - 92
SP - 305
EP - 312
JO - Journal of Trauma and Acute Care Surgery
JF - Journal of Trauma and Acute Care Surgery
IS - 2
ER -