title: Biliary obstruction during cholecystectomy: endoscopic retrograde cholangiopancreatography, evade, or explore?
abstract: Biliary obstruction discovered during cholecystectomy remains a challenging problem. To determine the best management, this retrospective study compared intervention during the same admission (SA) versus delayed/no intervention (DN). Furthermore, this study demonstrates the power  of a deidentified research database derived from electronic medical records. Patients undergoing cholecystectomy and intraoperative cholangiogram (IOC) were identified in the Vanderbilt Synthetic Derivative database. Patients with biliary obstruction discovered during IOC were included and  a cohort study was performed. Interventions for biliary obstruction included endoscopic retrograde cholangiopancreatography or common bile duct exploration. A composite measure of any biliary complication served as the primary outcome. A total of 1899 patients who underwent cholecystectomy  were evaluated; 151 met inclusion criteria. Mean age was 44 years with 69 per cent women. Sixty-three per cent of patients had intervention during the SA for cholecystectomy compared with 37 per cent for DN. Nineteen per cent of patients in the SA group had biliary complications versus  16 per cent for DN (P = 0.656). Patients in the SA group had a significantly increased length of stay (4.7 vs 2.1 days, P < 0.05). These data suggest an aggressive approach to biliary obstruction seen on IOC does not reduce postoperative biliary complications and may  incur unnecessary resource use.
authors.affiliation: Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA. poulose@vanderbilt.edu
authors.forename: Benjamin K
authors.initials: BK
authors.lastname: Poulose
authors.forename: Kristy L
authors.initials: KL
authors.lastname: Kummerow
authors.forename: William H
authors.initials: WH
authors.lastname: Nealon
authors.forename: Julia S
authors.initials: JS
authors.lastname: Shelton
authors.forename: Daniel R
authors.initials: DR
authors.lastname: Masys
authors.forename: Michael D
authors.initials: MD
authors.lastname: Holzman
mesh_terms: D000328:Adult; D002760:Cholangiopancreatography, Endoscopic Retrograde / Q000379:methods*; D017081:Cholecystectomy, Laparoscopic / Q000009:adverse effects / Q000379:methods*; D002779:Cholestasis / Q000000981:diagnostic imaging* / Q000601:surgery; D015331:Cohort Studies; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007431:Intraoperative Complications / Q000000981:diagnostic imaging* / Q000601:surgery; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000175:diagnosis / Q000453:epidemiology; D012189:Retrospective Studies; D018570:Risk Assessment; D016717:Sphincterotomy, Endoscopic / Q000009:adverse effects / Q000379:methods*; D018709:Statistics, Nonparametric; D016896:Treatment Outcome