title: Is routine intraoperative cholangiogram necessary in the twenty-first century? A national view.
abstract: BACKGROUND
  Intraoperative cholangiogram (IOC) can define biliary ductal anatomy. Routine IOC has been proposed previously. However, current surgeon IOC utilization practice patterns and outcomes are unclear.
  
  
  METHODS
  Nationwide Inpatient Sample 2004-2009 was queried for patients with acute biliary disease undergoing cholecystectomy (CCY). Analyses only included surgeons performing ≥10 CCY/year. We dichotomized surgeons into a routine IOC group vs. selective. Outcomes included bile duct injury, complications, mortality, length of stay, and cost.
  
  
  RESULTS
  Of the nonweighted patients, 111,815 underwent CCY. A total of 4,740 actual surgeon yearly volumes were examined. On average, each surgeon performed 23.6 CCYs and 7.9 IOCs annually, using IOC in 33 % of cases. The routine IOC group used IOC for 96 % of cases, whereas selective IOC group used IOC ∼25 % of the time. Routine IOC surgeons had no difference in mortality (0.4 %) or rate of bile duct injury (0.25 vs. 0.26 %), but higher overall complications (7.3 vs. 6.8 %, p = 0.04). Patients of routine IOC surgeons received more additional procedures and incurred higher costs.
  
  
  CONCLUSIONS
  Routine IOC does not decrease the rate of bile duct injury, but is associated with significant added cost. Surgeons' routine use of IOC is correlated with increased rates of postsurgical procedures, and is associated with increased overall complications. These data suggest routine IOC may not improve outcomes.
authors.affiliation: Department of Surgery, Surgical Outcomes Analysis & Research (SOAR), University of Massachusetts Medical School, Worcester, MA 01655, USA.
authors.forename: Elizaveta
authors.initials: E
authors.lastname: Ragulin-Coyne
authors.forename: Elan R
authors.initials: ER
authors.lastname: Witkowski
authors.forename: Zeling
authors.initials: Z
authors.lastname: Chau
authors.forename: Sing Chau
authors.initials: SC
authors.lastname: Ng
authors.forename: Heena P
authors.initials: HP
authors.lastname: Santry
authors.forename: Mark P
authors.initials: MP
authors.lastname: Callery
authors.forename: Shimul A
authors.initials: SA
authors.lastname: Shah
authors.forename: Jennifer F
authors.initials: JF
authors.lastname: Tseng
mesh_terms: D001652:Bile Ducts / Q000293:injuries*; D001660:Biliary Tract Diseases / Q000000981:diagnostic imaging* / Q000601:surgery*; D002758:Cholangiography / Q000191:economics / Q000706:statistics & numerical data*; D002763:Cholecystectomy / Q000706:statistics & numerical data; D005260:Female; D017048:Health Care Costs; D017052:Hospital Mortality; D006801:Humans; D007430:Intraoperative Care; D007902:Length of Stay; D016014:Linear Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D011183:Postoperative Complications / Q000209:etiology*; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data; D014481:United States