Technical complications are rising as common duct exploration is becoming rare

BACKGROUND: Both hospital and surgeon volume influence outcomes. With introduction of new technologies, some procedures are now performed less frequently. ERCP has replaced the need for common duct exploration (CDE) in most cases of choledocholithiasis. We explored the secular trends and outcomes of CDE and how they have changed relative to introduction of ERCP. STUDY DESIGN: The National Hospital Discharge Survey database was analyzed for the years 1979 to 2001. Procedural frequency of ERCP and CDE was determined. Charlson and Elixhauser comorbidity indices were used to characterize patients' disease burden for the years 1993 to 2001. Length of stay, mortality, and complication rates for each procedure were determined. RESULTS: At the beginning of the study period, an estimated 47,000 CDEs were performed annually. These declined to 7,700 per year as ERCP increased to 42,500 procedures per year at the end of the study period. CDE complication rates increased from 3.4% to 17.4% over the same period. Comorbidity analysis for the years 1993 to 2001 revealed that ERCP and CDE patients had equivalent disease burdens. Technical complication rates rose in parallel to the increased overall CDE complication rate. CONCLUSIONS: ERCP has replaced the need for most but not all CDE. With diminished CDE experience at a national level, the complication rate has markedly increased, at least in part from technical complications. Both choledocholithiasis treatment algorithms and clinical training paradigms need to account for the rarity of CDE and high complication rates associated with it, by incorporation of training modules in surgical residencies and advocating referral to centers having expertise in biliary tract operations from surgeons with little CDE experience.