2024 General Surgery/Global Health Engagement/Quality Improvement Presentations

Lauren M Heyda, MD1; Rathnayaka MKD Gunasingha, MD2; Stephanie Bedzis3; Carolyn Gosztyla4; 1Department of Surgery, Walter Reed National Military Medical Center, Bethesda, MD; 2Department of Surgery, Womack Army Medical Center, Fort Liberty, NC; 3Department of Surgery, Naval Hospital Guam, Agana Heights, Guam; 4Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD

OBJECTIVES: Common bile duct (CBD) stones are present in up to 15% of patients undergoing cholecystectomy. Contemporary management of choledocholithiasis includes pre- or post-operative endoscopic retrograde cholangiopancreatography (ERCP) and surgical common bile duct exploration (CBDE). Emergence of advanced endoscopy has led to a known decreased familiarity with CBD procedures among general surgeons. Recent increased academic interest in surgical management of complex biliary disease prompted us to evaluate the value of these skills for military surgeons by examining the biliary case volume of a military treatment facility (MTF) without ERCP and limited magnetic resonance cholangiopancreatography (MRCP) capabilities versus a tertiary MTF. We predicted military surgeons in a resource limited environment would perform more advanced biliary procedures.

METHODS: Data query using specific diagnosis and procedure keywords identified all patients who underwent a biliary procedure for acute biliary pathology at Naval Hospital Guam (NHG) from December 2010 to May 2023. We examined the number of cholecystectomies, intraoperative cholangiograms (IOC), and CBDEs. Secondary outcomes included laparoscopic versus open procedures, procedure times, length of stay, ICU admission, and postoperative antibiotics. We compared this to data from Walter Reed National Military Medical Center (WRNMMC).

RESULTS: At NHG, 454 patients had a biliary procedure, 230 (50.6%) underwent cholecystectomy alone, 223 (49.1%) underwent cholecystectomy + IOC, and 58 (12.8%) underwent cholecystectomy + CBDE. Patients who underwent CBDE were significantly more likely to have an open procedure compared to cholecystectomy with or without IOC (51.7%, p < 0.01). Compared to patients who underwent cholecystectomy with and without IOC, patients who underwent cholecystectomy + CBDE had longer lengths of stay (7.16 days, p < 0.01), higher risk for ICU admission (65.5%, p < 0.01), and higher risk for need for post-operative antibiotics (31%, p < 0.01).

From September 2015 to December 2019, 489 cholecystectomies were performed at WRNMMC, 53 underwent IOC (10.8%); no CBDEs (0%) were performed. During the same timeframe, 163 cholecystectomies were performed at NHG, of which, significantly more underwent IOC (97 (58.5%), p < 0.01) and CBDE (16 (9.8%), p < 0.01).

CONCLUSIONS: NHG data suggests complex biliary procedures are commonly performed in resource limited MTFs. These patients are more likely to undergo open procedures, have longer procedures, longer hospital stays, and have higher risk for postoperative antibiotics and ICU admission. This suggests deliberate training in advanced biliary procedures is particularly valuable for the military surgeon given an increased potential of practicing in a resource limited environment.