The current status of biliary tract surgery: An international study of 1072 consecutive patients

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Abstract
An international study to determine the practice patterns and outcome of operations for stone‐related biliary tract disorders was commissioned by the International Biliary Association in 1981. Twenty‐one institutions generated 69,700 data bits from 1,072 consecutive patients over an 18‐month period. These data were analyzed for approach to diagnosis, conduct of operation, and outcome. Of the 1,072 operations (412 United States, 660 international), 986 (92%) were primary and 86 (8%) were secondary or repeat procedures. Although elective cholecystectomy was preceded by 2 or more diagnostic tests in 25% of patients, institutional patterns ranged from a single test in 60% of patients to 94% of patients having more than 3 preoperative diagnostic tests. Elective cholecystectomy included operative cholangiography in 83% of patients and choledochotomies in 17% (182 of 1,072). The incidence of negative duct exploration and retained stones was 18.5% and 4.5%, respectively. Choledochoscopy was done before duct exploration in 25% (30.4%‐U.S.A.; 19.5%‐international) and prior to T‐tube insertion in 38% (29%‐U.S.A.; 43%‐international). Repeat operations for choledocholithiasis included a drainage procedure in 72% of American and 46% of European patients. Complications after primary procedures were 17% in the United States (12.4% biliary, 4.4% nonbiliary) and 35% (25% biliary, 9.1% nonbiliary) in the international series. Complications after secondary procedures were 48% (40% biliary, 8% nonbiliary). The mortality rate for all patients was 1.6% for primary procedures (0.6% for cholecystectomy alone) and 2.3% for secondary procedures. These data indicate that: (a) duplication of diagnostic procedures is frequent and characteristic of certain institutions; (b) cholangiography decreases the incidence of negative choledochotomy, and choledochoscopy reduces the incidence of retained stones; and (c) diagnosis, operative management, and outcome vary greatly among institutions.