Learning Curve of Laparoscopic Common Bile Duct Exploration: A Systematic Review
Kai Siang Chan, Zhe Hao Timothy Teo, Aung Myint Oo, Sameer P. Junnarkar, Vishal G. Shelat
Abstract
Background: Single-stage laparoscopic common bile duct exploration (LCBDE) with cholecystectomy has superior outcomes over two-stage endoscopic retrograde cholangiopancreatogram with interval cholecystectomy. With decreasing trend of LCBDE, this study aims to summarize the literature on learning curve (LC) in LCBDE. Materials and Methods: PubMed, Embase, Scopus, and the Cochrane Library were systematically searched for articles from inception to June 3, 2022 (PROSPERO Ref No: CRD42022328451). Basic clinical demographics were collected. Poisson means (95% confidence interval [95% CI]) was used to determine the number of cases required to surmount the LC (N LC ). Results: Eight articles ( n = 2071 patients) reported LC outcomes in LCBDE with mean study period of 5.9 ± 2.8 years. Majority of studies (62.5%) used arbitrary methods of LC analysis. Most common outcomes reported were complications (any or major) (75%), open conversion (75%), length of stay (62.5%), and operating time (50%). Mean CBD diameter was 11.3 ± 4.8 mm ( n = 1122 patients). Incidence of acute cholecystitis, acute cholangitis, and acute pancreatitis were 13.9% ( n = 232/1668), 7.8% ( n = 128/1629), and 13.7% ( n = 229/1668), respectively. Pooled analysis of all the included studies showed N LC of 78.8 cases (95% CI: 71.9–86.3). Studies that used cumulative sum control chart analysis, nonarbitrary methods, and arbitrary-based LC had N LC of 152.0 (95% CI: 135.4–170.1), 108.0 (95% CI: 96.6–120.4), and 49.7 (95% CI: 42.0–58.3) cases, respectively. N LC was 37.0 cases (95% CI: 29.1–46.5) for single surgeon LC, and 99.8 cases (95% CI: 90.2–110.0) for institutional LC. Conclusion: Studies reporting N LC in LCBDE are heterogeneous. Further studies should use nonarbitrary methods of analysis for patient-reported outcome measures and procedure-specific morbidity.