National Adherence to the ASGE-SAGES Guidelines for Managing Suspected Choledocholithiasis: an EAST Multicenter Study.

INTRODUCTION ASGE-SAGES provide guidelines for managing suspected common bile duct (CBD) stones. We sought to evaluate adherence to the guidelines among patients with choledocholithiasis and/or acute biliary pancreatitis (ABP) and to evaluate the ability of these guidelines to predict choledocholithiasis. METHODS We prospectively identified patients undergoing same-admission cholecystectomy for choledocholithiasis and/or ABP from 2016-2019 at 12 U.S. medical centers. Predictors of suspected CBD stones were very strong (CBD stone on ultrasound; bilirubin >4 mg/dL), strong (CBD > 6 mm; bilirubin ≥1.8 to ≤4 mg/dL), or moderate (abnormal LFTs other than bilirubin; age > 55 years; ABP). Patients were grouped by probability of CBD stones: high (any very strong or both strong predictors), low (no predictors), or intermediate (any other predictor combination). The management of each probability group was compared to the recommended management in the guidelines. RESULTS The cohort was comprised of 844 patients. High probability patients had 64.3% (n = 238/370) deviation from guidelines, intermediate probability patients had 29% (n = 132/455) deviation, and low probability patients had 78.9% (n = 15/19) deviation. ABP increased the odds of deviation for the high (OR 1.71, 95% CI 1.06-2.8, p = 0.03) and intermediate probability group (OR 1.6, 95% CI 1.07-2.42, p = 0.02). Age > 55 years (OR 2.19, 95% CI 1.4-3.43, p 6 mm predicted choledocholithiasis in the high (aOR 2.16, 95% CI 1.17-3.97, p = 0.01) and intermediate group (aOR 2.78, 95% CI 1.59-4.86, p < .001). Any very strong predictor (aOR 2.43, 95% CI 1.76-3.37, p < .0001) and both strong predictors predicted choledocholithiasis (aOR 2, 95% CI 1.35-2.96, p < .001). CONCLUSION Almost 45% of patients with suspected CBD stones were managed discordantly from the ASGE-SAGES guidelines. We believe these guidelines warrant revision to better reflect the ability of the clinical variables at predicting choledocholithiasis. LEVEL OF EVIDENCE IV, therapeutic.