Surgical Clinics of North America

Surgical Clinics of North America
There are many reasons to present an issue of the Surgical Clinics of North America on surgery of the biliary tract, and many of them are contradictory at some level. Nearly all general surgeons perform biliary tract surgery to some degree, and progressively fewer general surgeons seem comfortable with all aspects of biliary surgery. The historic progression of this ‘‘comfort dissociation’’ is fairly easy to trace but, in my opinion, difficult to completely understand. And, sadly, it may reflect a disturbing trend in our industry.
There are three main influences that have drastically altered the scope and distribution of biliary surgical practice: (1) the advent and wide distribution of available and competent flexible fiber optic endoscopic retrograde cholangiopancreatography (ERCP), (2) the rapid and nearly complete technical shift to laparoscopic cholecystectomy, and (3) the Wizard of Oz factor.
Although ERCP was developed in the 1970s, several years passed before it became widely available, and it remains readily available in far fewer facilities than laparoscopic cholecystectomy. ERCP is increasingly being performed by gastroenterologists or surgeons with advanced training beyond conventional residencies or fellowships. The clinical capability of advanced practice endoscopists has altered the conventional practice of biliary surgery in two major ways. First, it has provided a nonoperative solution to many problems that in the past were predominantly managed by surgeons. Second, it has created a patient geographic dislocation in that even in patients in whom endoscopic procedures do not resolve their problem, it is highly unlikely that they will be transferred back to the referring institution rather than stay at the ‘‘higher echelon’’ referral center.

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