Statewide patterns of intraoperative cholangiography utilization during inpatient and outpatient cholecystectomy in Texas.

backgroundRecent statements from the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) and commentary from the American College of Surgeons (ACS) have renewed interest in intraoperative cholangiography (IOC) during cholecystectomy. However, contemporary real-world IOC utilization remains poorly characterized, particularly with increasing robotic surgery and fluorescence-guided biliary imaging.

methodsWe performed a retrospective cross-sectional analysis of the 2024 Texas Public Use Data Files. Outpatient cholecystectomy encounters were identified using CPT codes 47,562 and 47,563. Inpatient cases were identified using ICD-10-PCS code 0FT44ZZ, with robotic assistance identified by 8E0W4CZ. Outpatient IOC was identified directly through CPT code 47,563, whereas inpatient IOC was inferred from co-occurring ICD-10-PCS fluoroscopic biliary imaging codes BF101ZZ, BF111ZZ, BF121ZZ, BF131ZZ, and BF141ZZ. The primary comparison evaluated conventional fluoroscopic IOC utilization between conventional laparoscopic and robotic inpatient procedures. Setting-specific utilization rates and quarterly patterns were evaluated descriptively, whereas analyses of outpatient robotic coding and potential surrogate codes for fluorescence cholangiography were exploratory.

resultsAmong 89,555 minimally invasive cholecystectomy encounters, 56,273 were outpatient and 33,282 were inpatient. IOC was performed in 18,078 outpatient procedures (32.1%) and 7949 inpatient procedures (23.9%). Among inpatient cases, IOC was identified in 6668 conventional laparoscopic procedures (30.1%) versus 1281 robotic procedures (11.5%; OR, 0.30; 95% CI 0.28-0.32). Outpatient IOC utilization showed a descriptive decline from 34.1% in quarter 1 to 29.8% in quarter 4, whereas inpatient utilization remained relatively stable (24.6 to 23.3%). Outpatient robotic modifier coding using S2900 appeared in only 5.2% of outpatient procedures, suggesting incomplete robotic capture. Exploratory adjunct imaging codes did not identify a consistent high-frequency surrogate for fluorescence cholangiography or indocyanine green imaging.

conclusionConventional fluoroscopic IOC utilization remains variable and is substantially lower during robotic than conventional laparoscopic inpatient procedures. Despite renewed interest in routine IOC, real-world adoption remains far from universal. Administrative datasets identify conventional fluoroscopic IOC but inadequately capture fluorescence-guided biliary imaging, limiting assessment of evolving robotic imaging strategies.