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MRCP is Not a Cost-Effective Strategy in the Management of Silent Common Bile Duct Stones

  • 2012 SSAT Poster Presentation
  • Published:
Journal of Gastrointestinal Surgery Aims and scope

Abstract

Background

Few formal cost-effectiveness analyses simultaneously evaluate radiographic, endoscopic, and surgical approaches to the management of choledocholithiasis.

Study Design

Using the decision analytic software TreeAge, we modeled the initial clinical management of a patient presenting with symptomatic cholelithiasis without overt signs of choledocholithiasis. In this base case, we assumed a 10 % probability of concurrent asymptomatic choledocholithiasis. Our model evaluated four diagnostic/therapeutic strategies: universal magnetic resonance cholangiopancreatography (MRCP), universal endoscopic retrograde cholangiopancreatography (ERCP), laparoscopic cholecystectomy (LC), or laparoscopic cholecystectomy with universal intraoperative cholangiogram (LCIOC). All probabilities were estimated from a review of published literature. Procedure and intervention costs were equated with Medicare reimbursements. Costs of hospitalizations were derived from median hospitalization reimbursement for New York State using diagnosis-related groups (DRG). Sensitivity analyses were performed on all cost and probability variables.

Results

The most cost-effective strategy in the diagnosis and management of symptomatic cholelithiasis with a 10 % risk of asymptomatic choledocholithiasis was LCIOC. This was followed by LC alone, MRCP, and ERCP. LC was preferred only when the probability that a retained CBD stone would eventually become symptomatic fell below 15 % or if the probability of technical success of an intraoperative cholangiogram (IOC) was less than 35 %. Universal MRCP and ERCP were both more costly and less effective than surgical strategies, even at a high probability of asymptomatic choledocholithiasis. Within the tested range for both procedural and hospitalization-related costs for any of the surgical or endoscopic interventions, LCIOC and LC were always more cost-effective than universal MRCP or ERCP, irrespective of the presence or absence of complications. Varying the cost, sensitivity, and specificity of MRCP had no effect on this outcome.

Conclusions

LC with routine IOC is the preferred strategy in a cost-effectiveness analysis of the management of symptomatic cholelithiasis with asymptomatic choledocholithiasis. MRCP was both more costly and less effective under all tested scenarios.

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Abbreviations

LC:

Laparoscopic cholecystectomy

IOC:

Intraoperative cholangiogram

CBD:

Common bile duct

CBDE:

Common bile duct exploration

LCBDE:

Laparoscopic common bile duct exploration

ERCP:

Endoscopic retrograde cholangiopancreatography

MRCP:

Magnetic resonance cholangiopancreatography

CPT:

Current procedural terminology

DRG:

Diagnosis-related group

CE:

Cost-effectiveness

References

  1. Buddingh KT, Nieuwenhuijs VB, van Buuren L, et al. Intraoperative assessment of biliary anatomy for prevention of bile duct injury: a review of current and future patient safety interventions. Surg Endosc. 2011;25:2449–2461.

    Article  PubMed  Google Scholar 

  2. Hall MJ, Owings MF. 2000 national hospital discharge survey. Adv Data. 2002:1–18.

    Google Scholar 

  3. Ledro-Cano D. Suspected choledocholithiasis: endoscopic ultrasound or magnetic resonance cholangio-pancreatography? A systematic review. European Journal of Gastroenterology & Hepatology. 2007;19:1007–1011.

    Article  Google Scholar 

  4. Scaffidi MG, Luigiano C, Consolo P, et al. Magnetic resonance cholangio-pancreatography versus endoscopic retrograde cholangio-pancreatography in the diagnosis of common bile duct stones: a prospective comparative study. Minerva Medica. 2009;100:341–348.

    PubMed  CAS  Google Scholar 

  5. Rogers SJ, Cello JP, Horn JK, et al. Prospective randomized trial of LC + LCBDE vs ERCP/S + LC for common bile duct stone disease. Arch Surg. 2010;145:28–33.

    Article  PubMed  Google Scholar 

  6. Kaltenthaler EC, Walters SJ, Chilcott J, et al. MRCP compared to diagnostic ERCP for diagnosis when biliary obstruction is suspected: a systematic review. BMC Medical Imaging. 2006;6:9.

    Article  PubMed  Google Scholar 

  7. Martin DJ, Vernon DR, Toouli J. Surgical versus endoscopic treatment of bile duct stones. Cochrane Database of Systematic Reviews. 2006, CD003327.

  8. Howard K, Lord SJ, Speer A, et al. Value of magnetic resonance cholangiopancreatography in the diagnosis of biliary abnormalities in postcholecystectomy patients: a probabilistic cost-effectiveness analysis of diagnostic strategies. Int J Technol Assess Health Care. 2006;22:109–118.

    Article  PubMed  Google Scholar 

  9. Vergel YB, Chilcott J, Kaltenthaler E, et al. Economic evaluation of MR cholangiopancreatography compared to diagnostic ERCP for the investigation of biliary tree obstruction. Int J Surg. 2006;4:12–19.

    Article  PubMed  Google Scholar 

  10. Brown LM, Rogers SJ, Cello JP, et al. Cost-effective treatment of patients with symptomatic cholelithiasis and possible common bile duct stones. Journal of the American College of Surgeons. 2011;212:1049–1060 e1041-1047

    Article  PubMed  Google Scholar 

  11. Poulose BK, Speroff T, Holzman MD. Optimizing choledocholithiasis management: a cost-effectiveness analysis. Arch Surg. 2007;142:43–48; discussion 49

    Article  PubMed  Google Scholar 

  12. Parra-Membrives P, Diaz-Gomez D, Vilegas-Portero R, et al. Appropriate management of common bile duct stones: a RAND Corporation/UCLA Appropriateness Method statistical analysis. Surgical Endoscopy. 2010;24:1187–1194.

    Article  PubMed  Google Scholar 

  13. Diagnosis and treatment of common bile duct stones (CBDS). Results of a consensus development conference. Scientific Committee of the European Association for Endoscopic Surgery (E.A.E.S.). Surgical Endoscopy. 1998;12:856–864

    Article  Google Scholar 

  14. Tranter SE, Thompson MH. Spontaneous passage of bile duct stones: frequency of occurrence and relation to clinical presentation. Annals of the Royal College of Surgeons of England. 2003;85:174–177.

    Article  PubMed  CAS  Google Scholar 

  15. Collins C, Maguire D, Ireland A, et al. A prospective study of common bile duct calculi in patients undergoing laparoscopic cholecystectomy: natural history of choledocholithiasis revisited. Annals of Surgery. 2004;239:28–33.

    Article  PubMed  Google Scholar 

  16. Lefemine V, Morgan RJ. Spontaneous passage of common bile duct stones in jaundiced patients. Hepatobiliary & Pancreatic Diseases International: HBPD INT. 2011;10:209–213.

    Article  Google Scholar 

  17. Centers for Medicare and Medicaid Services. Overview of the Medicare Physician Fee Schedule Search. Available from: http://www.cms.gov/apps/physician-fee-schedule/overview.aspx. Accessed on January 2012

  18. Tucker JJ, Yanagawa F, Grim R, et al. Laparoscopic cholecystectomy is safe but underused in the elderly. The American Surgeon. 2011;77:1014–1020.

    PubMed  Google Scholar 

  19. Dolan JP, Diggs BS, Sheppard BC, Hunter JG. The national mortality burden and significant factors associated with open and laparoscopic cholecystectomy: 1997–2006. Journal of Gastrointestinal Surgery: official journal of the Society for Surgery of the Alimentary Tract. 2009;13:2292–2301.

    Article  Google Scholar 

  20. Murphy MM, Shah SA, Simons JP, et al. Predicting major complications after laparoscopic cholecystectomy: a simple risk score. Journal of Gastrointestinal Surgery: official Journal of the Society for Surgery of the Alimentary Tract. 2009;13:1929–1936.

    Article  Google Scholar 

  21. Akyurek N, Salman B, Irkorucu O, et al. Laparoscopic cholecystectomy in patients with previous abdominal surgery. JSLS: Journal of the Society of Laparoendoscopic Surgeons/Society of Laparoendoscopic Surgeons. 2005;9:178–183.

    Google Scholar 

  22. Keus F, Gooszen HG, van Laarhoven CJ. Open, small-incision, or laparoscopic cholecystectomy for patients with symptomatic cholecystolithiasis. An overview of Cochrane Hepato-Biliary Group reviews. Cochrane Database of Systematic Reviews. 2010, CD008318.

  23. Lee KT, Chang WT, Huang MC, Chiu HC. Influence of surgeon volume on clinical and economic outcomes of laparoscopic cholecystectomy. Digestive Surgery. 2004;21:406–412.

    Article  PubMed  Google Scholar 

  24. Videhult P, Sandblom G, Rasmussen IC. How reliable is intraoperative cholangiography as a method for detecting common bile duct stones? A prospective population-based study on 1171 patients. Surgical Endoscopy. 2009;23:304–312.

    Article  PubMed  Google Scholar 

  25. Nassar AH, El Shallaly G, Hamouda AH. Optimising laparoscopic cholangiography time using a simple cannulation technique. Surgical Endoscopy. 2009;23:513–517.

    Article  PubMed  Google Scholar 

  26. Petelin JB. Laparoscopic common bile duct exploration. Surgical Endoscopy. 2003;17:1705–1715.

    Article  PubMed  CAS  Google Scholar 

  27. Nickkholgh A, Soltaniyekta S, Kalbasi H. Routine versus selective intraoperative cholangiography during laparoscopic cholecystectomy: a survey of 2,130 patients undergoing laparoscopic cholecystectomy. Surgical Endoscopy. 2006;20:868–874.

    Article  PubMed  CAS  Google Scholar 

  28. Kelly MD. Results of laparoscopic bile duct exploration via choledochotomy. ANZ Journal of Surgery. 2010;80:694–698.

    Article  PubMed  Google Scholar 

  29. Chiarugi M, Galatioto C, Decanini L, et al. Laparoscopic transcystic exploration for single-stage management of common duct stones and acute cholecystitis. Surgical Endoscopy. 2012;26:124–129.

    Article  PubMed  Google Scholar 

  30. Lyass S, Phillips EH. Laparoscopic transcystic duct common bile duct exploration. Surgical Endoscopy. 2006;20 Suppl 2:S441-445.

    Article  PubMed  Google Scholar 

  31. Cotton PB, Garrow DA, Gallagher J, Romagnuolo J. Risk factors for complications after ERCP: a multivariate analysis of 11,497 procedures over 12 years. Gastrointestinal Endoscopy. 2009;70:80–88.

    Article  PubMed  Google Scholar 

  32. Chatterjee S, Rees C, Dwarakanath AD, et al. Endoscopic retrograde cholangio-pancreatography practice in district general hospitals in North East England: a Northern Regional Endoscopy Group (NREG) study. The Journal of the Royal College of Physicians of Edinburgh. 2011;41:109–113.

    Article  PubMed  CAS  Google Scholar 

  33. De Lisi S, Leandro G, Buscarini E. Endoscopic ultrasonography versus endoscopic retrograde cholangiopancreatography in acute biliary pancreatitis: a systematic review. European Journal of Gastroenterology & Hepatology. 2011;23:367–374.

    Article  Google Scholar 

  34. Petrov MS, Savides TJ. Systematic review of endoscopic ultrasonography versus endoscopic retrograde cholangiopancreatography for suspected choledocholithiasis. The British Journal of Surgery. 2009;96:967–974.

    Article  PubMed  CAS  Google Scholar 

  35. Schreurs WH, Juttmann JR, Stuifbergen WN, et al. Management of common bile duct stones: selective endoscopic retrograde cholangiography and endoscopic sphincterotomy: short- and long-term results. Surgical Endoscopy. 2002;16:1068–1072.

    Article  PubMed  CAS  Google Scholar 

  36. Bailey AA, Bourke MJ, Williams SJ, et al. A prospective randomized trial of cannulation technique in ERCP: effects on technical success and post-ERCP pancreatitis. Endoscopy. 2008;40:296–301.

    Article  PubMed  CAS  Google Scholar 

  37. Nakai Y, Isayama H, Tsujino T, et al. Impact of introduction of wire-guided cannulation in therapeutic biliary endoscopic retrograde cholangiopancreatography. Journal of Gastroenterology and Hepatology. 2011;26:1552–1558.

    Article  PubMed  Google Scholar 

  38. Mehta PP, Sanaka MR, Parsi MA, et al. Effect of the time of day on the success and adverse events of ERCP. Gastrointestinal Endoscopy. 2011;74:303–308.

    Article  PubMed  Google Scholar 

  39. Trifan A, Sfarti C, Cretu M, et al. Guide-wire versus conventional contrast cannulation of the common bile duct for the prevention of post-ERCP pancreatitis in patients with choledocholithiasis. Journal of Gastrointestinal and Liver Diseases: JGLD. 2011;20:149–152.

    PubMed  Google Scholar 

  40. Katsinelos P, Kountouras J, Paroutoglou G, et al. A comparative study of 10-Fr vs. 7-Fr straight plastic stents in the treatment of postcholecystectomy bile leak. Surgical Endoscopy. 2008;22:101–106.

    Article  PubMed  Google Scholar 

  41. Artifon EL, Kumar A, Eloubeidi MA, et al. Prospective randomized trial of EUS versus ERCP-guided common bile duct stone removal: an interim report (with video). Gastrointestinal Endoscopy. 2009;69:238–243.

    Article  PubMed  Google Scholar 

  42. Heo JH, Kang DH, Jung HJ, et al. Endoscopic sphincterotomy plus large-balloon dilation versus endoscopic sphincterotomy for removal of bile-duct stones. Gastrointestinal Endoscopy. 2007;66:720–726; quiz 768, 771

    Article  PubMed  Google Scholar 

  43. Stabuc B, Drobne D, Ferkolj I, et al. Acute biliary pancreatitis: detection of common bile duct stones with endoscopic ultrasound. European Journal of Gastroenterology & Hepatology. 2008;20:1171–1175.

    Article  Google Scholar 

  44. Ainsworth AP, Rafaelsen SR, Wamberg PA, et al. Cost-effectiveness of endoscopic ultrasonography, magnetic resonance cholangiopancreatography and endoscopic retrograde cholangiopancreatography in patients suspected of pancreaticobiliary disease. Scandinavian Journal of Gastroenterology. 2004;39:579–583.

    Article  PubMed  CAS  Google Scholar 

  45. Hekimoglu K, Ustundag Y, Dusak A, et al. MRCP vs. ERCP in the evaluation of biliary pathologies: review of current literature. Journal of Digestive Diseases. 2008;9:162–169.

    Article  PubMed  Google Scholar 

  46. Rahman R, Ju J, Shamma’s J, et al. Correlation between MRCP and ERCP findings at a tertiary care hospital. The West Virginia Medical Journal. 2010;106:14–19.

    PubMed  Google Scholar 

  47. Verma D, Kapadia A, Eisen GM, Adler DG. EUS vs MRCP for detection of choledocholithiasis. Gastrointestinal Endoscopy. 2006;64:248–254.

    Article  PubMed  Google Scholar 

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Authors and Affiliations

  1. Department of Surgery, College of Physicians and Surgeons, Columbia University, New York, NY, USA

    Irene Epelboym, Megan Winner & John D. Allendorf

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  1. Irene Epelboym
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  2. Megan Winner
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Correspondence to Irene Epelboym.

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Epelboym, I., Winner, M. & Allendorf, J.D. MRCP is Not a Cost-Effective Strategy in the Management of Silent Common Bile Duct Stones. J Gastrointest Surg 17, 863–871 (2013). https://doi.org/10.1007/s11605-013-2179-4

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  • DOI: https://doi.org/10.1007/s11605-013-2179-4

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