Surgical Endoscopy

, Volume 15, Issue 1, pp 4–13 | Cite as

Cost-effective management of common bile duct stones

A decision analysis of the use of endoscopic retrograde cholangiopancreatography (ERCP), intraoperative cholangiography, and laparoscopic bile duct exploration
  • D. R. Urbach
  • Y. S. Khajanchee
  • B. A. Jobe
  • B. A. Standage
  • P. D. Hansen
  • L. L. Swanstrom
Original Articles

Abstract

Background

There are a variety of approaches to the diagnosis and treatment of common bile duct (CBD) stones in patients undergoing laparoscopic cholecystectomy (LC).

Methods

Decision modeling was used to evaluate the cost-effectiveness of four strategies for managing CBD stones around the time of LC: (a) routine preoperative endoscopic retrograde cholangiopancreatography (ERCP) (preoperative ERCP), (b) LC with intraoperative cholangiography (IOC), followed by laparoscopic common bile duct exploration (LCDE), (c) LC with IOC, followed by ERCP (postoperative ERCP), and (d) expectant management (LC without any tests for CBD stones). Local hospital data were used to estimate costs. Cost-effectiveness was expressed in terms of the cost per case of residual CBD stones prevented (in excess of the cost of LC alone). Diagnostic test characteristics, procedure success rates, and adverse event probabilities were derived from a systematic review of the literature. Sensitivity analysis was used to explore the effect of uncertainty on the results of the model.

Results

LC alone was the least costly strategy, but it was also the least effective. Of the more aggressive strategies, LCDE and preoperative ERCP were associated with marginal costs of $5993.60 and $299,259.35, respectively, per case of residual CBD stones prevented. Postoperative ERCP was more costly and less effective than LCDE, but it had a lower cost-effectiveness ratio than preoperative ERCP when the prevalence of CBD stones was <80%.

Conclusions

Compared to other common approaches, laparoscopic CBD exploration is a cost-effective method of managing CBD stones in patients who undergo LC. If expertise in LCDE is unavailable, selective postoperative ERCP is preferred over routine preoperative ERCP, unless the probability of CBD stones is very high (>80%).

Key words

Decision analysis Cost-effectiveness Choledocholithiasis Common bile duct exploration Endoscopic retrograde cholangiopancreatography Operative cholangiography 

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References

  1. 1.
    Abboud P-AC, Malet PF, Berlin JA, Staroscik R, Cabana MD, Clarke JR, Shea JA, Schwartz JS, Williams SV (1996) Predictors of common bile duct stones prior to cholecystectomy: a meta-analysis. Gastrointest Endosc 44: 450–459PubMedCrossRefGoogle Scholar
  2. 2.
    Aubertin JM, Levoir D, Bouillot JL, Becheur H, Bloch F, Aouad K, Alexandre JH, Petite JP (1996) Endoscopic ultrasonography immediately prior to laparoscopic cholecystectomy: a prospective evaluation. Endoscopy 28: 667–673PubMedCrossRefGoogle Scholar
  3. 3.
    Barteau JA, Castro D, Arregui ME, Tetik C (1995) A comparison of intraoperative ultrasound versus cholangiography in the evaluation of the common bile duct during laparoscopic cholecystectomy. Surg Endosc 9: 490–496PubMedCrossRefGoogle Scholar
  4. 4.
    Berci G, Morganstern L (1994) Laparoscopic management of common bile duct stones: a multi-institutional SAGES study. Surg Endosc 8: 1168–1175PubMedCrossRefGoogle Scholar
  5. 5.
    Birth M, Ehlers KU, Delinikolas K, Weiser HF (1998) Prospective randomized comparison of laparoscopic ultrasonography using a flexible-tip ultrasound probe and intraoperative dynamic cholangiography during laparoscopic cholecystectomy. Surg Endosc 12: 30–36 DOI: 10.1007/s004649900587PubMedCrossRefGoogle Scholar
  6. 6.
    Blatner ME, Wittgen CM, Andrus CH, Kaminski DL (1991) Cystic duct cholangiography during laparoscopic cholecystectomy. Arch Surg 126: 646–649PubMedGoogle Scholar
  7. 7.
    Chan Y-L, Chan ACW, Lam WWM, Lee DWH, Chung SSC, Sung JJY, Cheung HS, Li AKC, Metreweli C (1996) Choledocholithiasis: comparison of MR cholangiography and endoscopic retrograde cholangiography. Radiology 200: 85–89PubMedGoogle Scholar
  8. 8.
    Chang L, Lo S, Stabile BE, Lewis RJ, Toosie K, de Virgilio C (2000) Preoperative versus postoperative endoscopic retrograde cholangio-pancreatography in mild to moderate gallstone pancreatitis: a prospective randomized trial. Ann Surg 231: 82–87PubMedCrossRefGoogle Scholar
  9. 9.
    Cuschieri A, Lezoche E, Morino M, Croce E, Lacy A, Toouli J, Faggioni A, Ribeiro VM, Jakimowicz J, Visa J, Hanna GB (1999) E.A.E.S. multicenter prospective randomized trial comparing two-stage vs single-stage management of patients with gallstone disease and ductal calculi. Surg Endosc 13: 952–957 DOI: 10.1007/s004649901145PubMedCrossRefGoogle Scholar
  10. 10.
    Detsky AS, Naglie IG (1990) A clinician’s guide to cost-effectiveness analysis. Ann Intern Med 113: 147–154PubMedGoogle Scholar
  11. 11.
    Dwerryhouse SJ, Brown E, Vipond MN (1998) Prospective evaluation of magnetic resonance cholangiography to detect common bile duct stones before laparoscopic cholecystectomy. Br J Surg 85: 1364–1366PubMedCrossRefGoogle Scholar
  12. 12.
    Fan ST, Lai ECS, Mok FPT, Lo C-M, Zheng S-S, Wong J (1993) Early treatment of acute biliary pancreatitis by endoscopic papillotomy. N Engl J Med 328: 228–232PubMedCrossRefGoogle Scholar
  13. 13.
    Finkler SA (1982) The distinction between cost and charges. Ann Int Med 96: 102–109PubMedGoogle Scholar
  14. 14.
    Flowers JL, Zucker KA, Graham SM, Scolvill WA, Imbembo AL, Bailey RW (1992) Laparoscopic cholangiography: results and indications. Ann Surg 215: 209–216PubMedCrossRefGoogle Scholar
  15. 15.
    Folsch UR, Nitsche R, Ludtke R, Hilgers RA, Creutzfeldt W (1997) Early ERCP and papillotomy compared with conservative treatment for acute biliary pancreatitis. N Engl J Med 336: 237–242PubMedCrossRefGoogle Scholar
  16. 16.
    Freeman ML, Nelson DB, Sherman S, Haber GB, Herman ME, Dorsher PJ, Moore JP, Fennerty MB, Ryan ME, Shaw MJ, Lande JD, Pheley AM (1996) Complications of endoscopic biliary sphincterotomy. N Engl J Med 335: 909–918PubMedCrossRefGoogle Scholar
  17. 17.
    Frey CF, Burbige EJ, Meinke WB, Pullos TG, Wong HN, Hickman DM, Belber J (1982) Endoscopic retrograde cholangiopancreatography. Am J Surg 144: 109–113PubMedCrossRefGoogle Scholar
  18. 18.
    Goletti O, Buccianti P, Decanini L, Lippolis PV, Spisni R, Chiarugi M, Cavina E (1994) Intraoperative sonography of biliary tree during laparoscopic cholecystectomy. Surg Laparosc Endosc 4: 9–12PubMedGoogle Scholar
  19. 19.
    Greig JD, John TG, Mahadaven M, Garden OJ (1994) Laparoscopic ultrasonography in the evaluation of the biliary tree during laparoscopic cholecystectomy. Br J Surg 81: 1202–1206PubMedCrossRefGoogle Scholar
  20. 20.
    Machi J, Tateishi T, Oishi AJ, Furumoto NL, Oishi RH, Uchida S, Sigel B (1999) Laparoscopic ultrasonography versus operative cholangiography during laparoscopic cholecystectomy: review of the literature and a comparison with open intraoperative ultrasonography. Am J Surg 188: 361–367Google Scholar
  21. 21.
    McKay CJ, Curran F, Sharples C, Baxter JN, Imrie CW (1997) Prospective placebo-controlled randomized trial of lexipafant in predicted severe acute pancreatitis. Br J Surg 84: 1239–1243PubMedCrossRefGoogle Scholar
  22. 22.
    Neoptolemos JP, Carr-Locke DL, Fossard DP (1987) Prospective randomised study of preoperative endoscopic sphincterotomy versus surgery alone for common bile duct stones. Br Med J 294: 470–474CrossRefGoogle Scholar
  23. 23.
    Neoptolemos JP, London NJ, James D, Carr-Locke DL, Bailey IA, Fossard DP (1988) Controlled trial of urgent endoscopic retrograde cholangiopancreatography and endoscopic shincterotomy versus conservative treatment for acute pancreatitis due to gallstones. Lancet 3: 979–983CrossRefGoogle Scholar
  24. 24.
    NIH Consensus Development Panel on Gallstones and Laparoscopic Cholecystectomy Gallstones and laparoscopic cholecystectomy. JAMA 269: 1018–1024Google Scholar
  25. 25.
    Ohtani T, Kawai C, Shirai Y, Kawakami K, Yoshida K, Hatakeyama K (1997) Intraoperative ultrasonography versus cholangiography during laparoscopic cholecystectomy: a prospective comparative study. J Am Coll Surg 185: 274–282PubMedGoogle Scholar
  26. 26.
    Owings ME, Kozak LJ (1998) Ambulatory and inpatient procedures in the United States, 1996. National Center for Health Statistics. Vital Health Stat 13: 139Google Scholar
  27. 27.
    Pietrabissa A, Di Candio G, Giulianotti PC, Shimi SM, Cushieri A, Mosca F (1995) Comparative evaluation of contact ultrasonography and transcystic cholangiography during laparoscopic cholecystectomy: a prospective study. Arch Surg 130: 1110–1114PubMedGoogle Scholar
  28. 28.
    Pofahl WE, Walczak SM, Rhone E, Izenberg SD (1998) Use of an artificial neural network to predict length of stay in acute pancreatitis. Am Surg 64: 868–872PubMedGoogle Scholar
  29. 29.
    Prat F, Amouyal G, Amouyal P, Pelletier G, Fritsch J, Choury AD, Buffet C, Etienne J-P (1996) Prospective controlled study of endoscopic ultrasonography and endoscopic retrograde cholangiography in patients with suspected common bile duct lithiasis. Lancet 347: 75–79PubMedCrossRefGoogle Scholar
  30. 30.
    Rhodes M, Sussman L, Cohen L, Lewis MP (1998) Randomised trial of laparoscopic exploration of common bile duct versus postoperative endoscopic retrograde cholangiography for common bile duct stones. Lancet 351: 159–161PubMedCrossRefGoogle Scholar
  31. 31.
    Rothlin MA, Schlumpf R, Largiader F (1994) Laparoscopic sonography: an alternative to routine intraoperative cholangiography?. Arch Surg 129: 694–700PubMedGoogle Scholar
  32. 32.
    Sahai AV, Mauldin PD, Marsi V, Hawes RH, Hoffman BJ (1999) Bile duct stones and laparoscopic cholecystectomy: a decision analysis to assess the roles of intraoperative cholagiography, EUS and ERCP. Gastrointest Endosc 49: 334–343PubMedCrossRefGoogle Scholar
  33. 33.
    Scientific Committee for the European Association for Endoscopic Surgery (E.A.E.S.) Diagnosis and treatment of common bile duct stones (CBDS): results of a consensus development conference. Surg Endosc 12: 856–864 DOI: 10.1007/s004649900729Google Scholar
  34. 34.
    Siperstein, A, Pearl J, Macho J, Hansen P, Gitomirsky A, Rogers S (1999) Comparison of laparoscopic ultrasonography and fluorocholangiography in 300 patients undergoing laparoscopic cholecystectomy. Surg Endosc 13: 113–117 DOI: 10.1007/s004649900917PubMedCrossRefGoogle Scholar
  35. 35.
    Soto JA, Barish MA, Yucel EK, Siegenberg D, Ferrucci JT, Chuttani R (1996) Magnetic resonance cholangiography: comparison with endoscopic retrograde cholangiography. Gastroenterology 110: 589–597PubMedCrossRefGoogle Scholar
  36. 36.
    Soto JA, Yucel EK, Barish MA, Chuttani R, Ferrucci JT (1996) MR cholangiography after unsuccessful or incomplete ERCP. Radiology 199: 91–98PubMedGoogle Scholar
  37. 37.
    Stiegmann GV, Soper NJ, Filipi CJ, McIntyre RC, Callery MP, Cordova JF (1995) Laparoscopic ultrasonography as compared with static or dynamic cholangiography at laparoscopic cholecystectomy: a prospective multicenter trial. Surg Endosc 9: 1269–1273PubMedCrossRefGoogle Scholar
  38. 38.
    Thompson DM, Arregui ME, Tetik C, Madden MT, Wegener M, A comparison of laparoscopic ultrasound with digital fluorocholangiography for detecting choledocholithiasis, during laparoscopic cholecystectomy. A comparison of laparoscopic ultrasound with digital fluorocholangiography for detecting choledocholithiasis during laparoscopic cholecystectomy. Surg Endosc 12: 929–932 (1998) DOI: 10.1007/ s004649900749PubMedCrossRefGoogle Scholar
  39. 39.
    Yamashita Y, Kurohiji T, Hayashi J, Kimitsuki H, Hiraki M, Kakegawa T (1993) Intraoperative ultrasonography during laparoscopic cholecystectomy. Surg Laparosc Endosc 3: 167–171PubMedGoogle Scholar

Copyright information

© Springer-Verlag 2001

Authors and Affiliations

  • D. R. Urbach
    • 1
  • Y. S. Khajanchee
    • 1
  • B. A. Jobe
    • 1
  • B. A. Standage
    • 1
  • P. D. Hansen
    • 1
  • L. L. Swanstrom
    • 1
  1. 1.Department of Minimally Invasive Surgery and Surgical ResearchLegacy Health SystemsPortlandUSA

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