Cost-effective management of common bile duct stones
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There are a variety of approaches to the diagnosis and treatment of common bile duct (CBD) stones in patients undergoing laparoscopic cholecystectomy (LC).
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.
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%.
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 wordsDecision analysis Cost-effectiveness Choledocholithiasis Common bile duct exploration Endoscopic retrograde cholangiopancreatography Operative cholangiography
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- 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
- 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
- 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
- 24.NIH Consensus Development Panel on Gallstones and Laparoscopic Cholecystectomy Gallstones and laparoscopic cholecystectomy. JAMA 269: 1018–1024Google Scholar
- 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
- 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
- 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