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Bile duct stones and laparoscopic cholecystectomy: a decision analysis to assess the roles of intraoperative
A V Sahai1, P D Mauldin, V Marsi
1Digestive Disease Center, Medical University of South Carolina, Charleston, South Carolina 29425-2223, USA.
Background:
The least costly management strategy for patients undergoing laparoscopic cholecystectomy is unclear.
Methods:
A decision model incorporating cost ratios, test accuracy, complication, and failure rates was used to determine the costs of 4 peri-laparoscopic cholecystectomy strategies: endoscopic retrograde cholangiopancreatography (ERCP), intraoperative cholangiography (IOCG), endoscopic ultrasound (EUS), and expectant management.
Results:
Expert IOCG is least costly for intermediate-risk patients when the risk of stones is between 17% and 34%. If expert EUS is available, 0% to 10% ("low" risk) merits expectant management; 11% to 55% ("intermediate" risk) merits EUS; and greater than 55% ("high" risk) merits ERCP. Thresholds were most sensitive to changes in the risks of symptoms and complications due to retained stones; and to procedural costs, sensitivity, and success rates. Neither IOCG nor EUS appears likely to reduce overall costs unless their accuracy and success rates are greater than 90% and their procedural cost is less than 60% to 70% that of ERCP. When neither are available, ERCP is preferable when the risk of stones is greater than 22%. Thresholds were relatively insensitive to changes in the risk and severity of ERCP-induced pancreatitis.
Conclusions:
The least costly strategy for laparoscopic cholecystectomy patients depends primarily on the risk of stones and stone-related symptoms, but procedural costs and operator expertise are also critical.