Cost-Effective Treatment of Patients with Symptomatic Cholelithiasis and Possible Common Bile Duct Stones

Abstract

Background Clinicians must choose a treatment strategy for patients with symptomatic cholelithiasis without knowing whether common bile duct (CBD) stones are present. The purpose of this study was to determine the most cost-effective treatment strategy for patients with symptomatic cholelithiasis and possible CBD stones. Study Design Our decision model included five treatment strategies: (1) laparoscopic cholecystectomy (LC) alone followed by expectant management, (2) preoperative endoscopic retrograde cholangiopancreatography (ERCP) followed by LC, (3) LC with intraoperative cholangiography (IOC) ± common bile duct exploration (CBDE), (4) LC followed by postoperative ERCP, and (5) LC with IOC ± postoperative ERCP. The rates of successful completion of diagnostic testing and therapeutic intervention, test characteristics (sensitivity and specificity), morbidity, and mortality for all procedures are from current literature. Hospitalization costs and lengths of stay are from the 2006 National CMS data. The probability of CBD stones was varied from 0% to 100% and the most cost-effective strategy was determined at each probability. Results Across the CBD stone probability range of 4% to 100%, LC with IOC ± ERCP was the most cost-effective. If the probability was 0%, LC alone was the most cost-effective. Our model was sensitive to one health input: specificity of IOC, and three costs: cost of hospitalization for LC with CBDE, cost of hospitalization for LC without CBDE, and cost of LC with IOC. Conclusions The most cost-effective treatment strategy for the majority of patients with symptomatic cholelithiasis is LC with routine IOC. If stones are detected, CBDE should be forgone and the patient referred for ERCP.

Routine surveillance cholangiography after percutaneous cholecystostomy delays drain removal and cholecystectomy

“…When repeat cholangiogram and ERCP were performed at six weeks, nearly three out of four of patients had persistent choledocholithiasis (9). Several authors have reported that about 5–15% of patients undergoing laparoscopic cholecystectomy for uncomplicated symptomatic cholecystitis have common bile duct stones (12–14). …”

Prevalence and characteristics of clinically significant retained common bile duct stones after laparoscopic cholecystectomy for symptomatic cholelithiasis

“…In addition, Ammori et al [22] proposed that a "wait and see" policy of observation alone for patients with small bile duct calculi detected at intraoperative cholangiography (IOC) during laparoscopic cholecystectomy appears to be safe, and is more cost-effective than routine postoperative ERCP. Furthermore, some studies have suggested that the most cost-effective treatment strategy for most patients with symptomatic cholelithiasis involves laparoscopic cholecystectomy with routine IOC, as IOC can help laparoscopists to visualize the biliary anatomy and detect unexpected CBD stones [2324]. However, it remains debated whether IOC provides sufficient benefits in terms of its efficacy and safety to justify its routine application.…”

Management of Suspected Choledocholithiasis: A Decision Analysis for Choosing the Optimal Imaging Modality

“…Previous decision analyses have dealt mostly with the management of CBD stones, including cholecystectomy and intraoperative CBD exploration [11][12][13][14]. In contradistinction, the present analysis is restricted to the preoperative work-up by radiologic and endoscopic imaging techniques.…”