Bile duct stones and laparoscopic cholecystectomy: a decision analysis to assess the roles of intraoperative cholangiography, EUS, and ERCP.
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.
Digestive Disease Center, Medical University of South Carolina, Charleston, South Carolina 29425-2223, USA.
A V
AV
Sahai
P D
PD
Mauldin
V
V
Marsi
R H
RH
Hawes
B J
BJ
Hoffman
D002758:Cholangiography / Q000191:economics / Q000379:methods*; D002760:Cholangiopancreatography, Endoscopic Retrograde / Q000191:economics; D017081:Cholecystectomy, Laparoscopic; D002769:Cholelithiasis / Q000601:surgery*; D003365:Costs and Cost Analysis; D003661:Decision Support Techniques; D019160:Endosonography / Q000191:economics; D006801:Humans; D007430:Intraoperative Care / Q000191:economics; D011361:Professional Competence; D012680:Sensitivity and Specificity