title: 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.
  
  
  METHODS
  Our decision model included 5 treatment strategies: laparoscopic cholecystectomy (LC) alone followed by expectant management; preoperative endoscopic retrograde cholangiopancreatography (ERCP) followed by LC; LC with intraoperative cholangiography (IOC) ± common bile duct exploration (CBDE); LC followed by postoperative ERCP; and 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 Centers for Medicare and Medicaid Services 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 1 health input: specificity of IOC, and 3 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.
authors: Department of Surgery, University of California, San Francisco, CA, USA. Lisa.Brown@ucsfmedctr.org
authors: Lisa M
authors: LM
authors: Brown
authors: Stanley J
authors: SJ
authors: Rogers
authors: John P
authors: JP
authors: Cello
authors: Karen J
authors: KJ
authors: Brasel
authors: John M
authors: JM
authors: Inadomi
mesh_terms: D000328:Adult; D000368:Aged; D002758:Cholangiography / Q000009:adverse effects / Q000191:economics*; D002760:Cholangiopancreatography, Endoscopic Retrograde; D049448:Cholangiopancreatography, Magnetic Resonance; D017081:Cholecystectomy, Laparoscopic / Q000009:adverse effects / Q000191:economics* / Q000401:mortality; D002769:Cholelithiasis / Q000175:diagnosis / Q000000981:diagnostic imaging / Q000191:economics* / Q000601:surgery*; D003363:Cost Control; D003362:Cost-Benefit Analysis; D003661:Decision Support Techniques; D019160:Endosonography; D005260:Female; D042882:Gallstones / Q000175:diagnosis / Q000191:economics* / Q000601:surgery*; D006801:Humans; D007432:Intraoperative Period; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D011184:Postoperative Period; D057234:Preoperative Period; D012680:Sensitivity and Specificity; D016896:Treatment Outcome; D014481:United States; D057832:Watchful Waiting