Cost-effective management of common bile duct stones - A decision analysisof the use of endoscopic retrograde cholangiopancreatography (ERCP), intraoperative cholangiography, and laparoscopic bile duct exploration

Background: There are a variety of approaches to the diagnosis and treatmen t of common bile duct (CBD) stones in patients undergoing laparoscopic chol ecystectomy (LC). Methods: Decision modeling was used to evaluate the cost effectiveness of f our strategies for managing CBD stones around the time of LC: (a) routine p reoperative endoscopic retrograde cholangiopancreatography (ERCP) (preopera tive ERCP), (b) LC with intraoperative cholangiography (IOC), followed by l aparoscopic 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. Cos t-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 char acteristics, procedure success rates, and adverse event probabilities were derived from a systematic review of the literature. Sensitivity analysis wa s used to explore the effect of uncertainty on the results of the model. Results: LC alone was the least costly strategy, but it was also the least effective. Of the more aggressive strategies, LCDE and preoperative ERCP we re associated with marginal costs of $5993.60 and $299,259.35, respectively , per case of residual CBD stones prevented. Postoperative ERCP was more co stly and less effective than LCDE, but it had a lower cost-effectiveness ra tio than preoperative ERCP when the prevalence of CBD stones was < 80%. Conclusions: Compared to other common approaches, laparoscopic CBD explorat ion is a cost-effective method of managing CBD stones in patients who under go LC. If expertise in LCDE is unavailable, selective postoperative ERCP is preferred over routine preoperative ERCP, unless the probability of CBD st ones is very high (> 80%).