Optimizing Choledocholithiasis Management

Assessing the impact of center volume on the cost-effectiveness of centralizing ERCP

BACKGROUND AND AIMS

ERCP is a complex endoscopic procedure in which the center's procedure volume influences outcomes. With the increasing healthcare expenses and limited resources, promoting cost-effective care becomes essential for healthcare provision. This study was a cost-effectiveness analysis to evaluate the hypothesis that high-volume (HV) centers perform ERCP with higher quality at lower costs than low-volume (LV) centers.

METHODS

A baseline case compared the current distribution of ERCPs among HV and LV centers with a hypothetical scenario in which all ERCPs are performed at HV centers. A cost-effectiveness analysis was constructed, followed by 1- and 2-way sensitivity analyses, and probabilistic sensitivity analysis using Monte Carlo simulations.

RESULTS

In the baseline case, the incremental cost-effectiveness ratio was -$151,270 per year, due to the hypothetical scenario's lower costs and slightly higher quality-adjusted life years. The model was most sensitive to changes in transportation costs (109.34%), probability of significant adverse events (AEs) after successful ERCP at LV centers (42.12%), utility after ERCP with significant AEs (30.10%), and probability of significant AEs after successful ERCP at HV centers (23.53%); only transportation costs above $3655 changed the study outcome, however. The current ERCP distribution would only be cost-effective if LV centers achieved higher success (≥92.4% vs 89.3%), with much lower significant AEs (≤.5% vs 6.7%). The study's main findings remained unchanged while combining all model parameters in the probabilistic sensitivity analysis.

CONCLUSIONS

Our findings show that HV centers have high-performance rates at lower costs, raising the need to consider the principle of centralization of ERCPs into HV centers to improve the quality of care.

Comprehensive review on small common bile duct stones

Common bile duct stones are among the most common conditions encountered by endoscopists. Therefore, it is well researched; however, some items, such as indications for endoscopic papillary balloon dilatation (EPBD), safety of EPBD and endoscopic sphincterotomy in patients receiving dual antiplatelet therapy or direct oral anticoagulant, selection strategy for retrieval balloons and baskets, lack adequate evidence. Therefore, the guidelines have been updated with new research, while others remain unchanged due to weak evidence. In this review, we comprehensively summarize the standard methods in guidelines and new findings from recent studies on papillary dilation, stone retrieval devices, difficult-to-treat cases, troubleshooting during the procedure, and complicated cases of cholangitis, cholecystolithiasis, or distal biliary stricture.

Fully Covered Self-expanding Stents are Cost-effective at Remediating Biliary Strictures in Patients With Chronic Pancreatitis

Benign biliary strictures (BBS) develop in up to 10% to 30% of patients with chronic pancreatitis (CP).¹ Endoscopic endoprosthetics via endoscopic retrograde cholangiopancreatography (ERCP) has become the standard of care for remediating these strictures. Seventy percent to eighty percent of these strictures resolve with sequential or concurrent placement of multiple plastic stents (MPS).^1,2 More recently, placement of fully covered self-expanding metal stents (FCSEMS) have been shown to have similar outcomes as MPS.^3-6 FCSEMS provide a larger radial diameter and require fewer procedures, but may have drawbacks, including a higher risk of migration, cholecystitis, delamination, and tissue ingrowth. A recent study demonstrated that FCSEMS with a 12-month indwell had similar outcomes to MPS with fewer ERCP needed.⁷ However, the cost-effectiveness of either strategy for managing BBS has not been assessed previously nor has the impact of additional reimbursement to cover the cost of FCSEMS on the cost-effectiveness of FCSEMS utilization.

Evaluation of therapeutic efficacy, safety and economy of ERCP and LTCBDE in the treatment of common bile duct stones

Objectives: This study further compared the endoscopic retrograde cholangiopancreatography (ERCP) and laparoscopic transcystic common bile duct exploration (LTCBDE) approaches in the treatment of common bile duct stones (CBDS) from the perspective of efficacy, safety and economy.

Methods: The therapeutic efficacy and safety of ERCP and LTCBDE approaches were retrospectively compared. Cost-effectiveness analysis of clinical economics was performed to analyze and evaluate the two approaches.

Results: There was no significant difference in the success rate of surgery and bile stone residue between ERCP and LTCBDE group. The incidence of postoperative complications in ERCP group was significantly higher than that in the LTCBDE group; while the incidence of pancreatitis in the ERCP group was significantly higher than that in the LTCBDE group. There was no significant difference in biliary infection, bile leakage and sepsis between ERCP and LTCBDE groups. In terms of cost, the costs of surgery and nursing were significantly lower, the costs of treatment and sanitary materials were significantly higher in the ERCP group than that in the LTCBDE group. There was no significant difference in the costs of medical examination, laboratory test, medicine cost and total cost between ERCP group and LTCBDE group. The total length of hospital stay, length of hospital stay before surgery and duration of surgery in the ERCP group were significantly lower than that in the LTCBDE group; there was no significant difference in length of hospital stay after surgery between the ERCP and LTCBDE group. The cost-effectiveness ratio of ERCP group was 34171.25, and the cost-effectiveness of LTCBDE group was 34524.25. The incremental cost-effectiveness ratio (ICER) of the two groups was 51415.

Conclusion: ERCP and LTCBDE approaches had similar therapeutic efficacy in the treatment of CBDS. The safety of LTCBDE approach is superior to that of ERCP approach for the treatment of CBDS. ERCP approach is more economical in the treatment of CBDS than LTCBDE approach.

Inpatient Choledocholithiasis Management: a Cost-Effectiveness Analysis of Management Algorithms

BACKGROUND

Choledocholithiasis is commonly encountered. It is frequently managed with laparoscopic common bile duct exploration or endoscopic retrograde cholangiopancreatography (either preoperative, intraoperative, or postoperative relative to laparoscopic cholecystectomy). The purpose of this study is to determine the most cost-effective method to manage inpatient choledocholithiasis.

METHODS

A decision tree model was created to evaluate the cost-effectiveness of laparoscopic common bile duct exploration and preoperative, intraoperative, and postoperative endoscopic retrograde cholangiopancreatography. The primary outcome was incremental cost-effectiveness ratio with a ceiling willingness to pay threshold assumed of $100,000 per quality-adjusted life year. Model parameters were determined through review of published literature and institutional data. Costs were from the perspective of the healthcare system with a time horizon of 1 year. Sensitivity analyses were performed on model parameters.

RESULTS

In the base case analysis, laparoscopic common bile duct exploration was cost-effective, resulting in 0.9909 quality-adjusted life years at an expected cost of $18,357. Intraoperative endoscopic retrograde cholangiopancreatography yielded more quality-adjusted life years (0.9912) at a higher cost ($19,717) with an incremental cost-effectiveness ratio of $4,789,025, exceeding the willingness to pay threshold. Both preoperative and postoperative endoscopic retrograde cholangiopancreatographies were eliminated for being both more costly and less effective. Laparoscopic common bile duct exploration remained cost-effective if the probability of successful biliary clearance was above 0.79, holding all other variables constant. If its base cost remained below $18,400 and intraoperative endoscopic retrograde cholangiopancreatography base cost rose above $18,200, then laparoscopic common bile duct exploration remained cost-effective.

CONCLUSION

Laparoscopic common bile duct exploration is the most cost-effective method to manage choledocholithiasis. Efforts to ensure availability of local expertise and resources for this procedure are warranted.

Cost-effectiveness analysis of optimal diagnostic strategy for patients with symptomatic cholelithiasis with intermediate probability for choledocholithiasis

BACKGROUND AND AIMS

EUS, MRCP, and intraoperative cholangiogram (IOC) are the recommended diagnostic modalities for patients with intermediate probability for choledocholithiasis (IPC). The relative cost-effectiveness of these modalities in patients with cholelithiasis and IPC is understudied.

METHODS

We developed a decision tree for diagnosing IPC (base-case probability, 50%; range, 10%-70%); patients with a positive test were modeled to undergo therapeutic ERCP. The strategies tested were laparoscopic cholecystectomy with IOC (LC-IOC), MRCP, single-session EUS + ERCP, and separate-session EUS + ERCP. Costs and probabilities were extracted from the published literature. Effectiveness was assessed by assigning utility scores to health states, average proportion of true-positive diagnosis of IPC, and the mean length of stay (LOS) per strategy. Cost-effectiveness was assessed by extrapolating a net-monetary benefit (NMB) and average cost per true-positive diagnosis.

RESULTS

LC-IOC was the most cost-effective strategy to diagnose IPC (base-case probability of 50%) among patients with cholelithiasis in health state-based effectiveness analysis (NMB of $34,612), diagnostic test accuracy-based effectiveness analysis (average cost of $13,260 per true-positive diagnosis), and LOS-based effectiveness analysis (mean LOS of 4.13) compared with strategies 2 (MRCP), 3 (single-session EUS + ERCP), and 4 (separate-session EUS + ERCP). These findings were robust on deterministic and probabilistic sensitivity analyses.

CONCLUSIONS

For patients with cholelithiasis with IPC, LC-IOC is a cost-effective approach that should limit preoperative testing and may shorten hospital LOS. Our findings may be used to design institutional and organizational management protocols.

Incremental net benefit of cholecystectomy compared with alternative treatments in people with gallstones or cholecystitis: a systematic review and meta-analysis of cost–utility studies

Introduction

Cholecystectomy is a standard treatment in the management of symptomatic gallstone disease. Current literature has contradicting views on the cost-effectiveness of different cholecystectomy treatments. We have conducted a systematic reappraisal of literature concerning the cost-effectiveness of cholecystectomy in management of gallstone disease.

Methods

We systematically searched for economic evaluation studies from PubMed, Embase and Scopus for eligible studies from inception up to July 2020. We pooled the incremental net benefit (INB) with a 95% CI using a random-effects model. We assessed the heterogeneity using the Cochrane-Q test, I2 statistic. We have used the modified economic evaluation bias (ECOBIAS) checklist for quality assessment of the selected studies. We assessed the possibility of publication bias using a funnel plot and Egger’s test.

Results

We have selected 28 studies for systematic review from a search that retrieved 8710 studies. Among them, seven studies were eligible for meta-analysis, all from high-income countries (HIC). Studies mainly reported comparisons between surgical treatments, but non-surgical gallstone disease management studies were limited. The early laparoscopic cholecystectomy (ELC) was significantly more cost-effective compared with the delayed laparoscopic cholecystectomy (DLC) with an INB of US$1221 (US$187 to US$2255) but with high heterogeneity (I2=73.32%). The subgroup and sensitivity analysis also supported that ELC is the most cost-effective option for managing gallstone disease or cholecystitis.

Conclusion

ELC is more cost-effective than DLC in the treatment of gallstone disease or cholecystitis in HICs. There was insufficient literature on comparison with other treatment options, such as conservative management and limited evidence from other economies.

PROSPERO registration number

CRD42020194052.

Management of cholelithiasis with choledocholithiasis: Endoscopic and surgical approaches

Gallstone disease and complications from gallstones are a common clinical problem. The clinical presentation ranges between being asymptomatic and recurrent attacks of biliary pain requiring elective or emergency treatment. Bile duct stones are a frequent condition associated with cholelithiasis. Amidst the total cholecystectomies performed every year for cholelithiasis, the presence of bile duct stones is 5%-15%; another small percentage of these will develop common bile duct stones after intervention. To avoid serious complications that can occur in choledocholithiasis, these stones should be removed. Unfortunately, there is no consensus on the ideal management strategy to perform such. For a long time, a direct open surgical approach to the bile duct was the only unique approach. With the advent of advanced endoscopic, radiologic, and minimally invasive surgical techniques, however, therapeutic choices have increased in number, and the management of this pathological situation has become multidisciplinary. To date, there is agreement on preoperative management and the need to treat cholelithiasis with choledocholithiasis, but a debate still exists on how to cure the two diseases at the same time. In the era of laparoscopy and mini-invasiveness, we can say that therapeutic approaches can be performed in two sessions or in one session. Comparison of these two approaches showed equivalent success rates, postoperative morbidity, stone clearance, mortality, conversion to other procedures, total surgery time, and failure rate, but the one-session treatment is characterized by a shorter hospital stay, and more cost benefits. The aim of this review article is to provide the reader with a general summary of gallbladder stone disease in association with the presence of common bile duct stones by discussing their epidemiology, clinical and diagnostic aspects, and possible treatments and their advantages and limitations.

Single-stage management of choledocholithiasis: intraoperative ERCP versus laparoscopic common bile duct exploration

BACKGROUND

Laparoscopic cholecystectomy (LC) is the criterion standard for treating patients with symptomatic gallstone disease; however, the optimal technique for extracting common bile duct stones remains unclear. Recent studies have noted improved outcomes with single-stage techniques, such as intraoperative endoscopic retrograde cholangiopancreatography (iERCP) and laparoscopic common bile duct exploration (LCBDE); however only few studies have directly compared those two single-stage techniques.

OBJECTIVES

Using the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database, we retrospectively analyzed the postoperative outcomes of all patients who underwent single-stage LC for choledocholithiasis from 2005 to 2017. Using Current Procedural Terminology (CPT) codes, as well as International Classification of Diseases, Ninth Revision (ICD-9) and 10th Revision (ICD-10) codes, we stratified patients into two cohorts: those who underwent iERCP and LCBDE. Applying univariate techniques, we evaluated baseline characteristics and postoperative outcomes for both cohorts. Our primary outcomes of interest were 30-day morbidity and 30-day mortality; our secondary outcomes included rates of reoperation, readmission, operative time, and hospital length of stay.

RESULTS

Of the 1814 single-stage LC patients during our 13-year study period, 1185 (65.3%) underwent LCBDE; 629 (34.6%) underwent iERCP. Our univariate analysis showed that the two cohorts were homogeneous in terms of baseline characteristics, including demographics, preoperative comorbidities, laboratory values, and American Society of Anesthesiologists (ASA) scores. 30-day postoperative morbidity (including infectious and noninfectious complications) and overall mortality between groups were low and comparable. The mean operative time was slightly longer with LCBDE (125.1 ± 62.0 min) than iERCP (113.5 ± 65.2 min; P < 0.001), however the mean hospital length of stay, readmission rate, and reoperation rate were similar.

CONCLUSION

We found that both iERCP and LCBDE resulted in low, comparable rates of morbidity and mortality. Centers with readily available endoscopic expertise might favor iERCP for its ease of access and shorter operative time. However, LCBDE remains an appropriate technique for patients with choledocholithiasis, especially when immediate endoscopic intervention is unavailable.

Meta-analysis of single-stage versus two-staged management for concomitant gallstones and common bile duct stones

Objective:

The purpose of this article was to compare the effectiveness and safety of single-stage (laparoscopic cholecystectomy [LC] plus laparoscopic common bile duct exploration [LCBDE]) with two-stage (LC plus endoscopic retrograde cholangiopancreatography (ERCP)/endoscopic sphincterotomy [EST]) in management for concomitant gallstones and common bile duct (CBD) stones.

Materials and Methods:

Systematic review and meta-analysis of randomised controlled trials (RCTs) comparing outcomes following single-stage with two-stage management for concomitant gallstones and CBD stones published from 1990 to 2017 in PubMed, Embase and the Science Citation Index. The primary outcomes were stone clearance from the CBD, post-operative morbidity and mortality. The secondary outcomes were retained stone, conversion to other procedures, length of hospital stay and total operating time. Pooled risk ratio (RR) or weighted mean differences (WMD) with 95% confidence intervals (95% CIs) were calculated using either the fixed effects model or random effects model.

Results:

Eleven RCTs studies were included in this analysis. These studies included a total of 1338 patients: 666 underwent LC + LCBDE and 672 underwent LC + ERCP/EST. The meta-analysis showed that no significant difference was noted between the two groups regarding CBD stone clearance (RR: 1.06; 95% CI: 0.99–1.14; P = 0.12), post-operative morbidity (RR: 1.03; 95% CI: 0.79–1.34; P = 0.81), mortality (RR: 0.30; 95% CI: 0.06–1.41; P = 0.13), retained stone (RR: 0.91; 95% CI: 0.57–1.47; P = 0.71), conversion to other procedures (RR: 0.80; 95% CI: 0.55–0.16; P = 0.23), length of hospital stay (WMD: 1.24, 95% CI: 3.57–1.09, P = 0.30), total operating time (WMD: 25.42, 95% CI: 22.38–73.22, P = 0.30).

Conclusion:

Single-stage is efficient and safe in the treatment of patients with concomitant gallstones and CBD stones while avoiding the second procedure. In selected patients, single-stage management for concomitant gallstones and CBD stones might be considered as the preferred approach. However, the findings have to be carefully interpreted due to the existence of heterogeneity, in addition, patient's condition, operator's experience also should be taken into account in making treatment decisions.

Choledocholithiasis: Treatment Options in a Tertiary Care Setup in Pakistan

Introduction Among patients with cholelithiasis, choledocholithiasis may also be present in about 18% of cases. They can be treated through various endoscopic, laparoscopic, and open surgical procedures. Objective The objective of this study was to determine the outcome of patients with choledocholithiasis being treated in our setup. Methods This descriptive case series was conducted at Holy Family Hospital, Rawalpindi, Pakistan over two years from January 2015 to December 2016. All patients with choledocholithiasis admitted to Surgical Unit 1 were included in this study. All patients underwent elective endoscopic retrograde cholangiopancreatography (ERCP). In patients with successful ERCP, laparoscopic or open cholecystectomy was performed at a later date. In patients in whom ERCP failed, open surgical clearance of the common bile duct (CBD), along with cholecystectomy, was done. Results A total of 200 cases of choledocholithiasis were admitted during the study period. Most of the participants (73%) in this study were female. Liver function tests were found to be deranged in 88 patients (44%) and normal in 112 patients (56%). At presentation, 3.5% (n=7) had concomitant acute biliary pancreatitis and 8% (n=16) had cholangitis. Successful ERCP followed by cholecystectomy was performed in 88.5% of cases. On the other hand, 11.5% (n=23) patients had failed ERCP due to impacted stones. They underwent open surgical procedures, i.e. 43.48% (n=10) had choledochotomies, 47.82% (n=11) had choledochoduodenostomies and 8.69% (n=2) had hepaticojejunostomies. No postoperative mortality was observed. However, anastomotic leaking occurred in 8.69% cases (n=2). Conclusion A two-staged procedure consisting of ERCP, followed by laparoscopic cholecystectomy, should be the first line of treatment for common bile duct (CBD) stones. In cases where ERCP fails, open surgical procedures still remain a relevant and a definitive option in resource-constrained setups.

Cost-effective Decisions in Detecting Silent Common Bile Duct Gallstones During Laparoscopic Cholecystectomy

OBJECTIVE

To evaluate the cost-effectiveness of routine intraoperative ultrasonography (IOUS), cholangiography (IOC), or expectant management without imaging (EM) for investigation of clinically silent common bile duct (CBD) stones during laparoscopic cholecystectomy.

BACKGROUND

The optimal algorithm for the evaluation of clinically silent CBD stones during routine cholecystectomy is unclear.

METHODS

A decision tree model of CBD exploration was developed to determine the optimal diagnostic approach based on preoperative probability of choledocholithiasis. The model was parameterized with meta-analyses of previously published studies. The primary outcome was incremental cost per quality-adjusted life year (QALY) gained from each diagnostic strategy. A secondary outcome was the percentage of missed stones. Costs were from the perspective of the third party payer and sensitivity analyses were performed on all model parameters.

RESULTS

In the base case analysis with a prevalence of stones of 9%, IOUS was the optimal strategy, yielding more QALYs (0.9858 vs 0.9825) at a lower expected cost ($311 vs $574) than EM. IOC yielded more QALYs than EM in the base case (0.9854) but at a much higher cost ($1122). IOUS remained dominant as long as the preoperative probability of stones was above 3%; EM was the optimal strategy if the probability was less than 3%. The percentage of missed stones was 1.5% for IOUS, 1.8% for IOC and 9% for EM.

CONCLUSIONS

In the detection and resultant management of CBD stones for the majority of patients undergoing laparoscopic cholecystectomy, IOUS is cost-effective relative to IOC and EM.

Cost-effectiveness of emergency versus delayed laparoscopic cholecystectomy for acute gallbladder pathology

BACKGROUND

The optimal timing of cholecystectomy for patients admitted with acute gallbladder pathology is unclear. Some studies have shown that emergency cholecystectomy during the index admission can reduce length of hospital stay with similar rates of conversion to open surgery, complications and mortality compared with a 'delayed' operation following discharge. Others have reported that cholecystectomy during the index acute admission results in higher morbidity, extended length of stay and increased costs. This study examined the cost-effectiveness of emergency versus delayed cholecystectomy for acute benign gallbladder disease.

METHODS

Using data from a prospective population-based cohort study examining the outcomes of cholecystectomy in the UK and Ireland, a model-based cost-utility analysis was conducted from the perspective of the UK National Health Service, with a 1-year time horizon for costs and outcomes. Probabilistic sensitivity analysis was used to investigate the impact of parameter uncertainty on the results obtained from the model.

RESULTS

Emergency cholecystectomy was found to be less costly (£4570 versus £4720; €5484 versus €5664) and more effective (0·8868 versus 0·8662 QALYs) than delayed cholecystectomy. Probabilistic sensitivity analysis showed that the emergency strategy is more than 60 per cent likely to be cost-effective across willingness-to-pay values for the QALY from £0 to £100 000 (€0-120 000).

CONCLUSION

Emergency cholecystectomy is less costly and more effective than delayed cholecystectomy. This approach is likely to be beneficial to patients in terms of improved health outcomes and to the healthcare provider owing to the reduced costs.

Scoring System for the Management of Acute Gallstone Pancreatitis: Cost Analysis of a Prospective Study

Predicting the presence of a persistent common bile duct (CBD) stone is a difficult and expensive task. The aim of this study is to determine if a previously described protocol-based scoring system is a cost-effective strategy. The protocol includes all patients with gallstone pancreatitis and stratifies them based on laboratory values and imaging to high, medium, and low likelihood of persistent stones. The patient's stratification then dictates the next course of management. A decision analytic model was developed to compare the costs for patients who followed the protocol versus those that did not. Clinical data model inputs were obtained from a prospective study conducted at The Mount Sinai Medical Center to validate the protocol from Oct 2009 to May 2013. The study included all patients presenting with gallstone pancreatitis regardless of disease severity. Seventy-three patients followed the proposed protocol and 32 did not. The protocol group cost an average of $14,962/patient and the non-protocol group cost $17,138/patient for procedural costs. Mean length of stay for protocol and non-protocol patients was 5.6 and 7.7 days, respectively. The proposed protocol is a cost-effective way to determine the course for patients with gallstone pancreatitis, reducing total procedural costs over 12 %.

Surgeons, ERCP, and laparoscopic common bile duct exploration: do we need a standard approach for common bile duct stones?

BACKGROUND

Variation exists in the management of choledocholithiasis (CDL). This study evaluated associations between demographic and practice-related characteristics and CDL management.

METHODS

A 22-item, web-based survey was administered to US general surgeons. Respondents were classified into metropolitan or nonmetropolitan groups by zip code. Univariate tests and multivariable logistic regression were used to determine factors associated with CDL management preferences.

RESULTS

The survey was sent to 32,932 surgeons; 9902 performed laparoscopic cholecystectomy within the last year; 750 of 771 respondents had a valid US zip code and were included in the analysis. Mean practice time was 18 ± 10 years, 87% were male, and 83% practiced in a metropolitan area. For preoperatively known CDL, 86% chose preoperative endoscopic retrograde cholangiopancreatography (ERCP). Those in metropolitan areas were more likely to select preoperative ERCP than those in nonmetropolitan areas (88 vs. 79%, p < 0.001). For CDL discovered intraoperatively, 30% selected laparoscopic common bile duct exploration (LCBDE) as their preferred method of management with no difference between metropolitan and nonmetropolitan areas (30 vs. 26%, p = 0.335). The top reasons for not performing LCBDE were: having a reliable ERCP proceduralist available, lack of equipment, and lack of comfort performing LCBDE. Factors associated with preoperative ERCP were: metropolitan status, selective intraoperative cholangiography (IOC), and availability of a reliable ERCP proceduralist. Those who perform selective IOC were 70% less likely to prefer LCBDE (OR 0.32, 95% CI 0.18-0.57, p < 0.001). Those with a reliable ERCP proceduralist available were 90% less likely to prefer LCBDE (OR 0.10, 95% CI 0.04-0.26, p < 0.001).

CONCLUSIONS

The majority of respondents preferred ERCP for the management of CDL. Having a reliable ERCP proceduralist available, use of selective IOC, and metropolitan status were independently associated with preoperative ERCP. Postoperative ERCP was preferred for managing intraoperatively discovered CDL. Many surgeons are uncomfortable performing LCBDE, and increased training may be needed.

Single-session minimally invasive management of common bile duct stones

Up to 18% of patients submitted to cholecystectomy had concomitant common bile duct stones. To avoid serious complications, these stones should be removed. There is no consensus about the ideal management strategy for such patients. Traditionally, open surgery was offered but with the advent of endoscopic retrograde cholangiopancreatography (ERCP) and laparoscopic cholecystectomy (LC) minimally invasive approach had nearly replaced laparotomy because of its well-known advantages. Minimally invasive approach could be done in either two-session (preoperative ERCP followed by LC or LC followed by postoperative ERCP) or single-session (laparoscopic common bile duct exploration or LC with intraoperative ERCP). Most recent studies have found that both options are equivalent regarding safety and efficacy but the single-session approach is associated with shorter hospital stay, fewer procedures per patient, and less cost. Consequently, single-session option should be offered to patients with cholecysto-choledocholithiaisis provided that local resources and expertise do exist. However, the management strategy should be tailored according to many variables, such as available resources, experience, patient characteristics, clinical presentations, and surgical pathology.

Comparative quality of life study between endoscopic sphincterotomy and surgical choledochotomy

AIM: To determine quality of life improvement in choledocholithiasis patients who underwent endoscopic sphincterotomy (EST) versus open choledochotomy (OCT).

METHODS: Eligible choledocholithiasis patients (n = 216) hospitalized in the Changhai Hospital between May 2010 and January 2011 were enrolled into a prospective study using cluster sampling. Patients underwent EST (n = 135) or OCT (n = 81) depending on the patient’s wishes. Patients were followed-up with a field survey and by correspondence. Patients were also given the self-administered Gastrointestinal Quality of Life Index (GIQLI) to measure patient quality of life before surgery, and at two and six weeks after the procedures.

RESULTS: With respect to baseline patient characteristics, the EST and OCT groups were comparable. After the procedure, gallstones were completely eliminated in all patients. Among 216 eligible patients, 191 patients (88.4%) completed all three surveys, including 118 patients who underwent EST (118/135; 87.4%) and 73 patients who underwent OCT (73/81; 90.1%). EST was associated with a significantly shorter hospital stay than OCT (8.8 ± 6.5 vs 13.9 ± 6.7 d; P < 0.001). The GIQLI score was similar between the EST and OCT groups before cholelithotomy (103.0 ± 15.4 vs 99.7 ± 10.2), but increased significantly in the EST group at two weeks (113.4 ± 12.0 vs 107.2 ± 11.2; P < 0.001) and six weeks (120.7 ± 10.6 vs 116.9 ± 7.5; P < 0.05) after the procedures.

CONCLUSION: EST, compared with OCT, is associated with better postoperative quality of life in patients treated for choledocholithiasis.

Results of treatment of patients with gallstone disease and ductal calculi by single-stage laparoscopic cholecystectomy and bile duct exploration

INTRODUCTION

Choledocholithiasis is the most common cause of obstructive jaundice. Common bile duct stones are observed in 10-14% of patients diagnosed with gall bladder stones. In the case of gall bladder and common bile duct stones the procedure involves not only performing cholecystectomy but also removing the stones from bile ducts.

AIM

To compare the results of the treatment of patients with gallstone disease and ductal calculi by one-stage laparoscopic cholecystectomy and common bile duct exploration with two other methods: one-stage open cholecystectomy and common bile duct exploration, and a two-stage procedure involving endoscopic retrograde cholangiopancreatography (ERCP) followed by laparoscopic cholecystectomy.

MATERIAL AND METHODS

Between 2004 and 2011 three groups of 100 patients were treated for obstructive jaundice caused by choledocholithiasis. The first group of 42 patients underwent ERCP followed by laparoscopic cholecystectomy. The second group of 23 patients underwent open cholecystectomy and common bile duct exploration, whereas the third group of 35 patients underwent laparoscopic cholecystectomy with common bile duct exploration. The data were analysed prospectively. The methods were compared according to complete execution, bile duct clearance and complication rate. Complications were analysed according to Clavien's Classification of Surgical Complications. The results were compared using the ANOVA statistical test and Student's t-test in Statistica. Value of p was calculated statistically. A p-value less than 0.05 (p < 0.05) signified that groups differed statistically, whereas a p-value more than 0.05 (p > 0.05) suggested no statistically significant differences between the groups.

RESULTS

The procedure could not be performed in 11.9% of patients in the first group and in 14.3% of patients in the third group. Residual stones were found in 13.5% of the patients in the first group, in 4.3% of the patients in the second group and in 6.7% of the patients in the third group. According to Clavien's classification of complications grade II and III, we can assign the range in the first group at 21.6% for grade II and 0% for grade III, in the second group at 21.4% and 3.6% and in the third group at 6.7% and 3.3% respectively.

CONCLUSIONS

The use of all three methods of treatment gives similar results. One-stage laparoscopic cholecystectomy with common bile duct exploration is after all the least invasive, safer and more effective procedure.

Single-stage vs. two-stage management for concomitant gallstones and common bile duct stones: a prospective randomized trial with long-term follow-up

AIM

The preferred approach to the management of common bile duct (CBD) stones is uncertain, with single-stage laparoscopic cholecystectomy and CBD exploration vs. two-stage preoperative endoscopic CBD clearance followed by laparoscopic cholecystectomy being debated. To address this, a prospective randomized study which compared these two management strategies was undertaken.

METHODS

Between Jan 2002 and Dec 2005, patients with gallstones and common bile duct stones diagnosed by preoperative ultrasonography and magnetic resonance cholangiopancreatography were randomized to single-stage vs. two-stage treatment. In a single-stage group, laparoscopic cholecystectomy and CBD exploration were undertaken at the same operation, whereas in a two-stage group, endoscopic stone clearance was followed by laparoscopic cholecystectomy 2-5 days later. Early treatment success and complications and longer-term follow-up for the two groups were compared.

RESULTS

Two hundred twenty-one patients were enrolled in the trial, 110 in the single-stage group and 111 in the two-stage group. There was no significant difference in the success rate of CBD clearance (93.6 vs. 94.6%, p = 0.76) or the complication rates (3.6 vs. 5.1%, p = 0.527) between the groups. However, at longer-term follow-up, recurrent CBD stones were seen more often in the two-stage group (9.5 vs. 2.1%, p = 0.037).

CONCLUSION

The single-stage and two-stage approaches were equally effective in achieving initial clearance of CBD stones. However, recurrent CBD stones occurred more commonly in patients who had undergone two-stage treatment with initial endoscopic stone clearance, followed by laparoscopic cholecystectomy.

Use of rigid tubal ligation scope: Serendipity in laparoscopic common bile duct exploration

AIM

To assess the feasibility, safety of rigid tubal ligation scope in laparoscopic common bile duct (CBD) exploration.

MATERIALS AND METHODS

Rigid nephroscope was used for laparoscopic CBD exploration until one day we tried the same with the rigid tubal ligation scope, which was passed easily into CBD both proximally and distally visualising the interior of the duct for presence of stone that were removed using endoscopic retrograde cholangiopancreaticography (ERCP) basket. This serendipity led us to use this scope for numerous patients from then on. A total of 62 patients, including male and female, underwent laparoscopic CBD exploration after choledochotomy with rigid tubal ligation scope between March 2007 and December 2012 followed by cholecystectomy. All the patients had both cholelithiasis and choledocholithiasis with minimum duct diameter of 12 mm. A total of 48 patients were given T-tube through choledochotomy and closed, and the remaining 14 patients had primary closure of choledochotomy.

RESULTS

There were no intra-operative complications in any of the patients like CBD injury or portal vein injury. Post-operatively graded clamping of T-tube was done and was removed after 15 days in the patients who were given T-tube. None had retained the stone after T-tube cholangiography, which was done before removing the tube. Mean duration of follow up was 6 months. No patients had any complaints during the follow up.

CONCLUSION

Laparoscopic CBD exploration is also feasible with rigid tubal ligation scope. With experienced surgeons, CBD injury is very minimal and stone clearance can be achieved in almost all patients. This rigid tubal ligation scope can be an alternative to other rigid and flexible scopes.

One-stage versus Two-stage Management for Concomitant Gallbladder Stones and Common Bile Duct Stones in Patients with Obstructive Jaundice

No consensus exists regarding the optimal management of concomitant gallbladder stones and common bile duct stones (CBDS). Previous studies showed a significant association between the presence of obstructive jaundice and increased risk of postoperative complications and conversion to open surgery. This retrospective study evaluated the effectiveness and safety of one-stage (laparoscopic cholecystectomy [LC] plus laparoscopic common bile duct exploration) management versus two-stage (preoperative endoscopic retrograde cholangiopancreatography/endoscopic sphincterotomy 1 LC) management for patients with obstructive jaundice, concomitant gallbladder stones, and CBDS. One-stage management (n = 88) or two-stage management (n = 122) was used for 210 eligible patients between January 2009 and March 2011. Both types of management proved to be effective and safe. No significant difference was observed in terms of stone clearance from the common bile duct (CBD), postoperative morbidity, mortality, or conversion to open surgery. However, one-stage management was more cost-effective and decreased the number of procedures. In addition, postoperative hospital stay and operative time were shorter for patients who received one-stage management. Especially for patients with CBD greater than 1 cm in diameter, one-stage management is a better choice.

MRCP is not a cost-effective strategy in the management of silent common bile duct stones

BACKGROUND

Few formal cost-effectiveness analyses simultaneously evaluate radiographic, endoscopic, and surgical approaches to the management of choledocholithiasis.

STUDY DESIGN

Using the decision analytic software TreeAge, we modeled the initial clinical management of a patient presenting with symptomatic cholelithiasis without overt signs of choledocholithiasis. In this base case, we assumed a 10 % probability of concurrent asymptomatic choledocholithiasis. Our model evaluated four diagnostic/therapeutic strategies: universal magnetic resonance cholangiopancreatography (MRCP), universal endoscopic retrograde cholangiopancreatography (ERCP), laparoscopic cholecystectomy (LC), or laparoscopic cholecystectomy with universal intraoperative cholangiogram (LCIOC). All probabilities were estimated from a review of published literature. Procedure and intervention costs were equated with Medicare reimbursements. Costs of hospitalizations were derived from median hospitalization reimbursement for New York State using diagnosis-related groups (DRG). Sensitivity analyses were performed on all cost and probability variables.

RESULTS

The most cost-effective strategy in the diagnosis and management of symptomatic cholelithiasis with a 10 % risk of asymptomatic choledocholithiasis was LCIOC. This was followed by LC alone, MRCP, and ERCP. LC was preferred only when the probability that a retained CBD stone would eventually become symptomatic fell below 15 % or if the probability of technical success of an intraoperative cholangiogram (IOC) was less than 35 %. Universal MRCP and ERCP were both more costly and less effective than surgical strategies, even at a high probability of asymptomatic choledocholithiasis. Within the tested range for both procedural and hospitalization-related costs for any of the surgical or endoscopic interventions, LCIOC and LC were always more cost-effective than universal MRCP or ERCP, irrespective of the presence or absence of complications. Varying the cost, sensitivity, and specificity of MRCP had no effect on this outcome.

CONCLUSIONS

LC with routine IOC is the preferred strategy in a cost-effectiveness analysis of the management of symptomatic cholelithiasis with asymptomatic choledocholithiasis. MRCP was both more costly and less effective under all tested scenarios.

Synchronous vs sequential laparoscopic cholecystectomy for cholecystocholedocholithiasis

AIM: To compare synchronous laparoscopic cholecystectomy (LC) combined with endoscopic sphincterotomy (EST) and sequential LC combined with EST for treating cholecystocholedocholithiasis.

METHODS: A total of 150 patients were included and retrospectively studied. Among these, 70 were selected for the synchronous operation, in which the scheme was endoscopic retrograde cholangiopancreatography combined with EST during LC. The other 80 patients were selected for the sequential operation, in which the scheme involved first cutting the papillary muscle under endoscopy and then performing LC. The indexes in the two groups, including the operation time, the success rate, the incidence of complications, and the length of the hospital stay, were observed.

RESULTS: There were no significant differences between the groups in terms of the numbers of patients, sex distribution, age, American Society of Anesthesiologists score, serum bilirubin, γ-glutamyl transpeptidase, mean diameter of common bile duct stones, and previous medical and surgical history (P = 0.54, P = 0.18, P = 0.52, P = 0.22, P = 0.32, P = 0.42, P = 0.68, P = 0.70, P = 0.47 and P = 0.57). There was no significant difference in the surgical operation time between the two groups (112.1 ± 30.8 min vs 104.9 ± 18.2 min). Compared with the sequential operation group, the incidence of pancreatitis was lower (1.4% vs 6.3%), the incidence of hyperamylasemia (1.4% vs 10.0%, P < 0.05) was significantly reduced, and the length of the hospital stay was significantly shortened in the synchronous operation group (3 d vs 4.5 d, P < 0.001).

CONCLUSION: For treatment of cholecystocholedocholithiasis, synchronous LC combined with EST reduces incidence of complications, decreases length of hospital stay, simplifies the surgical procedure, and reduces operation time.

Two-stage vs single-stage management for concomitant gallstones and common bile duct stones

AIM: To evaluate the safety and effectiveness of two-stage vs single-stage management for concomitant gallstones and common bile duct stones.

METHODS: Four databases, including PubMed, Embase, the Cochrane Central Register of Controlled Trials and the Science Citation Index up to September 2011, were searched to identify all randomized controlled trials (RCTs). Data were extracted from the studies by two independent reviewers. The primary outcomes were stone clearance from the common bile duct, postoperative morbidity and mortality. The secondary outcomes were conversion to other procedures, number of procedures per patient, length of hospital stay, total operative time, hospitalization charges, patient acceptance and quality of life scores.

RESULTS: Seven eligible RCTs [five trials (n = 621) comparing preoperative endoscopic retrograde cholangiopancreatography (ERCP)/endoscopic sphincterotomy (EST) + laparoscopic cholecystectomy (LC) with LC + laparoscopic common bile duct exploration (LCBDE); two trials (n = 166) comparing postoperative ERCP/EST + LC with LC + LCBDE], composed of 787 patients in total, were included in the final analysis. The meta-analysis detected no statistically significant difference between the two groups in stone clearance from the common bile duct [risk ratios (RR) = -0.10, 95% confidence intervals (CI): -0.24 to 0.04, P = 0.17], postoperative morbidity (RR = 0.79, 95% CI: 0.58 to 1.10, P = 0.16), mortality (RR = 2.19, 95% CI: 0.33 to 14.67, P = 0.42), conversion to other procedures (RR = 1.21, 95% CI: 0.54 to 2.70, P = 0.39), length of hospital stay (MD = 0.99, 95% CI: -1.59 to 3.57, P = 0.45), total operative time (MD = 12.14, 95% CI: -1.83 to 26.10, P = 0.09). Two-stage (LC + ERCP/EST) management clearly required more procedures per patient than single-stage (LC + LCBDE) management.

CONCLUSION: Single-stage management is equivalent to two-stage management but requires fewer procedures. However, patient’s condition, operator’s expertise and local resources should be taken into account in making treatment decisions.

[Minimising hospital costs in the treatment of bile duct calculi: a comparison study]

INTRODUCTION

The treatment of bile duct calculi associated with cholelithiasis is controversial. The hospital costs could be a decisive factor in choosing between the different therapeutic options.

OBJECTIVES

To compare the effectiveness and costs of two options in the treatment of common bile duct calculi: 1) One-stage: Laparoscopic cholecystectomy and bile duct exploration, and 2) Two-stage: sequential endoscopic retrograde cholangiopancreatography and laparoscopic cholecystectomy.

MATERIAL AND METHODS

A retrospective, observational study was performed on 49 consecutive patients with bile duct calculi and gallbladder in situ, treated consecutively and simultaneously over a two year period. The post-operate complication, hospital stay, number of procedures per patient, conversion to laparotomy, efficacy of removing the calculi, and hospital costs.

RESULTS

There were no differences as regards the patient clinical features or morbidity. The mean post-surgical hospital stay for the One-stage group was less than that in the Two-stage group. Three patients of the Two-stage group required conversion to laparotomy. The median costs per patient were less for the One-stage strategy, representing an overall saving of 37,173€ during the period studied.

CONCLUSIONS

No significant differences were found between the two treatment options as regards efficacy or post-surgical morbidity and mortality, but there were differences in hospital stay and costs. The management of patients with gallstones in one-stage surgery represents a saving of 3 days hospital stay and 1,008€ per patient.

Cost-effectiveness analysis of pancreatin minimicrospheres in patients with pancreatic exocrine insufficiency due to chronic pancreatitis

OBJECTIVE

Chronic pancreatitis (CP) is the most common cause of pancreatic exocrine insufficiency (PEI). Management of PEI due to CP is achieved through lifelong treatment with pancreatic enzyme replacement therapy (PERT). To the authors' knowledge, no cost-effectiveness analysis on the benefit of PERT in CP patients with PEI has been performed to date. The objective of this analysis was to examine the cost-effectiveness of Creon (pancreatin minimicrospheres [MMS]), one of the main PERTs available in Poland, in treating patients with CP-related PEI.

METHODS

The cost-effectiveness of pancreatin MMS in the treatment of patients with CP-related PEI vs no PERT treatment was estimated using a decision analysis based on clinical data from relevant studies. The model horizon was 20 years. Main outcomes included the percentage of patients with controlled PEI, survival, total medical costs, number of quality-adjusted life years (QALYs), and the incremental cost-effectiveness ratio (ICER). All costs were analysed from the Polish payer perspective.

RESULTS

The model included clinical data from 176 patients treated in five pancreatin MMS randomized trials. Treatment with pancreatin MMS resulted in a considerably higher proportion of patients with controlled PEI compared to those not treated with any PERT. Over a horizon of 20 years, the total treatment cost and the ICER for pancreatin MMS was €8223 and €6312 per QALY, respectively.

LIMITATIONS

Important limitations include the lack of long-term and comparative clinical data available. The use of 'no PERT treatment' as a comparator against pancreatin MMS treatment may not accurately reflect current practice in Poland.

CONCLUSIONS

Treatment of CP-related PEI with pancreatin MMS is cost-effective from a Polish payer perspective, with an ICER below the accepted 'willingness to pay' threshold of 3-times gross domestic product (GDP) per capita. These results are likely to apply to other European countries.

Choledocholithiasis management in rural America: health disparity or health opportunity?

BACKGROUND

Choledocholithiasis (CDL) management is dictated by local expertise, individual training, and availability of appropriate staff. This study evaluates the management of CDL between urban and rural communities.

MATERIALS AND METHODS

Patients undergoing inpatient management of CDL were identified from the 2007 Healthcare Cost and Utilization Project. Availability of endoscopic retrograde cholangiopancreatography (ERCP) was determined from the 2007 American Hospital Association survey. The proportion of common bile duct exploration (CBDE), ERCP, or percutaneous (PERC) interventions were compared across census regions and National Centers for Health Statistics (NCHS) urban-rural classes. The NCHS urban-rural classification scheme divides counties from most populous (NCHS 1) to rural (NCHS 6). Proportions were compared using the 95% confidence interval (95%CI) approach.

RESULTS

We estimated 111,021 CDL hospitalizations in the U.S. in 2007. Of these, 67% had a coded intervention. Intervention frequencies were similar across census regions. Comparisons across NCHS classes revealed higher proportions of ERCP in urban areas (NCHS 1-4) while a higher proportion of CBDE was seen in rural areas (NCHS 5-6). ERCP availability was high in metropolitan areas (available in 35%-44% of hospitals NCHS 1-4) and low in rural areas (25% of NCHS 5 hospitals and 5% NCHS 6). PERC management was similar across NCHS classes.

CONCLUSIONS

Rural hospitals and communities need surgeons trained in CBDE, where ERCP expertise may not be readily available. Feasible ways of expanding ERCP coverage to the nation's rural areas need to be explored. These observations may impact surgical training at least for those targeting careers in rural surgery.

Cost-effective treatment of patients with symptomatic cholelithiasis and possible common bile duct stones

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 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.

Preoperative versus intraoperative endoscopic sphincterotomy for management of common bile duct stones

BACKGROUND

ERCP remains the prevailing method of treating CBDS; however, its ideal timing in respect to laparoscopic cholecystectomy (LC) is not defined. LC combined with intraoperative endoscopic sphincterotomy (IOES) was compared with preoperative endoscopic sphincterotomy (PES) followed by LC for management of preoperatively known cholecystocholedocholithiasis.

METHODS

Between June 2006 and September 2009, 198 patients diagnosed preoperatively by clinical assessment, liver chemistry, ultrasonography, and magnetic resonance cholangiopancreatography (MRCP) to have combined choledochocystolithiasis were eligible. They were randomly divided into two groups: PES/LC group (n = 100) and LC/IOES group (n = 98). The surgical times, surgical success rates, number of stone extractions, postoperative complications, retained common bile duct stones, and postoperative lengths of stay were compared prospectively.

RESULTS

There were no statistically significant differences in surgical time, surgical success rate, CBD diameter, stone size, or stone number between the two groups. The success rate was 95.3% and 97.8% for PES/LC and LC/IOES, respectively. There were no significant difference in postoperative retained stones, surgical time, and complications, but the total hospital stay was significantly shorter in the LC/IOES group.

CONCLUSIONS

PES/LC and LC/IOES are both good options for dealing with preoperatively diagnosed CBDS, but when there is enough experience and facilities, LC/IOES, as a single-stage treatment, would be preferable.

Simultaneous laparoendoscopic rendezvous for the treatment of cholecystocholedocholithiasis

BACKGROUND

Different approaches are available for the treatment of combined cholecystocholedocholithiasis including totally laparoscopic (TL) treatment, simultaneous laparoendoscopic treatment, and sequential treatments (ST) combining endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic sphincterotomy (ES) with cholecystectomy. This review aimed to clarify the issue of the simultaneous laparoendoscopic rendezvous (RV).

METHODS

A careful analysis of papers was performed to determine the results, technical differences, limits, disadvantages, and advantages of RV compared with other options.

RESULTS

Data were collected from 27 papers concerning 795 patients. The overall effectiveness of RV was 92.3%. The morbidity rate was 5.1%, and the mortality rate was 0.37%. Almost all the authors were satisfied with the procedure. The authors' comparison to ST and TL showed that the advantages outweigh the disadvantages mostly related to logistical problems.

CONCLUSIONS

There is confusion concerning the definitions and techniques of RV due to differences in combining surgical and endoscopic steps of the procedure. The results are at least comparable with those of the other available approaches. The effectiveness of RV is greater with reciprocal implementation of surgical and endoscopic procedures. The morbidity and the risk of iatrogenic damage seem lower than with ERCP-ES and the risk of residual stones lower than with TL treatment. The RV procedure is safe and can sometimes be the preferable option, but collaboration between surgeon and endoscopist is mandatory.

Cost minimization analysis comparing diagnostic strategies in unexplained pancreatitis

OBJECTIVES

Both endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasonography (EUS) are commonly performed in the evaluation of idiopathic pancreatitis. However, comparative trials of these modalities are lacking, and thus the ideal endoscopic diagnostic strategy to evaluate idiopathic pancreatitis remains unknown.

METHODS

A decision analysis model of patients with 2 attacks of idiopathic pancreatitis with gallbladder in situ was constructed using TreeAge software. We analyzed cost and overall diagnostic ability of 3 strategies, namely, EUS, ERCP with manometry and bile aspiration, and laparoscopic cholecystectomy.

RESULTS

Using the base case analysis, initial EUS was the preferred initial modality for the diagnosis. The expected cost for initial EUS was $4469 compared with $4615 for ERCP and $6268 for laparoscopic cholecystectomy. For cholecystectomy to be the preferred strategy, the total cost would need to be less than $1314, well below any realistic cost estimate. If the prevalence of microlithiasis/sludge was greater than 80%, then cholecystectomy would be preferred, whereas ERCP would be preferred with a prevalence of less than 41%.

CONCLUSIONS

This cost minimization study identifies EUS as the least costly initial test for the diagnostic evaluation of patients with idiopathic pancreatitis with gallbladder in situ.