Optimizing Choledocholithiasis Management

Abstract

Endoscopic retrograde cholangiopancreatography (ERCP) is more cost-effective for managing incidental choledocholithiasis (CDL) after laparoscopic cholecystectomy and intraoperative cholangiogram (LC/IOC) than laparoscopic common bile duct exploration (LCBDE). A cost-effectiveness analysis was performed to compare ERCP with LCBDE. Sensitivity analyses were performed to determine the key contributors to cost-effectiveness between the 2 treatment options. Costs were approached from the institutional perspective considering a typical patient undergoing LC/IOC at a large referral center. The base case patient evaluated was a woman 18 years of age or older with symptomatic cholelithiasis and incidental CDL discovered at the time of LC/IOC. Endoscopic retrograde cholangiopancreatography with drainage procedure performed after LC/IOC or LCBDE during LC/IOC. Costs, quality-adjusted life years gained, mean cost-effectiveness ratios, and incremental cost-effectiveness ratios. In the base case analysis, ERCP was the optimal treatment choice with a cost of $24 300 for 0.9 quality-adjusted life years gained compared with $28 400 and 0.88 quality-adjusted life years for LCBDE. Endoscopic retrograde cholangiopancreatography remained the optimal strategy for CDL in multiway probabilistic sensitivity analysis. If LCBDE were performed and the cost of a potential operative case lost was $3100 or less and the cost of ERCP hospitalization was $18 000 or more, then LCBDE became the preferred treatment for CDL. Endoscopic retrograde cholangiopancreatography was both less costly and more effective than LCBDE. Factors important to choosing the best strategy for CDL management included the cost of a potential case lost due to LCBDE performance and the cost of ERCP hospitalization.