Nagorney D M, Lohmuller J L
Department of Surgery, Mayo Clinic, Rochester, Minnesota 55905.
Ann Surg. 1990 Mar;211(3):354-9. doi: 10.1097/00000658-199003000-00007.
Although choledochoscopy for the prevention of retained bile duct stones has been postulated as cost effective, no economic evaluation exists to substantiate this claim. We performed a cost-minimization analysis on 287 patients who underwent choledochoscopy during operations for biliary tract calculi between 1981 and 1987 to assess the economic impact of choledochoscopy versus noncholedochoscopic alternatives in obtaining a stone-free duct. Common duct exploration was positive for calculi in 75% of patients. Choledochoscopy-detected residual stones after duct exploration in 10% of patients. Residual stones were more frequent after positive (12.5%) than negative (2.7%) duct explorations. retained stones occurred in 4.5% of patients after operation. Sensitivity, specificity, and negative predictive values of choledochoscopy were 67%, 100%, and 95%, respectively. Cost-minimization analysis showed that total cost of either selective ($75,250) or routine ($110,450) choledochoscopy significantly exceeded the total cost of obtaining a stone-free duct for patients with retained stones via either extraction through a T-tube tract ($17,545) or by endoscopic papillotomy ($45,675). Because choledochoscopy was not economically competitive with noncholedochoscopic, nonoperative alternatives, reduction of choledochoscopy fees was implemented to economically justify continued use of choledochoscopy. We conclude that choledochoscopy is clinically efficacious in obtaining a stone-free duct, but endorsement of either routine or selective choledochoscopy by cost-minimization analysis requires careful assessment of fee structure to make choledochoscopy competitive economically.
尽管有人假定胆管镜检查预防胆管残留结石具有成本效益，但尚无经济评估来证实这一说法。我们对1981年至1987年间因胆道结石手术而接受胆管镜检查的287例患者进行了成本最小化分析，以评估胆管镜检查与非胆管镜检查替代方法在实现无结石胆管方面的经济影响。75%的患者胆总管探查发现结石。胆管镜检查在10%的患者胆管探查后检测到残留结石。阳性胆管探查后残留结石更常见（12.5%），而阴性胆管探查后残留结石较少见（2.7%）。术后4.5%的患者出现残留结石。胆管镜检查的敏感性、特异性和阴性预测值分别为67%、100%和95%。成本最小化分析表明，选择性（75,250美元）或常规（110,450美元）胆管镜检查的总成本显著超过了通过经T管窦道取石（17,545美元）或内镜乳头切开术（45,675美元）为残留结石患者获得无结石胆管的总成本。由于胆管镜检查在经济上与非胆管镜检查的非手术替代方法不具竞争力，因此降低了胆管镜检查费用，以便从经济角度证明继续使用胆管镜检查的合理性。我们得出结论，胆管镜检查在获得无结石胆管方面具有临床疗效，但通过成本最小化分析认可常规或选择性胆管镜检查需要仔细评估费用结构，以使胆管镜检查在经济上具有竞争力。
