Department of Surgery, Vanderbilt University Medical Center, Nashville, TN 37232-4753, USA.
J Am Coll Surg. 2012 Jun;214(6):919-27. doi: 10.1016/j.jamcollsurg.2012.01.054. Epub 2012 Apr 10.
Controversy exists regarding the optimal timing of repair after iatrogenic bile duct injuries (BDI). Several studies advocate late repair (≥6 weeks after injury) with mandatory drainage and resolution of inflammation. Others indicate that early repair (<6 weeks after injury) produces comparable or superior clinical outcomes. Additionally, although most studies have reported inferior outcomes with primary surgeon repair, this practice continues. With disparate published recommendations and rising health care costs, decision analysis was used to examine the cost-effectiveness of BDI repair.
A Markov model was developed to evaluate primary surgeon repair (PSR), late repair by a hepatobiliary surgeon (LHBS), and early repair by a hepatobiliary surgeon (EHBS). Baseline values and ranges were collected from the literature. Sensitivity analsyses were conducted to test the strength of the model and variability of parameters.
The model demonstrated that EHBS was associated with lower costs, earlier return to normal activity, and better quality of life. Specifically, 1 year after repair, PSR yielded 0.53 quality adjusted life years (QALYs) ($120,000/QALY) and LHBS yielded 0.74 QALYs ($74,000/QALY); EHBS yielded 0.82 QALYs ($48,000/QALY). Sensitivity analyses supported these findings at clinically meaningful probabilities.
This cost-effectiveness model demonstrates that early repair by a hepatobiliary surgeon is the superior strategy for the treatment of BDI in properly selected patients. Although there is little clinical difference between early and late repair, there is a great difference in cost and quality of life. Ideally, costs and quality of life should be considered in decisions regarding strategies of repair of injured bile ducts.
医源性胆管损伤（BDI）后修复的最佳时机存在争议。一些研究主张延迟修复（损伤后≥6 周），并强制性引流和炎症消退。另一些研究则表明早期修复（损伤后<6 周）可产生相似或更优的临床结果。此外，尽管大多数研究报告原发性外科医生修复的结果较差，但这种做法仍在继续。由于发表的建议存在差异且医疗保健成本不断上升，因此使用决策分析来研究 BDI 修复的成本效益。
开发了一个 Markov 模型来评估原发性外科医生修复（PSR）、由肝胆外科医生进行的延迟修复（LHBS）和由肝胆外科医生进行的早期修复（EHBS）。基础值和范围从文献中收集。进行了敏感性分析，以测试模型的强度和参数的可变性。
该模型表明，EHBS 与较低的成本、更早地恢复正常活动和更好的生活质量相关。具体来说，在修复后 1 年，PSR 产生 0.53 个质量调整生命年（QALY）（$120,000/QALY），LHBS 产生 0.74 个 QALY（$74,000/QALY）；EHBS 产生 0.82 个 QALY（$48,000/QALY）。在具有临床意义的概率下，敏感性分析支持这些发现。
该成本效益模型表明，在适当选择的患者中，由肝胆外科医生进行早期修复是治疗 BDI 的更优策略。尽管早期和晚期修复之间的临床差异很小，但在成本和生活质量方面存在很大差异。理想情况下，在决定修复受伤胆管的策略时，应考虑成本和生活质量。
