Morrell David J, Pauli Eric M, Hollenbeak Christopher S
Department of Surgery, Penn State Health Milton S. Hershey Medical Center, Hershey, PA, USA.
Department of Health Policy and Administration, Pennsylvania State University, State College, University Park, PA, USA.
J Gastrointest Surg. 2022 Apr;26(4):837-848. doi: 10.1007/s11605-022-05249-5. Epub 2022 Jan 26.
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.
背景：胆总管结石较为常见。其治疗通常采用腹腔镜胆总管探查术或内镜逆行胰胆管造影术（相对于腹腔镜胆囊切除术，可在术前、术中或术后进行）。本研究的目的是确定治疗住院患者胆总管结石最具成本效益的方法。 方法：创建决策树模型以评估腹腔镜胆总管探查术以及术前、术中、术后内镜逆行胰胆管造影术的成本效益。主要结果是增量成本效益比，假定支付意愿上限为每质量调整生命年100,000美元。模型参数通过查阅已发表文献和机构数据确定。成本从医疗保健系统的角度计算，时间范围为1年。对模型参数进行敏感性分析。 结果：在基础病例分析中，腹腔镜胆总管探查术具有成本效益，预期成本为18,357美元，可产生0.9909个质量调整生命年。术中内镜逆行胰胆管造影术可产生更多的质量调整生命年（0.9912），但成本更高（19,717美元），增量成本效益比为4,789,025美元，超过了支付意愿阈值。术前和术后内镜逆行胰胆管造影术因成本更高且效果更差而被排除。如果胆管清除成功的概率高于0.79，且所有其他变量保持不变，腹腔镜胆总管探查术仍具有成本效益。如果其基础成本保持在18,400美元以下，而术中内镜逆行胰胆管造影术的基础成本升至18,200美元以上，那么腹腔镜胆总管探查术仍具有成本效益。 结论：腹腔镜胆总管探查术是治疗胆总管结石最具成本效益的方法。有必要努力确保当地具备开展该手术的专业知识和资源。
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