Optimizing choledocholithiasis management - A cost-effectiveness analysis

Hypothesis: 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). Design: 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. Setting: Costs were approached from the institutional perspective considering a typical patient undergoing LC/IOC at a large referral center. Patients: 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. Interventions: Endoscopic retrograde cholangiopancreatography with drainage procedure performed after LC/IOC or LCBDE during LC/IOC. Main Outcome Measures: Costs, quality-adjusted life years gained, mean cost-effectiveness ratios, and incremental cost-effectiveness ratios. Results: In the base case analysis, ERCP was the optimal treatment choice with a cost of $24300 for 0.9 quality-adjusted life years gained compared with $28400 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 $18000 or more, then LCBDE became the preferred treatment for CDL. Conclusions: 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.