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Cost-effective Decisions in Detecting Silent Common Bile Duct Gallstones During Laparoscopic Cholecystectomy

Sun, Susie X. MD; Kulaylat, Afif N. MD; Hollenbeak, Christopher S. PhD; Soybel, David I. MD

doi: 10.1097/SLA.0000000000001348

Objective: To evaluate the cost-effectiveness of routine intraoperative ultrasonography (IOUS), cholangiography (IOC), or expectant management without imaging (EM) for investigation of clinically silent common bile duct (CBD) stones during laparoscopic cholecystectomy.

Background: The optimal algorithm for the evaluation of clinically silent CBD stones during routine cholecystectomy is unclear.

Methods: A decision tree model of CBD exploration was developed to determine the optimal diagnostic approach based on preoperative probability of choledocholithiasis. The model was parameterized with meta-analyses of previously published studies. The primary outcome was incremental cost per quality-adjusted life year (QALY) gained from each diagnostic strategy. A secondary outcome was the percentage of missed stones. Costs were from the perspective of the third party payer and sensitivity analyses were performed on all model parameters.

Results: In the base case analysis with a prevalence of stones of 9%, IOUS was the optimal strategy, yielding more QALYs (0.9858 vs 0.9825) at a lower expected cost ($311 vs $574) than EM. IOC yielded more QALYs than EM in the base case (0.9854) but at a much higher cost ($1122). IOUS remained dominant as long as the preoperative probability of stones was above 3%; EM was the optimal strategy if the probability was less than 3%. The percentage of missed stones was 1.5% for IOUS, 1.8% for IOC and 9% for EM.

Conclusions: In the detection and resultant management of CBD stones for the majority of patients undergoing laparoscopic cholecystectomy, IOUS is cost-effective relative to IOC and EM.

*Department of Surgery, The Pennsylvania State University, College of Medicine, Hershey, PA

Department of Public Health Sciences, The Pennsylvania State University, College of Medicine, Hershey, PA.

Reprints: David I. Soybel, MD, Division of General Surgery Specialties and Surgical Oncology, Department of Surgery, College of Medicine, The Pennsylvania State University, 500 University Drive, Hershey, PA 17033-0850. E-mail:

Disclosure: This original study is a cost-effectiveness analysis. The authors declare no conflicts of interest.

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