Nonsurgical treatment of cholelithiasis. An analysis of clinical opportunity

Cholecystectomy in Sweden 1989 and 1994: long admissions assessed by the inpatient registry

The purpose of this study was to compare cholecystectomy in Sweden (pop. 8.9 million) 1989 to 1994 when the diffusion of laparoscopic cholecystectomy (LC) was completed, focusing on long hospital admissions as a proxy indicator of adverse events. This was an observational study of all patients operated on with cholecystectomy in 1989 and 1994 (n = 19,432) from the National Inpatient Registry. The risk of a long admission was analyzed by multivariate analyses. Odds ratios of long admissions were computed considering gender, age groups, acute or chronic gallstone disease, 1989 and 1994, county level of operations per 1000 inhabitants, and hospital categories. Stratified analyses were performed by acuteness of disease, and year. Long admissions were defined as lasting longer than 20 days in 1989 and 14 days in 1994. Odds ratios of a long admission increased steeply with age and acute gallstone disease. The county level of operations per 1000 inhabitants had no influence on risk nor did hospital category. The absolute number of those operated on with an acute gallstone disease changed little between 1989 and 1994, whereas operations for chronic disease increased significantly. Stratification revealed that their risk of a long admission was increased both in 1989 and 1994, particularly for women. Those with chronic gallstone disease had no increased risk. After the introduction of the laparoscope and a rise in the number of cholecystectomies, patients with chronic gallstone disease seem to have a constant risk of long hospital stay. However, because patients with acute disease had an increased risk in both 1989 and 1994, further longitudinal analyses are needed to analyze the level of complications in this group.

Treatment of symptomatic cholelithiasis in France. A decision analysis comparing cholecystectomy and biliary lithotripsy

To determine the potential role of extracorporeal shock wave lithotripsy (ESWL) in the treatment of symptomatic gallstone patients in France, a simulation model evaluated the health and economic effects of three different treatment strategies. Decision analysis of conventional cholecystectomy alone and either of two strategies using a combination of biliary lithotripsy and conventional cholecystectomy reveals that a strategy employing biliary ESWL results in a significant number of successfully treated patients, thus avoiding the risks and costs of abdominal surgery. Moreover, cost analysis shows that expanding the use of lithotripsy to all patients for whom the procedure is indicated increases the average cost per successfully treated patient, but, more importantly, decreases the overall costs incurred by the cohort. From a societal viewpoint, a policy using biliary ESWL in appropriate patients is superior to one of cholecystectomy alone, from both clinical and economic perspectives.