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

Assessing the impact of center volume on the cost-effectiveness of centralizing ERCP

BACKGROUND AND AIMS

ERCP is a complex endoscopic procedure in which the center's procedure volume influences outcomes. With the increasing healthcare expenses and limited resources, promoting cost-effective care becomes essential for healthcare provision. This study was a cost-effectiveness analysis to evaluate the hypothesis that high-volume (HV) centers perform ERCP with higher quality at lower costs than low-volume (LV) centers.

METHODS

A baseline case compared the current distribution of ERCPs among HV and LV centers with a hypothetical scenario in which all ERCPs are performed at HV centers. A cost-effectiveness analysis was constructed, followed by 1- and 2-way sensitivity analyses, and probabilistic sensitivity analysis using Monte Carlo simulations.

RESULTS

In the baseline case, the incremental cost-effectiveness ratio was -$151,270 per year, due to the hypothetical scenario's lower costs and slightly higher quality-adjusted life years. The model was most sensitive to changes in transportation costs (109.34%), probability of significant adverse events (AEs) after successful ERCP at LV centers (42.12%), utility after ERCP with significant AEs (30.10%), and probability of significant AEs after successful ERCP at HV centers (23.53%); only transportation costs above $3655 changed the study outcome, however. The current ERCP distribution would only be cost-effective if LV centers achieved higher success (≥92.4% vs 89.3%), with much lower significant AEs (≤.5% vs 6.7%). The study's main findings remained unchanged while combining all model parameters in the probabilistic sensitivity analysis.

CONCLUSIONS

Our findings show that HV centers have high-performance rates at lower costs, raising the need to consider the principle of centralization of ERCPs into HV centers to improve the quality of care.

The Safety and Cost Analysis of Outpatient Laparoendoscopy in the Treatment of Cholecystocholedocholithiasis: A Retrospective Study

INTRODUCTION

The advantages of single-stage treatment of cholecystocholedocholithiasis are well established, but the conditions for carrying out treatment on an outpatient basis require a review of concepts and practices of medical corporations.

OBJECTIVE

To evaluate the practice of treating cholecystocholedocholithiasis by laparoendoscopy on an outpatient basis with cost analysis.

METHOD

A retrospective study was conducted on patients with cholecystocholedocholithiasis treated by combined laparoscopic cholecystectomy and endoscopic choledocholithotomy from January 2015 to January 2019. After collecting data from physical and digital medical records, the patients were divided into two groups-AR (n = 42)-ambulatory regimen and HR (n = 28)-hospitalization regimen-which were compared in terms of demographic, clinical and treatment variables and their results, as well as in terms of costs.

RESULTS

The mean age of the AR group was lower than that of the HR group and the physical status of the AR patients was better when assessed according to the American Society of Anesthesiologists (ASA) (p = 0.01). There was no difference between groups regarding the risk of choledocholithiasis (p = 0.99). For the AR group, the length of stay was shorter: 11.29 h × 65.21 h (p = 0.02), as was the incidence of postoperative complications assessed by applying the Clavien-Dindo classification: 3 (7.1%) × 11 (39.2%) (p < 0.01). The total mean costs were higher for the HR group (USD 2489.93) than the AR group (USD 1650.98) (p = 0.02).

CONCLUSION

Outpatient treatment of cholecystocholedocholithiasis by laparoendoscopy is safe and viable for most cases, has a lower cost and can support the reorientation of training and practice of hepatobiliary surgeons.

A Systematic Review of Laparoscopic Ultrasonography During Laparoscopic Cholecystectomy

We aim to investigate the potential of laparoscopic ultrasonography (LUS) as a replacement for intraoperative cholangiography (IOC) in the context of laparoscopic cholecystectomy focusing on various aspects related to both techniques. We made our search through PubMed, Web of Science, Cochrane Library, and Scopus, with the use of the following search strategy: ("laparoscopic ultrasonography" OR LUS OR "laparoscopic US" OR "laparoscopic ultrasound") AND ("laparoscopic cholecystectomy" OR LC). We incorporated diverse studies that addressed our topic, offering data on the identification of biliary anatomy and variations, the utilization of laparoscopic ultrasound in cholecystitis, the detection of common bile duct stones, and the criteria utilized to assess the accuracy of LUS. A total of 1526 articles were screened and only 20 were finally included. This systematic review assessed LUS and IOC techniques in cholecystectomy. IOC showed higher failure rates due to common duct catheterization challenges, while LUS had lower failure rates, often linked to factors like steatosis. Cost-effectiveness comparisons favored LUS over IOC, potentially saving patients money. LUS procedures were quicker due to real-time imaging, while IOC required more time and personnel. Bile duct injuries were discussed, highlighting LUS limitations in atypical anatomies. LUS aided in diagnosing crucial conditions, emphasizing its relevance post surgery. Surgeon experience significantly impacted outcomes, regardless of the technique. A previous study discussed that LUS's learning curve was steeper than IOC's, with proficient LUS users adjusting practices and using IOC selectively. Highlighting LUS's benefits and limitations in cholecystectomy, we stress its value in complex anatomical situations. LUS confirms no common bile duct stones, avoiding cannulation. LUS and IOC equally detect common bile duct stones and visualize the biliary tree. LUS offers safety, speed, cost-effectiveness, and unlimited use. Despite the associated expenses and learning curve, the enduring benefits of using advanced probes in LUS imaging suggest that it could surpass traditional IOC. The validation of this potential advancement relies heavily on incorporating modern probe studies. Our study could contribute to the medical literature by evaluating their clinical validity, safety, cost-effectiveness, learning curve, patient outcomes, technological advancements, and potential impact on guidelines and recommendations for clinical professionals.

Detection and management of bile duct injury during cholecystectomy

INTRODUCTION

Cholecystectomy represents one of the most performed surgical procedures. Bile duct injuries (BDIs) are a dangerous complication of this intervention. With the advent of the laparoscopy, the rate of BDIs showed a growing trend that was partially justified by the learning curve of this technique.

EVIDENCE ACQUISITION

A literature search was conducted on Embase, Medline, and Cochrane databases to identify studies published up to October 2022 that analyzed the intraoperative detection and management of BDIs diagnosed during cholecystectomy.

EVIDENCE SYNTHESIS

According to the literature, approximately 25% of BDIs is diagnosed during the laparoscopic cholecystectomy. In the clinical suspicion of BDI, an intraoperative cholangiography is performed to confirm it. Complimentary technology, such as near-infrared cholangiography, can be also adopted. Intraoperative ultrasound represents a useful tool to furtherly define the biliary and the vascular anatomy. The proper classification of the type of BDI allows to identify the correct treatment. When a good expertise in hepato-pancreato-biliary surgery is available, a direct repair is performed with good outcomes both in case of simple and complex lesions. When the local resources are limited or there is a lack of dedicated surgical experience, patient referral to a reference center shows better outcomes. In particular, complex vasculo-biliary injuries require a highly specialized treatment. The key elements to transfer the patients are a good documentation of the injury, a proper drainage of the abdomen, and an antibiotic therapy.

CONCLUSIONS

BDI management requires a proper diagnostic process and prompt treatment to reduce the morbidity and mortality of this feared complication occurring during cholecystectomy.

When Critical View of Safety Fails: A Practical Perspective on Difficult Laparoscopic Cholecystectomy

The incidence of common bile duct injuries following laparoscopic cholecystectomy (LC) remains three times higher than that following open surgery despite numerous attempts to decrease intraoperative incidents by employing better training, superior surgical instruments, imaging techniques, or strategic concepts. This paper is a narrative review which discusses from a contextual point of view the need to standardise the surgical approach in difficult laparoscopic cholecystectomies, the main strategic operative concepts and techniques, complementary visualisation aids for the delineation of anatomical landmarks, and the importance of cognitive maps and algorithms in performing safer LC. Extensive research was carried out in the PubMed, Web of Science, and Elsevier databases using the terms "difficult cholecystectomy", "bile duct injuries", "safe cholecystectomy", and "laparoscopy in acute cholecystitis". The key content and findings of this research suggest there is high intersocietal variation in approaching and performing LC, in the use of visualisation aids, and in the application of safety concepts. Limited papers offer guidelines based on robust data and a timid recognition of the human factors and ergonomic concepts in improving the outcomes associated with difficult cholecystectomies. This paper highlights the most relevant recommendations for dealing with difficult laparoscopic cholecystectomies.

Fully Covered Self-expanding Stents are Cost-effective at Remediating Biliary Strictures in Patients With Chronic Pancreatitis

Benign biliary strictures (BBS) develop in up to 10% to 30% of patients with chronic pancreatitis (CP).¹ Endoscopic endoprosthetics via endoscopic retrograde cholangiopancreatography (ERCP) has become the standard of care for remediating these strictures. Seventy percent to eighty percent of these strictures resolve with sequential or concurrent placement of multiple plastic stents (MPS).^1,2 More recently, placement of fully covered self-expanding metal stents (FCSEMS) have been shown to have similar outcomes as MPS.^3-6 FCSEMS provide a larger radial diameter and require fewer procedures, but may have drawbacks, including a higher risk of migration, cholecystitis, delamination, and tissue ingrowth. A recent study demonstrated that FCSEMS with a 12-month indwell had similar outcomes to MPS with fewer ERCP needed.⁷ However, the cost-effectiveness of either strategy for managing BBS has not been assessed previously nor has the impact of additional reimbursement to cover the cost of FCSEMS on the cost-effectiveness of FCSEMS utilization.

Inpatient Choledocholithiasis Management: a Cost-Effectiveness Analysis of Management Algorithms

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.

Incremental net benefit of cholecystectomy compared with alternative treatments in people with gallstones or cholecystitis: a systematic review and meta-analysis of cost–utility studies

Introduction

Cholecystectomy is a standard treatment in the management of symptomatic gallstone disease. Current literature has contradicting views on the cost-effectiveness of different cholecystectomy treatments. We have conducted a systematic reappraisal of literature concerning the cost-effectiveness of cholecystectomy in management of gallstone disease.

Methods

We systematically searched for economic evaluation studies from PubMed, Embase and Scopus for eligible studies from inception up to July 2020. We pooled the incremental net benefit (INB) with a 95% CI using a random-effects model. We assessed the heterogeneity using the Cochrane-Q test, I2 statistic. We have used the modified economic evaluation bias (ECOBIAS) checklist for quality assessment of the selected studies. We assessed the possibility of publication bias using a funnel plot and Egger’s test.

Results

We have selected 28 studies for systematic review from a search that retrieved 8710 studies. Among them, seven studies were eligible for meta-analysis, all from high-income countries (HIC). Studies mainly reported comparisons between surgical treatments, but non-surgical gallstone disease management studies were limited. The early laparoscopic cholecystectomy (ELC) was significantly more cost-effective compared with the delayed laparoscopic cholecystectomy (DLC) with an INB of US$1221 (US$187 to US$2255) but with high heterogeneity (I2=73.32%). The subgroup and sensitivity analysis also supported that ELC is the most cost-effective option for managing gallstone disease or cholecystitis.

Conclusion

ELC is more cost-effective than DLC in the treatment of gallstone disease or cholecystitis in HICs. There was insufficient literature on comparison with other treatment options, such as conservative management and limited evidence from other economies.

PROSPERO registration number

CRD42020194052.

Intraoperative cholangiography with filling defects: comparative complication analysis of postoperative transcystic duct (TCD) catheter maintenance

BACKGROUND

This is a retrospective cohort of patients undergoing laparoscopic cholecystectomy with intraoperative cholangiography (IOC) with positive findings for filling defects. We comparatively assessed differences in complication risks for patients that had their cholangiography catheter maintained in its transcystic duct (TCD) position postoperatively. This is a practice proposed to overcome the limited availability of Endoscopic Retrograde Cholangiopancreatography (ERCP) as well as to avoid surgical exploration of the common bile duct.

METHODS

Retrospective medical record review of all positive IOC from January 2015 to December 2018 were assessed. Patients' demographic and perioperative data from the hospital stay period in which the cholecystectomy occurred until the last surgical ambulatory visit for perioperative characteristics were compared between groups (with vs. without TCD catheter). Complications were operationalized using the Clavien-Dindo scale.

RESULTS

Univariate analysis of complications showed a 2.4-fold risk increase in complications (95% CI 1.13-5.1) between comparison groups. Number of ERCPs (18 vs. 30), and MRCPs (5 vs. 17) were not significantly different between maintaining or not the TCD catheter postop, respectively. Stratified analysis followed by exact logistic regression supported the findings that maintaining the TCD catheter postoperatively increased complication rates (OR = 5.34, 95% CI 1.22, 29.83, p = 0.022), adjusting for potential confounders.

CONCLUSION

The maintenance of the TCD catheter postoperatively did not prove to be effective in significantly reducing the number of ERCP nor associated complications. Also, outcomes inherited from the practice caused adverse events that surpassed its potential benefits. Moreover, expectant follow-up is reasonable for patients with evidence of common bile duct stones, even in setting with limited resource availability. We do not recommend this practice, even in settings where there are limited resources of more modern management of choledocholithiasis.

Laparoscopic Ultrasonography Versus Magnetic Resonance Cholangiopancreatography in Laparoscopic Surgery for Symptomatic Cholelithiasis and Suspected Common Bile Duct Stones

BACKGROUND

There continues to be controversy regarding the optimal screening modality in patients with symptomatic cholelithiasis and suspected common bile duct (CBD) stones. The aim of this study was to assess the diagnostic accuracy of laparoscopic ultrasonography (LUS) compared to magnetic resonance cholangiopancreatography (MRCP).

METHODS

Both LUS and MRCP were performed to evaluate the CBD stones and biliary anatomy in 200 patients undergoing laparoscopic surgery. Pre-, intra-, and postoperative data were collected prospectively and reviewed retrospectively.

RESULTS

Coexisting CBD stones were identified in 64 of 200 (32%) patients by surgical exploration or postoperative ERCP. For the detection of CBD stones, LUS yielded a positive predictive value of 100%, a negative predictive value of 99.3%, a sensitivity of 98.4%, and a specificity of 100%. Preoperative MRCP had a positive predictive value of 87.9%, a negative predictive value of 95.5%, a sensitivity of 90.6%, and a specificity of 94.1%. The non-random concordance between MRCP and LUS was considered to be excellent with a kappa coefficient of 0.92 (p < 0.01).

CONCLUSIONS

LUS can reduce the need for MRCP examination and can become the primary imaging method for the evaluation of CBD stones in laparoscopic surgery.

ASGE guideline on the role of endoscopy in the evaluation and management of choledocholithiasis

Each year choledocholithiasis results in biliary obstruction, cholangitis, and pancreatitis in a significant number of patients. The primary treatment, ERCP, is minimally invasive but associated with adverse events in 6% to 15%. This American Society for Gastrointestinal Endoscopy (ASGE) Standard of Practice (SOP) Guideline provides evidence-based recommendations for the endoscopic evaluation and treatment of choledocholithiasis. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework was used to rigorously review and synthesize the contemporary literature regarding the following topics: EUS versus MRCP for diagnosis, the role of early ERCP in gallstone pancreatitis, endoscopic papillary dilation after sphincterotomy versus sphincterotomy alone for large bile duct stones, and impact of ERCP-guided intraductal therapy for large and difficult choledocholithiasis. Comprehensive systematic reviews were also performed to assess the following: same-admission cholecystectomy for gallstone pancreatitis, clinical predictors of choledocholithiasis, optimal timing of ERCP vis-à-vis cholecystectomy, management of Mirizzi syndrome and hepatolithiasis, and biliary stent therapy for choledocholithiasis. Core clinical questions were derived using an iterative process by the ASGE SOP Committee. This body developed all recommendations founded on the certainty of the evidence, balance of risks and harms, consideration of stakeholder preferences, resource utilization, and cost-effectiveness.

Laparoscopic ultrasonography as an alternative to intraoperative cholangiography during laparoscopic cholecystectomy

AIM

To assess the role of laparoscopic ultrasound (LUS) as a substitute for intraoperative cholangiography (IOC) during cholecystectomy.

METHODS

We present a MEDLINE and PubMed literature search, having used the key-words “laparoscopic intraoperative ultrasound” and “laparoscopic cholecystectomy”. All relevant English language publications from 2000 to 2016 were identified, with data extracted for the role of LUS in the anatomical delineation of the biliary tract, detection of common bile duct stones (CBDS), prevention or early detection of biliary duct injury (BDI), and incidental findings during laparoscopic cholecystectomy. Data for the role of LUS vs IOC in complex situations (i.e., inflammatory disease/fibrosis) were specifically analyzed.

RESULTS

We report data from eighteen reports, 13 prospective non-randomized trials, 5 retrospective trials, and two meta-analyses assessing diagnostic accuracy, with one analysis also assessing costs, duration of the examination, and anatomical mapping. Overall, LUS was shown to provide highly sensitive mapping of the extra-pancreatic biliary anatomy in 92%-100% of patients, with more difficulty encountered in delineation of the intra-pancreatic segment of the biliary tract (73.8%-98%). Identification of vascular and biliary variations has been documented in two studies. Although inflammatory disease hampered accuracy, LUS was still advantageous vs IOC in patients with obscured anatomy. LUS can be performed before any dissection and repeated at will to guide the surgeon especially when hilar mapping is difficult due to fibrosis and inflammation. In two studies LUS prevented conversion in 91% of patients with difficult scenarios. Considering CBDS detection, LUS sensitivity and specificity were 76%-100% and 96.2%-100%, respectively. LUS allowed the diagnosis/treatment of incidental findings of adjacent organs. No valuable data for BDI prevention or detection could be retrieved, even if no BDI was documented in the reports analyzed. Literature analysis proved LUS as a safe, quick, non-irradiating, cost-effective technique, which is comparatively well known although largely under-utilized, probably due to the perception of a difficult learning curve.

CONCLUSION

We highlight the advantages and limitations of laparoscopic ultrasound during cholecystectomy, and underline its value in difficult scenarios when the anatomy is obscured.

Protocol for laparoscopic cholecystectomy: Is it rocket science?

Laparoscopic cholecystectomy (LC) does not require advanced techniques, and its performance has therefore rapidly spread worldwide. However, the rate of biliary injuries has not decreased. The concept of the critical view of safety (CVS) was first documented two decades ago. Unexpected injuries are principally due to misidentification of human factors. The surgeon’s assumption is a major cause of misidentification, and a high level of experience alone is not sufficient for successful LC. We herein describe tips and pitfalls of LC in detail and discuss various technical considerations. Finally, based on a review of important papers and our own experience, we summarize the following mandatory protocol for safe LC: (1) consideration that a high level of experience alone is not enough; (2) recognition of the plateau involving the common hepatic duct and hepatic hilum; (3) blunt dissection until CVS exposure; (4) Calot’s triangle clearance in the overhead view; (5) Calot’s triangle clearance in the view from underneath; (6) dissection of the posterior right side of Calot’s triangle; (7) removal of the gallbladder body; and (8) positive CVS exposure. We believe that adherence to this protocol will ensure successful and beneficial LC worldwide, even in patients with inflammatory changes and rare anatomies.