There are a variety of procedures to use once a common bile duct stone is discovered at the time of cholecystectomy. To be cost-effective, the surgeon must know how much money will be spent with each procedure chosen. Cost data is largely unavailable because costs are difficult to estimate and charge data are jealously guarded. In addition, costs are not the same at different hospitals and therefore cannot be compared. The factors that increase costs for treating bile duct stones are outlined in this report and real costs are used from one hospital to help with illustration. Surgical costs vary with the severity of the disease, the amount of operating room time required, and length of stay. These surgical costs can be avoided by choosing endoscopic retrograde cholangiopancreatography, but the new costs increase almost twice that of a successful laparoscopic common bile duct exploration. Knowledge of the pattern of choledocholithiasis, the varieties of treatment, the cost implications, and the outcomes of each are the subject of this report.
Limitations and possible biases in this study are the lack of randomization which may have caused some selection bias, and the small number of patients making the detection of small differences between the study groups unreliable. The study design was retrospective and therefore cost-analysis instead of cost-benefit analysis was undertaken. Capital costs of laparoscopic equipment were excluded because laparoscopic equipment is nowadays considered standard operating room equipment used in many different operations. Costs in the Finnish healthcare are not applicable to every country, since the pricing of goods and services vary between healthcare systems. However, the share-out of the one-stage and two-stage management costs reflects the relative distribution of expenses between the the one-stage and two-stage management. Also the success rate of laparoscopic CBD stone clearance and hospital stay are in line with previous studies, suggesting that the quality of surgery has been as good as elsewhere.
In order to rationalize the treatment of CCL the aim of this study was to compare the success and costs of one-stage versus traditional two-stage management for CCL. Based on previous studies (3,10) our hypothesis was that the laparoscopic one-stage treatment is more cost-efficient, and is associated with an improved outcome and shorter hospital stay.
The proportion of readmission costs within total expenses were higher in the transductal group mainly due to ambulatory T- removal. However, the use of T-tube was dramatically reduced after reports on the safety of choledochotomy closure without T-tube .
CBD stones are commonly managed with pre-, intra or post-operative ERCP although laparoscopic common bile duct exploration (LCBDE) has gained wide acceptance over the last 20 years .
Three of the 4 randomized trials reported longer total operative times in the two-stage management group [3, 7, 9, 10] in contrast to our study showing that one-stage management resulted in significantly longer operative time than the two-stage management. Conversion to transcholedochal approach after failed attempt of transcystic clearance increased the operative time in our study. Despite shorter total operative time in the two-stage management group, the operating room costs nested mainly from personnel expenditure of two separate procedures and disposable equipment used in ERCP.
Costs were calculated according to the year 2014 prices (€). Pre-existing data on some major resources and their allocated costs in 2014 were obtained from the hospital administration (Table 1). Costs of operative room resources (basic costs, anesthesia and nurses, surgical team, instrument use) and recovery room services were calculated according to the time spent in the operating and recovery rooms, duration of surgery, and the level of training required. The costs of disposable instruments including Dormia baskets, sphincterotomes, cannulas, extraction balloons, guidewires, stents, contrast agents, cholangiography catheters, trocars, drains, hemostatic agents, hemostatic sealing devices, and hemostatic clips for LCBD exploration in LC and ERCP were calculated according to the use. Excluded were costs of preoperative waiting time for the operation or ERCP, capital costs of reusable instruments, standard laparoscopic equipment, duodenoscopes, administration and societal costs. The correction coefficient of 0.82 for ERCP procedure price was based on the use of intravenous sedation without the presence of an anesthesiologist, permitting the ERCP time to be less costly than LC despite the same qualification of the attending surgeon.
Finland offers its residents government-subsidised public-sector specialised healthcare. Central Hospital of Central Finland hospital is a university-affiliated secondary referral center, and the only hospital offering surgical and advanced endoscopic service in the catchment area of 276,000 inhabitants.
Previous randomized trials and meta-analyses have demonstrated the safety and efficacy of one-stage management for CCL with a success rate of 75% to 96.8%, and with an associated postoperative morbidity of 3.6% to 43.2% [2,3,4,5,6,7,8, 10, 20]. Overall success of two –stage management has been 61.7% to 94.6%, with an associated postoperative morbidity of 5.1% to 29.8% [2,3,4, 7, 8, 10]. Our overall success rate for CBD stone removal and postoperative morbidity after one-stage and two-stage management are in accordance with these results. This was achieved with apparently similar surgical and ERCP-related morbidity.
Two- stage treatment is currently the most commonly used strategy for of CCL. Costs of one-stage versus two-stage treatment of CBD stones, however, are scantily reported in the literature. Two randomized studies have reported in-hospital costs in favour of one –stage method [3, 10]. Non-randomized studies using propensity score or cost analysis have also shown lower total in-hospital costs for one-stage than for two-stage method [11,12,13,14,15].
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