Your browser doesn't support javascript.
Mostrar: 20 | 50 | 100
Resultados 1 - 14 de 14
Filtrar
1.
J Laparoendosc Adv Surg Tech A ; 29(11): 1481-1485, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31566486

RESUMO

Introduction: Endoscopic retrograde cholangiopancreatography (ERCP) and laparoscopic cholecystectomy (LC) are standard of care for pediatric choledocholithiasis. Patients typically undergo separate procedures during hospitalization. Collaboration between surgical and gastroenterology services led to performance of both procedures concurrently during one anesthetic. We hypothesized that concurrent procedures would reduce costs without increasing complications as compared with separate procedures. Materials and Methods: We evaluated patients admitted to our institution from 2013 to 2018 with choledocholithiasis who underwent both ERCP and LC during the same admission. Fourteen patients underwent both procedures during concurrent anesthetic. Forty-two patients who underwent LC and ERCP under separate anesthetics were randomly selected to perform a 3:1 matched case-control study. Demographic and clinical data were collected, including imaging and laboratory findings, outcomes, and costs. Comparative analysis was completed with Fisher's exact and Mann-Whitney U tests. Results: On presentation, there was no difference in common bile duct size, total bilirubin, or white blood cell count between the concurrent and separate procedure cohorts. Significantly, there was no difference in total length of anesthesia (117.9 ± 40 minutes versus 119.6 ± 52 minutes, P = .747). There were also no differences in complications, emergency department visits, or readmissions. Patients who underwent concurrent procedures had significantly lower total cost of stay ($45,597 ± 11,513 versus $61,008 ± 17,960, P = .006). Conclusions: In pediatric patients with choledocholithiasis, performing LC and ERCP may be performed concurrently during one anesthetic, which decreases costs without increasing in anesthesia time or complications.


Assuntos
Colangiopancreatografia Retrógrada Endoscópica , Colecistectomia Laparoscópica , Coledocolitíase/cirurgia , Adolescente , Anestesia , Estudos de Casos e Controles , Criança , Pré-Escolar , Colangiopancreatografia Retrógrada Endoscópica/efeitos adversos , Colecistectomia Laparoscópica/efeitos adversos , Coledocolitíase/diagnóstico por imagem , Coledocolitíase/economia , Serviço Hospitalar de Emergência/estatística & dados numéricos , Feminino , Custos de Cuidados de Saúde , Humanos , Tempo de Internação , Masculino , Duração da Cirurgia , Readmissão do Paciente , Complicações Pós-Operatórias
2.
World J Gastroenterol ; 25(8): 1002-1011, 2019 Feb 28.
Artigo em Inglês | MEDLINE | ID: mdl-30833805

RESUMO

BACKGROUND: A clinical pathway (CP) is a standardized approach for disease management. However, big data-based evidence is rarely involved in CP for related common bile duct (CBD) stones, let alone outcome comparisons before and after CP implementation. AIM: To investigate the value of CP implementation in patients with CBD stones undergoing endoscopic retrograde cholangiopancreatography (ERCP). METHODS: This retrospective study was conducted at Nanjing Drum Tower Hospital in patients with CBD stones undergoing ERCP from January 2007 to December 2017. The data and outcomes were compared by using univariate and multivariable regression/linear models between the patients who received conventional care (non-pathway group, n = 467) and CP care (pathway group, n = 2196). RESULTS: At baseline, the main differences observed between the two groups were the percentage of patients with multiple stones (P < 0.001) and incidence of cholangitis complication (P < 0.05). The percentage of antibiotic use and complications in the CP group were significantly less than those in the non-pathway group [adjusted odds ratio (OR) = 0.72, 95% confidence interval (CI): 0.55-0.93, P = 0.012, adjusted OR = 0.44, 95%CI: 0.33-0.59, P < 0.001, respectively]. Patients spent lower costs on hospitalization, operation, nursing, medication, and medical consumable materials (P < 0.001 for all), and even experienced shorter length of hospital stay (LOHS) (P < 0.001) after the CP implementation. No significant differences in clinical outcomes, readmission rate, or secondary surgery rate were presented between the patients in the non-pathway and CP groups. CONCLUSION: Implementing a CP for patients with CBD stones is a safe mode to reduce the LOHS, hospital costs, antibiotic use, and complication rate.


Assuntos
Colangiopancreatografia Retrógrada Endoscópica/estatística & dados numéricos , Coledocolitíase/cirurgia , Procedimentos Clínicos/estatística & dados numéricos , Análise de Dados , Complicações Pós-Operatórias/epidemiologia , Idoso , Big Data , Colangiopancreatografia Retrógrada Endoscópica/economia , Colangiopancreatografia Retrógrada Endoscópica/métodos , Coledocolitíase/economia , Ducto Colédoco/cirurgia , Procedimentos Clínicos/economia , Feminino , Gastos em Saúde/estatística & dados numéricos , Preços Hospitalares/estatística & dados numéricos , Humanos , Tempo de Internação/economia , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/economia , Complicações Pós-Operatórias/etiologia , Avaliação de Programas e Projetos de Saúde , Estudos Retrospectivos , Resultado do Tratamento
3.
Surg Endosc ; 32(3): 1223-1227, 2018 03.
Artigo em Inglês | MEDLINE | ID: mdl-28812193

RESUMO

AIM: The aim of this study is to evaluate the clinical outcomes and cost-effectiveness of elective, robot-assisted choledochotomy and common bile duct exploration (RCD/CBDE) compared to open surgery for ERCP refractory choledocholithiasis. METHOD: A prospective database of all RCD/CBDE has been maintained since our first procedure in April 2007 though April 2016. With ethics approval, this database was compared with all contemporaneous elective open procedures (OCD/CBDE) performed since March 2005. Emergency procedures were excluded from analysis. Cost analysis was calculated using a micro-costing approach. Outcomes were analyzed on the basis of intent-to-treat. A p value of 0.05 denoted statistical significance. RESULTS: A total of 80 cases were performed since 2005 compromising 50 consecutive, unselected RCD/CBDE and 30 OCD/CBDE. Comparing RCD/CBDE to OCD/CBDE there were no significant differences between groups with respect to age (65 ± 20 vs. 67 ± 18 years, p = 0.09), gender (14/30 vs. 16/25 male/female, p = 0.52), ASA class or co-morbidities. The mean duration of surgery for RCD/CBDE trended longer compared to OCD/CBDE (205 ± 70 min vs. 174 ± 73 min, p = 0.08). However, there was significant reduction in postoperative complications with RCD/CBDE versus OCD/CBDE (22% vs. 56%, p = 0.002). Median hospital stay was also significantly reduced (6 vs 12 days, p = 0.01). The net overall hospital cost for RCD/CBDE was lower ($8449.88 CAD vs. $11671.2 CAD). CONCLUSION: In this single-centre, cohort study, robotic-assisted CD/CBDE for ERCP refractory common bile duct stones provides the dominating strategy of improved patient outcomes with a reduction of overall cost.


Assuntos
Colangiopancreatografia Retrógrada Endoscópica , Coledocolitíase/cirurgia , Ducto Colédoco/cirurgia , Complicações Pós-Operatórias/cirurgia , Procedimentos Cirúrgicos Robóticos , Adulto , Idoso , Idoso de 80 Anos ou mais , Colangiopancreatografia Retrógrada Endoscópica/economia , Coledocolitíase/economia , Custos e Análise de Custo , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/economia , Estudos Prospectivos , Procedimentos Cirúrgicos Robóticos/economia
4.
World J Gastroenterol ; 21(12): 3564-70, 2015 Mar 28.
Artigo em Inglês | MEDLINE | ID: mdl-25834321

RESUMO

AIM: To evaluate the feasibility of hepatectomy and primary closure of common bile duct for intrahepatic and extrahepatic calculi. METHODS: From January 2008 to May 2013, anatomic hepatectomy followed by biliary tract exploration without biliary drainage (non-drainage group) was performed in 43 patients with intrahepatic and extrahepatic calculi. After hepatectomy, flexible choledochoscopy was used to extract residual stones and observe the intrahepatic bile duct and common bile duct (CBD) for determination of biliary stricture and dilatation. Function of the sphincter of Oddi was determined by manometry of the CBD. Primary closure of the CBD without T-tube drainage or bilioenteric anastomosis was performed when there was no biliary stricture or sphincter of Oddi dysfunction. Dexamethasone and anisodamine were intravenously injected 2-3 d after surgery to prevent postoperative retrograde infection due to intraoperative bile duct irrigation, and to maintain relaxation of the sphincter of Oddi, respectively. During the same period, anatomic hepatectomy followed by biliary tract exploration with biliary drainage (drainage group) was performed in 48 patients as the control group. Postoperative complications and hospital stay were compared between the two groups. RESULTS: There was no operative mortality in either group of patients. Compared to intrahepatic and extrabiliary drainage, hepatectomy with primary closure of the CBD (non-drainage) did not increase the incidence of complications, including residual stones, bile leakage, pancreatitis and cholangitis (P > 0.05). Postoperative hospital stay and costs were nevertheless significantly less in the non-drainage group than in the drainage group. The median postoperative hospital stay was shorter in the non-drainage group than in the drainage group (11.2 ± 2.8 d vs 15.4 ± 2.1 d, P = 0.000). The average postoperative cost of treatment was lower in the non-drainage group than in the drainage group (29325.6 ± 5668.2 yuan vs 32933.3 ± 6235.1 yuan, P = 0.005). CONCLUSION: Hepatectomy followed by choledochoendoscopic stone extraction without biliary drainage is a safe and effective treatment of hepatolithiasis combined with choledocholithiasis.


Assuntos
Coledocolitíase/cirurgia , Ducto Colédoco/cirurgia , Hepatectomia , Litíase/cirurgia , Hepatopatias/cirurgia , Adulto , Idoso , Anti-Inflamatórios não Esteroides/administração & dosagem , Coledocolitíase/complicações , Coledocolitíase/diagnóstico , Coledocolitíase/economia , Redução de Custos , Análise Custo-Benefício , Dexametasona/administração & dosagem , Drenagem , Estudos de Viabilidade , Feminino , Glucocorticoides/administração & dosagem , Hepatectomia/efeitos adversos , Hepatectomia/economia , Custos Hospitalares , Humanos , Tempo de Internação , Litíase/complicações , Litíase/diagnóstico , Litíase/economia , Hepatopatias/complicações , Hepatopatias/diagnóstico , Hepatopatias/economia , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/prevenção & controle , Estudos Retrospectivos , Alcaloides de Solanáceas/administração & dosagem , Fatores de Tempo , Resultado do Tratamento , Adulto Jovem
5.
BMC Surg ; 15: 7, 2015 Jan 26.
Artigo em Inglês | MEDLINE | ID: mdl-25623774

RESUMO

BACKGROUND: Laparoscopic common bile duct exploration (LCBDE) for stone can be carried out by either laparoscopic transcystic stone extraction (LTSE) or laparoscopic choledochotomy (LC). It remains unknown as to which approach is optimal for management of gallbladder stone with common bile duct stones (CBDS) in Chinese patients. METHODS: From May 2000 to February 2009, we prospective treated 346 consecutive patients with gallbladder stones and CBDS with laparoscopic cholecystectomy and LCBDE. Intraoperative findings, postoperative complications, postoperative hospital stay and costs were analyzed. RESULTS: Because of LCBDE failure,16 cases (4.6%) required open surgery. Of 330 successful LCBDE-treated patients, 237 underwent LTSE and 93 required LC. No mortality occurred in either group. The bile duct stone clearance rate was similar in both groups. Patients in the LTSE group were significantly younger and had fewer complications with smaller, fewer stones, shorter operative time and postoperative hospital stays, and lower costs, compared to those in the LC group. Compared with patients with T-tube insertion, patients in the LC group with primary closure had shorter operative time, shorter postoperative hospital stay, and lower costs. CONCLUSIONS: In cases requiring LCBDE, LTSE should be the first choice, whereas LC may be restricted to large, multiple stones. LC with primary closure without external drainage of the CBDS is as effective and safe as the T-tube insertion approach.


Assuntos
Colecistectomia Laparoscópica , Coledocolitíase/cirurgia , Cálculos Biliares/cirurgia , Adulto , Idoso , China , Colecistectomia Laparoscópica/economia , Coledocolitíase/diagnóstico , Coledocolitíase/economia , Feminino , Cálculos Biliares/diagnóstico , Cálculos Biliares/economia , Custos Hospitalares/estatística & dados numéricos , Humanos , Tempo de Internação/economia , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/economia , Estudos Prospectivos , Resultado do Tratamento
6.
World J Gastroenterol ; 20(41): 15144-52, 2014 Nov 07.
Artigo em Inglês | MEDLINE | ID: mdl-25386063

RESUMO

Up to 18% of patients submitted to cholecystectomy had concomitant common bile duct stones. To avoid serious complications, these stones should be removed. There is no consensus about the ideal management strategy for such patients. Traditionally, open surgery was offered but with the advent of endoscopic retrograde cholangiopancreatography (ERCP) and laparoscopic cholecystectomy (LC) minimally invasive approach had nearly replaced laparotomy because of its well-known advantages. Minimally invasive approach could be done in either two-session (preoperative ERCP followed by LC or LC followed by postoperative ERCP) or single-session (laparoscopic common bile duct exploration or LC with intraoperative ERCP). Most recent studies have found that both options are equivalent regarding safety and efficacy but the single-session approach is associated with shorter hospital stay, fewer procedures per patient, and less cost. Consequently, single-session option should be offered to patients with cholecysto-choledocholithiaisis provided that local resources and expertise do exist. However, the management strategy should be tailored according to many variables, such as available resources, experience, patient characteristics, clinical presentations, and surgical pathology.


Assuntos
Colangiopancreatografia Retrógrada Endoscópica , Colecistectomia Laparoscópica , Coledocolitíase/cirurgia , Colangiopancreatografia Retrógrada Endoscópica/efeitos adversos , Colangiopancreatografia Retrógrada Endoscópica/economia , Colecistectomia Laparoscópica/efeitos adversos , Colecistectomia Laparoscópica/economia , Coledocolitíase/diagnóstico , Coledocolitíase/economia , Custos de Cuidados de Saúde , Humanos , Tempo de Internação , Seleção de Pacientes , Complicações Pós-Operatórias/etiologia , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento
7.
J Gastrointest Surg ; 18(12): 2116-22, 2014 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-25319034

RESUMO

BACKGROUND AND OBJECTIVES: Robotic-assisted cholecystectomy (RAC) was introduced several years ago. With its more extensive use by surgeons, more information is needed regarding clinical and economic outcomes. METHODS: The Nationwide Inpatient Sample from the Health Cost Utilization Project was analyzed using HCUPnet, National Inpatient Sample (NIS) datasets and SAS 9.2 for the years 2010-2011. Queries were made for RAC and laparoscopic cholecystectomy (LC) procedures with a primary diagnosis of gallbladder disease. Overall charges, costs, number of chronic conditions, comorbidities, and length of stay were calculated. RESULTS: RAC was $7518, +54 % (p < 0.05), and $4044, +29 % (p < 0.05), more costly compared to LC in 2010 and 2011, respectively. Total costs for RAC decreased by 14.6 % (p = 0.27) between 2010 and 2011, even though RAC was still costlier than LC in 2011. There was no significant difference in the LOS between RAC and LC in either years. Patients undergoing RAC had an increased number of chronic conditions compared to patients undergoing LC in both 2010 and 2011. CONCLUSION: LOS of RAC is similar to LC. Cost of RAC remains higher compared to LC although there was reduction in cost of RAC in 2011 versus 2010.


Assuntos
Colecistectomia Laparoscópica/métodos , Coledocolitíase/cirurgia , Custos de Cuidados de Saúde , Pacientes Internados , Robótica/métodos , Colecistectomia Laparoscópica/economia , Coledocolitíase/economia , Feminino , Humanos , Tempo de Internação/tendências , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Robótica/economia , Resultado do Tratamento
8.
Gut Liver ; 8(4): 438-44, 2014 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-25071911

RESUMO

BACKGROUND/AIMS: We evaluated the efficacy and cost-effectiveness of endoscopic papillary large balloon dilation (EPLBD) for large common bile duct (CBD) stone removal compared with endoscopic sphincterotomy (EST). METHODS: A total of 1,580 patients who underwent endoscopic CBD stone extraction between January 2001 and July 2010 were reviewed. The following inclusion criteria were applied: choledocholithiasis treated by EPLBD with minor EST or EST with mechanical lithotripsy; and follow-up >9 months after treatment. RESULTS: Forty-nine patients with EPLBD and 41 with EST were compared. There was no significant difference in the complication rates and stone recurrence rates between the two groups. However, significantly more endoscopic retrograde cholangiopancreatography (ERCP) sessions were required in the EST group to achieve the complete removal of stones (1.7 times vs 1.3 times; p=0.03). The mean cost required for complete stone removal per patient was significantly higher in the EST group compared to the EPLBD group (USD $1,644 vs $1,225, respectively; p=0.04). Dilated CBD was the only significant factor associated with recurrent biliary stones (relative risk, 1.09; 95% confidence interval, 1.02 to 1.17; p=0.02). CONCLUSIONS: EPLBD is the better treatment (compared to EST) for removing large CBD stones because EPLBD requires fewer ERCP sessions and is less expensive.


Assuntos
Coledocolitíase/cirurgia , Dilatação/métodos , Esfinterotomia Endoscópica/métodos , Adulto , Idoso , Idoso de 80 Anos ou mais , Colangiopancreatografia Retrógrada Endoscópica , Coledocolitíase/economia , Análise Custo-Benefício , Dilatação/economia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco , Prevenção Secundária , Esfinterotomia Endoscópica/economia
9.
J Gastrointest Surg ; 17(5): 863-71, 2013 May.
Artigo em Inglês | MEDLINE | ID: mdl-23515912

RESUMO

BACKGROUND: Few formal cost-effectiveness analyses simultaneously evaluate radiographic, endoscopic, and surgical approaches to the management of choledocholithiasis. STUDY DESIGN: Using the decision analytic software TreeAge, we modeled the initial clinical management of a patient presenting with symptomatic cholelithiasis without overt signs of choledocholithiasis. In this base case, we assumed a 10 % probability of concurrent asymptomatic choledocholithiasis. Our model evaluated four diagnostic/therapeutic strategies: universal magnetic resonance cholangiopancreatography (MRCP), universal endoscopic retrograde cholangiopancreatography (ERCP), laparoscopic cholecystectomy (LC), or laparoscopic cholecystectomy with universal intraoperative cholangiogram (LCIOC). All probabilities were estimated from a review of published literature. Procedure and intervention costs were equated with Medicare reimbursements. Costs of hospitalizations were derived from median hospitalization reimbursement for New York State using diagnosis-related groups (DRG). Sensitivity analyses were performed on all cost and probability variables. RESULTS: The most cost-effective strategy in the diagnosis and management of symptomatic cholelithiasis with a 10 % risk of asymptomatic choledocholithiasis was LCIOC. This was followed by LC alone, MRCP, and ERCP. LC was preferred only when the probability that a retained CBD stone would eventually become symptomatic fell below 15 % or if the probability of technical success of an intraoperative cholangiogram (IOC) was less than 35 %. Universal MRCP and ERCP were both more costly and less effective than surgical strategies, even at a high probability of asymptomatic choledocholithiasis. Within the tested range for both procedural and hospitalization-related costs for any of the surgical or endoscopic interventions, LCIOC and LC were always more cost-effective than universal MRCP or ERCP, irrespective of the presence or absence of complications. Varying the cost, sensitivity, and specificity of MRCP had no effect on this outcome. CONCLUSIONS: LC with routine IOC is the preferred strategy in a cost-effectiveness analysis of the management of symptomatic cholelithiasis with asymptomatic choledocholithiasis. MRCP was both more costly and less effective under all tested scenarios.


Assuntos
Colangiopancreatografia por Ressonância Magnética/economia , Coledocolitíase/diagnóstico , Coledocolitíase/economia , Coledocolitíase/cirurgia , Colangiografia , Colangiopancreatografia Retrógrada Endoscópica , Colecistectomia Laparoscópica , Análise Custo-Benefício , Árvores de Decisões , Grupos Diagnósticos Relacionados/economia , Hospitalização/economia , Humanos , Medicare/economia , New York , Probabilidade , Sensibilidade e Especificidade , Software , Estados Unidos
10.
Cir. Esp. (Ed. impr.) ; 90(5): 310-317, mayo 2012. ilus, tab
Artigo em Espanhol | IBECS | ID: ibc-105000

RESUMO

Introducción El tratamiento de la coledocolitiasis asociada a colelitiasis es controvertido. Los costes hospitalarios podrían ser un factor decisivo para elegir entre las distintas opciones terapéuticas. Objetivos Comparar la eficacia y los costes de 2 alternativas en el tratamiento de la coledocolitiasis: 1) Un-tiempo: colecistectomía y exploración de la vía biliar por laparoscopia y 2) Dos-tiempos: colangiopancreatografía retrógrada endoscópica y colecistectomía laparoscópica secuencial. Material y métodos Estudio observacional, retrospectivo de 49 pacientes con coledocolitiasis y vesícula in situ, tratados de forma consecutiva y simultánea durante 2 años, mediante una de las 2 estrategias. Se compararon las complicaciones postoperatorias, estancia, número de procedimientos por paciente, conversión a laparotomía, eficacia en la extracción de cálculos y costes hospitalarios. Resultados No hubo diferencias en cuanto a características clínicas y morbilidad de los pacientes. La estancia postoperatoria media para el grupo Un-tiempo fue menor que para el grupo Dos-tiempos. Tres pacientes del grupo Dos-tiempos requirieron conversión a laparotomía. La mediana de costes por paciente fue menor para la estrategia en Un-tiempo, representando un ahorro global de 37.173€ durante el período estudiado. Conclusiones Entre las 2 opciones terapéuticas, no se han encontrado diferencias significativas en cuanto a la eficacia, ni la morbimortalidad postoperatorias, pero sí desde el punto de vista de la estancia y los costes hospitalarios. El manejo de los pacientes con coledocolitiasis en un solo tiempo representó un ahorro de 3 días de estancia y 1.008€ por paciente (AU)


Introduction The treatment of bile duct calculi associated with cholelithiasis is controversial. The hospital costs could be a decisive factor in choosing between the different therapeutic options. Objectives To compare the effectiveness and costs of two options in the treatment of common bile duct calculi: 1) One-stage: Laparoscopic cholecystectomy and bile duct exploration, and 2) Two-stage: sequential endoscopic retrograde cholangiopancreatography and laparoscopic cholecystectomy. Material and methods A retrospective, observational study was performed on 49 consecutive patients with bile duct calculi and gallbladder in situ, treated consecutively and simultaneously over a two year period. The post-operate complication, hospital stay, number of procedures per patient, conversion to laparotomy, efficacy of removing the calculi, and hospital costs. Results There were no differences as regards the patient clinical features or morbidity. The mean post-surgical hospital stay for the One-stage group was less than that in the Two-stage group. Three patients of the Two-stage group required conversion to laparotomy. The median costs per patient were less for the One-stage strategy, representing an overall saving of 37,173€ during the period studied. Conclusions No significant differences were found between the two treatment options as regards efficacy or post-surgical morbidity and mortality, but there were differences in hospital stay and costs. The management of patients with gallstones in one-stage surgery represents a saving of 3 days hospital stay and 1,008€ per patient (AU)


Assuntos
Humanos , Coledocolitíase/cirurgia , Colelitíase/etiologia , Colecistectomia/economia , Colecistite/complicações , Coledocolitíase/economia , Estudos Retrospectivos , /estatística & dados numéricos , Colecistectomia Laparoscópica/estatística & dados numéricos , Colangiopancreatografia Retrógrada Endoscópica/economia , Esfinterotomia Endoscópica/economia , Hospitalização/economia
11.
Am Surg ; 73(5): 472-7, 2007 May.
Artigo em Inglês | MEDLINE | ID: mdl-17521002

RESUMO

The ideal management of presumed choledocholithiasis is controversial. We hypothesized that patients admitted with presumed choledocholithiasis would be better served financially to undergo laparoscopic cholecystectomy (LC) with possible intraoperative intervention versus preoperative endoscopic retrograde cholangiopancreatography followed by LC. A chart review was performed from September 1, 2000 to August 31, 2003. One hundred seventy-one consecutive patients identified with presumed choledocholithiasis were reviewed. Six patients were excluded because of missing charge data. Professional and technical fees from the total hospital charges were used for comparison. Three groups of patients were compared for charge analysis. Group 1 underwent LC with laparoscopic common bile duct exploration. Group 2 underwent LC with preoperative or postoperative endoscopic retrograde cholangiopancreatography. Group 3 was a control group of LC only. Student's t test was used for statistical analysis with a P value of <0.05 defined as statistically significant. P values reflect comparisons with Group 1. Group 1 charges were $13,026, Group 2 charges were $15,303, and Group 3 charges were $9,122. For suspected choledocholithiasis, LC with intraoperative intervention is the most economically advantageous approach.


Assuntos
Colangiopancreatografia Retrógrada Endoscópica/economia , Colecistectomia Laparoscópica/economia , Colecistectomia Laparoscópica/métodos , Coledocolitíase/diagnóstico , Coledocolitíase/cirurgia , Preços Hospitalares , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Criança , Coledocolitíase/economia , Ducto Colédoco/patologia , Análise Custo-Benefício , Feminino , Humanos , Tempo de Internação/economia , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos
12.
Arch Surg ; 142(1): 43-8; discussion 49, 2007 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-17224499

RESUMO

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 $24 300 for 0.9 quality-adjusted life years gained compared with $28 400 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 $18 000 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.


Assuntos
Colangiopancreatografia Retrógrada Endoscópica/economia , Colecistectomia Laparoscópica/economia , Coledocolitíase/economia , Coledocolitíase/cirurgia , Ducto Colédoco/cirurgia , Análise Custo-Benefício , Técnicas de Apoio para a Decisão , Custos de Cuidados de Saúde/estatística & dados numéricos , Humanos , Laparoscopia/economia , Tempo de Internação , Anos de Vida Ajustados por Qualidade de Vida
13.
Am J Gastroenterol ; 101(4): 753-4, 2006 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-16635223

RESUMO

Drake et al. constructed a decision model to compare, in an older population, the costs and 2-yr survival rates of elective cholecystectomy versus expectant management after endoscopic removal of common bile duct (CBD) stones. The base case analysis indicated that the expectant management strategy dominated (less expensive and more effective) the elective surgery strategy. Sensitivity analysis suggested that the two strategies likely had equivalent effectiveness and that results were sensitive to the rate of recurrent biliary symptoms. Patient preferences for the different strategies (i.e., utilities) were not included in the model but are important to elicit and consider in clinical practice.


Assuntos
Colecistectomia Laparoscópica , Coledocolitíase/cirurgia , Idoso , Colangiopancreatografia Retrógrada Endoscópica , Colecistectomia Laparoscópica/economia , Coledocolitíase/economia , Redução de Custos , Análise Custo-Benefício , Técnicas de Apoio para a Decisão , Custos de Cuidados de Saúde , Humanos , Pessoa de Meia-Idade , Qualidade de Vida , Esfinterotomia Endoscópica , Resultado do Tratamento
14.
Am J Gastroenterol ; 101(4): 746-52, 2006 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-16494588

RESUMO

BACKGROUND: Common bile duct stones (CBDS) are especially prevalent in the elderly population. Although the standard of care for stone removal is endoscopic retrograde cholangiography with sphincterotomy (ERC-S), the clinician's decision to refer a patient for cholecystectomy after ERC-S depends on several factors including potential for future biliary symptoms and complications, morbidity and mortality related to cholecystectomy, and costs associated with referral for cholecystectomy versus conservative approach. Using decision analysis, we explored the economic implications of cholecystectomy versus expectant management following ERC-S in elderly patients with CBDS. MATERIALS AND METHOD: A decision tree was constructed with DATA 3.5 (Williamstown, MA) to estimate the costs and outcomes associated with two treatment strategies following ERC-S for CBDS in patients age 60 yr and older: (1) elective cholecystectomy, and (2) expectant management. Probabilities for potential complications and outcomes were derived from the medical literature and cost reflected Medicare reimbursement rates at our institution. The time horizon of the analysis was 2 yr. RESULTS: Elective cholecystectomy was associated with total costs of 5,259 dollars with 94.3% of the cohort alive (1.886 life-years) at 2 yr, whereas expectant management was associated with total costs of 1,173 dollars with 94.7% of the cohort alive (1.894 life-years). The results were sensitive to the probability of recurrent biliary symptoms in patients treated conservatively. Compared to elective cholecystectomy, expectant management became less effective and more expensive at a yearly probability of recurrent symptoms greater than 40% and 90%, respectively. CONCLUSIONS: In patients aged 60 and older, expectant management after ERC-S for CBDS is a reasonable approach, but the economic attractiveness of this strategy is highly dependent on the probability of recurrent symptoms.


Assuntos
Coledocolitíase/economia , Coledocolitíase/terapia , Idoso , Colangiopancreatografia Retrógrada Endoscópica , Colecistectomia/economia , Colecistectomia Laparoscópica/economia , Coledocolitíase/diagnóstico , Coledocolitíase/cirurgia , Análise Custo-Benefício , Técnicas de Apoio para a Decisão , Custos de Cuidados de Saúde , Humanos , Pessoa de Meia-Idade , Recidiva , Esfinterotomia Endoscópica
SELEÇÃO DE REFERÊNCIAS
DETALHE DA PESQUISA