Abstracts
1998 Digestive Disease Week

#1051

PREOPERATIVE ERCP IS MORE COSTLY THAN INTRAOPERATIVE OR POSTOPERATIVE ENDOSCOPIC AND SURGICAL TECHNIQUES IN THE MANAGEMENT OF CHOLEDOCHOLITHIASIS. JW Hazey, LM Rock, JM Marks, D Asseff, JL Ponsky, Department of Surgery, Case Western Reserve University, Cleveland, OH.

Introduction: The most cost effective management of suspected common bile duct stones(CBDS) including endoscopic, laparoscopic, open and combined techniques has yet to be defined. The purpose of this study was to compare the costs of preoperative endoscopic retrograde cholangiopancreatography (Pre-ERCP) to intra- or post-operative endoscopic and surgical techniques for CBDS management (IOSM/POSM).

Methods: A multi-center, retrospective review of all patients undergoing cholecystectomy from January 1994 to December 1994 was performed. Data regarding patient demographics, diagnosis, management, and length of stay (LOS) were obtained. Patients who underwent stone management and laparoscopic(LC), open(OC), or conversion(CONV) cholecystectomy were included for study. Techniques of Intraoperative Stone Management/Postoperative Stone Management (IOSM/POSM) included intraoperative ERCP (Intra-ERCP), postoperative ERCP (Post-ERCP), laparoscopic transcystic common bile duct exploration (LTCBDE), laparoscopic choledochotomy (LCBDE), and open common bile duct exploration (OCBDE). Variable costs (VC) and total costs (TC) were calculated for each patient. Statistical analysis was performed using the Student's t-test.

Results: Of 413 patients identified, 42 underwent Pre-ERCP and 23 underwent IOSM/POSM. VC of Pre-ERCP was significantly greater than IOSM/POSM irrespective of the type of cholecystectomy performed (.23 vs .76, p<0.05). TC was also greater when comparing Pre-ERCP and IOSM/POSM (,728.18 vs ,612.75, p=0.055). The tendency for open cholecyst-ectomy was greater in patients undergoing Pre-ERCP than IOSM/POSM (14/42 vs 2/23), despite there being no difference in the rate of acute cholecystitis. VC and TC of Intra-ERCP and Post-ERCP were greater when compared to LTCBDE and LCBDE, but lower than costs incurred by OCBDE.

Conclusion: Pre-ERCP incurred significantly greater costs as compared to IOSM/POSM in the management of CBDS, irrespective of the type of cholecystectomy performed, and therefore should be used selectively. Intra-ERCP and Post-ERCP, however, are cost effective tools when the skills and instrumentation to perform LTCBDE and LCBDE are not available.

Copyright 1996 - 1998, SSAT, Inc. Revised 29 June 1998.