Bile duct injury versus choledocholithiasis: does one outweigh the other in the decision to use intraoperative cholangiogram during laparoscopic cholecystectomy? A model-based economic analysis.

BACKGROUND

Routine intraoperative cholangiogram (IOC) remains controversial. Current literature evaluating routine (rIOC) versus selective (sIOC) during laparoscopic cholecystectomy (LC) often overlooks the impact of bile duct injuries (BDIs) and choledocholithiasis.

METHODS

Decision analysis models evaluated costs and quality-adjusted life years (QALYs) of rIOC versus sIOC during LC. Models were based on 0.36 and 0.53% BDI detection in rIOC and sIOC, and 11.8% and 3.9% choledocholithiasis, respectively. Sensitivity analysis assessed model robustness to data input changes.

RESULTS

sIOC was associated with $18,600 and 0.90 QALYs, while rIOC increased costs by $1,300 and reduced QALYs, consistent in 93% of probabilistic sensitivity analyses. In choledocholithiasis with high likelihood of persistence, rIOC was preferred in 88% of iterations.

DISCUSSION: rIOC increases costs without improving QALY when considering both choledocholithiasis and BDI. rIOC was preferred in high-risk choledocholithiasis, implying that judicious intraoperative management of choledocholithiasis is prudent in the decision to utilize IOC.