Exploración laparoscópica de la vía biliar como tratamiento en un solo tiempo de la coledocolitiasis Estudio coste-efectividad del procedimiento en comparación con el abordaje clásico, CPRE seguido de colecistectomía laparoscópica

Résumé

Laparoscopic bile duct exploration as a one-stage treatment for choledocholithiasis. Cost-effectiveness study of the procedure compared to the classical approach: ERCP followed by laparoscopic cholecystectomy. Introduction Choledocholithiasis is the presence of a stone in the main bile duct. Its treatment is based on the extraction of the calculus from this location. The standard of treatment is endoscopic retrograde cholangiopancreatography (ERCP). In this way, a patient with choledocholithiasis needs two interventions: ERCP and surgical cholecystectomy. It means it is necessary two anesthetic processes, more possibilities of failure of any of the interventions, complications of these, more hospital stay and more expenses for the health system. Thanks to laparoscopic surgery, the possibility of laparoscopic common bile duct exploration (LCBE) is possible only with a single intervention. Currently, there is controversy over which is the best therapeutic option: preoperative ERCP followed by laparoscopic cholecystectomy or LCBE. We designed this prospective, non-randomized, single-center study of 118 patients diagnosed with choledocholithiasis to establish the validity and safety of a new implantation program for LCBE in our hospital. We analyze the results in terms of hospital stay and cost-effectiveness. Results There are 118 patients in the study (67 women and 51 men with a mean age of 69.8 ± 17.3 years). Sixty-six patients received a two-stage management (ERCP + LC). Fifteen of them failed to clean the bile duct. LCBE was carried out in 59 patients (49 plus 11 ERCP failure). Seven of them required conversion to open surgery. No statistically significant differences were found between the LCBE group and the ERCP + LC group in terms of clinical-demographic terms. LCBE was more effective cleaning the bile duct than ERCP (88.1% vs. 72.7%; p = 0.032) with no differences in terms of postoperative morbidity or mortality. Previous comorbidity (ICC 5.7 ± 2.7 vs. 3.7 ± 2.6; p = 0.008), cholecystitis (56.3% vs. 12.5%; p <0.001), multiple lithiasis (93.3% vs. 34.3%; p < 0.001) and big stones in the main bile duct (72.2% vs. 31.3%; p = 0.003) were associated with ERCP failure. No variable was associated to the failure of LCBE. However, learning curve of the technique influenced the decision to initiate open surgery or conversion to open surgery. LCBE was an independent factor in the reduction of the hospital stay and the economic expenses, reducing on average of 6.13 days (95% CI 2.98 - 9.27; p <0.001) the hospital stay and about 3.218, 16¿ (95% CI 1.082,4 - 5.354,8; p = 0.001) the costs compared to the classic approach, with an incremental cost-effectiveness indicator (CEI) of -209. Conclusions LCBE is more effective and has a similar safety than two-stage approach in patients with a diagnosis of choledocholithiasis. It significantly reducing hospital stay and expenses derived from the management of these patients.