Cost effectiveness of endoscopic gallbladder drainage to treat acute cholecystitis in poor surgical candidates.

BACKGROUND: Endoscopic gallbladder drainage (GBD) is an alternative to percutaneous GBD (PGBD) to treat acute cholecystitis, yielding similar success rates and fewer adverse events. To our knowledge, no cost-effectiveness analysis has compared these procedures. We performed an economic analysis to identify clinical and cost determinants of three treatment options for acute cholecystitis in poor surgical candidates. METHODS: We compared three treatment strategies: PGBD, endoscopic retrograde cholangiographic transpapillary drainage (ERC-GBD), and endosonographic GBD (EUS-GBD). A decision tree was created over a 3-month period. Effectiveness was measured using hospital length of stay, including adverse events and readmissions. Costs of care were calculated from the National Inpatient Sample. Technical and clinical success estimates were obtained from the published literature. Cost effectiveness was measured as incremental cost effectiveness and compared to the national average cost of one hospital bed per diem. RESULTS: Analysis of a hypothetical cohort of poor candidates for cholecystectomy showed that, compared to PGBD, ERC-GBD was a cost-saving strategy and EUS-GBD was cost effective, requiring $1312 per hospitalization day averted. Additional costs of endoscopic interventions were less than the average cost of one hospital bed per diem. Compared to ERC-GBD, EUS-GBD required expending an additional $8950 to prevent one additional day of hospitalization. Our model was considerably affected by lumen-apposing metal stent cost and hospital length of stay for patients managed conservatively and those requiring delayed surgery. CONCLUSIONS: Endoscopic GBD is cost effective compared to PGBD, favoring ERC-GBD over EUS-GBD. Further efforts are needed to make endoscopic GBD available in more medical centers, reduce equipment costs, and shorten inpatient stay.

Acute cholecystitis in high risk surgical patients: percutaneous cholecystostomy versus laparoscopic cholecystectomy (CHOCOLATE trial): study protocol for a randomized controlled trial.

BACKGROUND: Laparoscopic cholecystectomy in acute calculous cholecystitis in high risk patients can lead to significant morbidity and mortality. Percutaneous cholecystostomy may be an alternative treatment option but the current literature does not provide the surgical community with evidence based advice. METHODS/DESIGN: The CHOCOLATE trial is a randomised controlled, parallel-group, superiority multicenter trial. High risk patients, defined as APACHE-II score 7-14, with acute calculous cholecystitis will be randomised to laparoscopic cholecystectomy or percutaneous cholecystostomy. During a two year period 284 patients will be enrolled from 30 high volume teaching hospitals. The primary endpoint is a composite endpoint of major complications within three months following randomization and need for re-intervention and mortality during the follow-up period of one year. Secondary endpoints include all other complications, duration of hospital admission, difficulty of procedures and total costs. DISCUSSION: The CHOCOLATE trial is designed to provide the surgical community with an evidence based guideline in the treatment of acute calculous cholecystitis in high risk patients. TRIAL REGISTRATION: Netherlands Trial Register (NTR): NTR2666.

Percutaneous cholecystostomy using a central venous catheter is effective for treating high-risk patients with acute cholecystitis.

Percutaneous cholecystostomy (PC) using a pigtail catheter is performed on high-risk patients with acute cholecystitis as their general condition does not usually allow them to undergo a "definite" cholecystectomy. However, this method of PC is time-consuming and expensive and requires an interventional radiologist and specially designed radiologic equipment. To determine whether another PC approach was viable, we retrospectively compared patients who underwent PC using a central venous catheter (group A, n = 15) with those who underwent standard pigtail catheter PC (group B, n = 29). The waiting time prior to undergoing the PC was 1.8 days in group A and 3.5 days in group B (P < 0.05). The cost per patient was 293,364 won (254.44 dollars) for group A, and 438,719 won (380.50 dollars) for group B (P < 0.05). There were 4 complications in group A and 5 in group B. Following PC, 7 patients in group A and 15 patients in group B underwent delayed definite cholecystectomy, and there were no differences between these groups in terms of complications, mortality, and the delayed definite cholecystectomy surgical method. We conclude that in combination with careful patient selection, PC using a central venous catheter in high-risk patients with acute cholecystitis is a viable alternative to pigtail catheter PC.

The efficacy of percutaneous cholecystostomy in critically ill patients.

Percutaneous cholecystostomy (PC) has been proposed as a method of biliary decompression in critically ill patients with acute cholecystitis. We evaluated the efficacy of PC in this setting. The charts of 33 critically ill patients (mean age 52, range 5-87) who underwent PC for suspected acute cholecystitis were retrospectively examined. Univariate analysis was performed to identify which patients might benefit from PC. PC was technically successful in all patients with no direct mortality or major complications. Failure to improve within 24 hours was associated with increased mortality (P = 0.02). A total of 22/33 patients improved, 17/33 survived, and 8/33 required surgery. PC delayed definitive operation in two patients. Cholelithiasis was associated with surgical intervention (P = 0.01) but not increased mortality. Favorable prognosticators for survival included gallbladder dilatation (P = 0.01), pericholecystic fluid (P = 0.01), and absence of a pulmonary artery catheter (P = 0.02). Predictors of improvement included gallbladder nonvisualization on hepatobiliary scan (P = 0.047), positive bile cultures (P = 0.017), and initial drainage of < / = 100 cc (P = 0.009). Age, laboratory data, the use of total parenteral nutrition, and intubation did not predict outcome. Nine positive bile cultures prompted antibiotic changes in five cases. Finally, PC was less expensive than open cholecystostomy ($1620 versus $3155). PC is a safe, cost-effective, minimally invasive procedure that has diagnostic and therapeutic value in critically ill patients with acute cholecystitis. The involvement of a general surgeon is important to ensure that those patients who do not improve within 24 hours receive early surgical intervention and provide long-term definitive care for those patients with cholelithiasis.