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Surgical Endoscopy
Published in: Surgical Endoscopy 12/2020

01-12-2020 | Cholecystectomy | Review Article

Decision analysis of minimally invasive management options for cholecysto-choledocholithiasis

Authors: Alison Bradley, Sharukh Sami, Niroshini Hemadasa, Anne Macleod, Leo R. Brown, Jeyakumar Apollos

Published in: Surgical Endoscopy | Issue 12/2020

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Abstract

Background

The management of cholecysto-choledocholithiasis is controversial with the risks and benefits of one versus two-stage approaches debated. This study aims to perform decision analysis of minimally invasive laparo-endoscopic approaches.

Methods

An advanced decision tree was constructed to compare pre, intra and post-operative ERCP and laparoscopic common bile duct exploration in terms of primary ductal clearance and significant complications for patients intended to undergo laparoscopic cholecystectomy. Transition probabilities were calculated from randomised controlled trials following a comprehensive literature search. Model uncertainties were extensively tested through deterministic and probabilistic Monte Carlo sensitivity analysis. Utility outcomes were 1 and 0.5 for successful primary clearance without and with complications, respectively, and 0 for failure of primary clearance of the duct.

Results

Twenty-one studies (n = 2697) were included in the analysis. At base case analysis, a laparo-endoscopic rendezvous approach had the highest utility output (0.90; no complication probability: 0.87/complication probability 0.06). Laparoscopic common bile duct exploration was ranked second with a utility output 0.87 (no complication probability: 0.82/complication probability 0.10). Pre-operative ERCP utility score was 0.84 (no complication probability: 0.78/ complication probability 0.11) and post-operative ERCP utility score was 0.78 (no complication probability: 0.71/complication probability 0.13). Monte Carlo analysis showed that laparo-endoscopic rendezvous and laparoscopic common bile duct exploration had an equal mean utility output of 0.57 (standard deviation 0.36; variance 0.13; 95% confidence interval 0.00–0.99 versus standard deviation 0.34; variance 0.12; 95% confidence interval 0.01–0.98). Laparo-endoscopic rendezvous had a superior treatment selection frequency of 39.93% followed by laparoscopic bile duct exploration (36.11%), pre-operative ERCP (20.67%) and post-operative ERCP (2.99%).

Conclusion

One-stage approach to the management of cholecysto-choledocholithiasis is superior to two-stage, in terms of primary clearance of the duct and risk of operative morbidity. Laparo-endoscopic rendezvous approach could offer marginal additional benefit but more high-quality randomised controlled trials are needed.
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Metadata
Title
Decision analysis of minimally invasive management options for cholecysto-choledocholithiasis
Authors
Alison Bradley
Sharukh Sami
Niroshini Hemadasa
Anne Macleod
Leo R. Brown
Jeyakumar Apollos
Publication date
01-12-2020
Publisher
Springer US
Published in
Surgical Endoscopy / Issue 12/2020
Print ISSN: 0930-2794
Electronic ISSN: 1432-2218
DOI
https://doi.org/10.1007/s00464-020-07816-w

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