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Invited Critique
January 1, 2007

Optimizing Choledocholithiasis Management—Invited Critique

Arch Surg. 2007;142(1):49. doi:10.1001/archsurg.142.1.49

This report posits that postoperative ERCP is more cost-effective for incidental choledocholithiasis management after LC/IOC than LCBDE. They appear to prove this by performing a theoretical cost-effectiveness analysis. The authors make several very broad assumptions that do not necessarily reflect common scenarios in which we practice. For example, they calculate an opportunity cost of $4074 for taking the extra operating room time to perform the LCBDE. However, they do not acknowledge an opportunity cost for use of an ERCP suite, which would tend to counterbalance. They assume that the success rate of a “rescue” ERCP was 100% should either the initial ERCP or LCBDE fail. This is inaccurate, and the success rate diminishes after each successive failed attempt. Additionally, there is often a delay between the performance of a laparoscopic cholecystectomy with cholangiogram and subsequent ERCP in the order of days at most institutions, whereas an LCBDE can be done immediately at the time of operation. It is not clear how this is factored into the calculations.

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