Decision analysis of minimally invasive management options for cholecysto-choledocholithiasis
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and Other Interventional Techniques
REVIEW ARTICLE
Decision analysis of minimally invasive management options for cholecysto‑choledocholithiasis Alison Bradley1 · Sharukh Sami1 · Niroshini Hemadasa1 · Anne Macleod1 · Leo R. Brown1 · Jeyakumar Apollos1 Received: 23 April 2020 / Accepted: 10 July 2020 © Springer Science+Business Media, LLC, part of Springer Nature 2020
Abstract Background The management of cholecysto-choledocholithiasis is controversial with the risks and benefits of one versus twostage 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. Keywords Cholecysto-choledocholithiasis · ERCP · Gallstones The management of cholecysto-choledocholithiasis in the era of laparoscopic cholecystectomy is controversial [1]. Current guidelines state that perioperative endoscopic retrograde cholangiopancreatography (ERCP) and laparoscopic common bile duct exploration a
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