Cholecystectomy during gastric bypass deemed cost effective.
Dr. White and his colleagues performed a cost analysis, comparing ursodiol treatment for 6 months post operatively, to concurrent cholecystectomy and to watchful waiting, assuming that patients who developed gallstones with watchful waiting or while on ursodiol would undergo cholecystectomy.
Data on the risk of developing gallstones after a Roux-en-Y by pass, on the effectiveness of ursodiol treatment, and on the likelihood of complications with any of the strategies were culled from the peer-reviewed literature.
In their payer-perspective analysis, the investigators found that concurrent cholecystectomy was the least expensive treatment, with an average cost of $1,046 per patient, followed by ursodiol at $2,623 and watchful waiting at $3,964, said Dr. White of the surgery department at Dartmouth Hitchcock Medical Center, Lebanon, N.H.
The three treatments showed almost the same number of quality-adjusted life-years achieved: 21.39 years for concurrent cholecystectomy, 21.44 years for ursodiol, and 21.43 years for watchful waiting.
When the cost per quality-adjusted life-year of watchful waiting was computed for a population of patients, it was found to exceed the benchmark of what is considered a cost-effective strategy. Ursodiol, on the other hand, was cost effective, as long as one considered it to be at least 60% effective in preventing gallstones.
On the basis of these findings, Dr. White concluded that "surgeons who currently employ a watchful waiting approach should consider either using ursodiol or performing a concurrent cholecystectomy." Studies have suggested that anywhere from 32% to 71% of patients who have a Roux-en-Y bypass will develop gallstones, he noted.
In a 2002 survey of surgeons who perform bariatric procedures, 30% said they use ursodiol treatment after a Roux-en-Y procedure, 15% remove the gallbladder routinely, and the remainder watch and wait, Dr. White said.
The landmark trial of ursodiol treatment found that it cut the rate of gallstone formation to 2%, from 32% in controls.
In commenting on the analysis, Dr. David Flum of the University of Washington, Seattle, noted that bile duct injury may occur with gallbladder removal, and it has a devastating impact on the patient. In addition, as more procedures are done laparoscopically that would make removing the gallbladder more difficult.
TIMOTHY F. KIRN
DATA WATCH Major Comorbidities Raise Risk of Bariatric Surgery Complications BMI [greater than BMI [greater than or equal to]35 or equal to] 40 kg/[m.sup.2] plus kg/[m.sup.2] minor/no major comorbidities comorbidities (n = 1,045) (n = 420) Major wound infection 3.9% 1.4% Anastomotic leak 4.1% 1.2% Mortality 2.3% 0.24% Note: BMI is body mass index. Source: Surgery for Obesity and Related Diseases 2005; 1:511-6 Note: Table made from bar graph.
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|Title Annotation:||Clinical Rounds|
|Author:||Kirn, Timothy F.|
|Publication:||Family Practice News|
|Date:||Jan 15, 2006|
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