J L Lohmuller | PubMed Health

PubMed1990

Choledochoscopy. A cost-minimization analysis.

Although choledochoscopy for the prevention of retained bile duct stones has been postulated as cost effective, no economic evaluation exists to substantiate this claim. We performed a cost-minimization analysis on 287 patients who underwent choledochoscopy during operations for biliary tract calculi between 1981 and 1987 to assess the economic impact of choledochoscopy versus noncholedochoscopic alternatives in obtaining a stone-free duct. Common duct exploration was positive for calculi in 75% of patients. Choledochoscopy-detected residual stones after duct exploration in 10% of patients. Residual stones were more frequent after positive (12.5%) than negative (2.7%) duct explorations. retained stones occurred in 4.5% of patients after operation. Sensitivity, specificity, and negative predictive values of choledochoscopy were 67%, 100%, and 95%, respectively. Cost-minimization analysis showed that total cost of either selective ($75,250) or routine ($110,450) choledochoscopy significantly exceeded the total cost of obtaining a stone-free duct for patients with retained stones via either extraction through a T-tube tract ($17,545) or by endoscopic papillotomy ($45,675). Because choledochoscopy was not economically competitive with noncholedochoscopic, nonoperative alternatives, reduction of choledochoscopy fees was implemented to economically justify continued use of choledochoscopy. We conclude that choledochoscopy is clinically efficacious in obtaining a stone-free duct, but endorsement of either routine or selective choledochoscopy by cost-minimization analysis requires careful assessment of fee structure to make choledochoscopy competitive economically.

Aged↗

PubMed1990

Pouchitis and extraintestinal manifestations of inflammatory bowel disease after ileal pouch-anal anastomosis.

Although the etiology of pouchitis after ileal pouch-anal anastomosis (IPAA) is unknown, its manifestations resemble those of nonspecific inflammatory bowel disease, including, anecdotally, the apparent ability to evoke extraintestinal manifestations (EIM) of inflammatory bowel disease (IBD). Our aim was to determine in what manner pouchitis and EIMs were associated. The computerized records of 819 consecutive patients who underwent IPAA between January 1981 and December 1988 were reviewed. Eighty-five patients were excluded (because of incomplete follow-up, death, or permanent ileostomy). Follow-up of the remaining 734 patients was complete (mean, 41 months). The mean age was 32 years and the ratio of men to women was 1:1. Ileal pouch-anal anastomosis was performed for chronic ulcerative colitis in 91% of patients and for familial adenomatous polyposis in 9%. Pouchitis occurred in 31% of chronic ulcerative colitis patients and 6% of familial adenomatous polyposis patients (p less than 0.01). The mean time to first occurrence was 17 months. Pouchitis recurred in 61% of patients at risk. Patients with preoperative and postoperative EIMs had significantly higher rates of pouchitis than did patients without EIMs (39% preoperative EIMs versus 26% with no EIMs, p less than 0.001; 53% postoperative EIMs versus 25% with no EIMs, p less than 0.001). Of patients with pouchitis in whom EIMs resolved after IPAA but then recurred (n = 12), EIMs recurred when pouchitis occurred and abated when pouchitis was treated in seven patients. We concluded that pouchitis occurred frequently after IPAA and that patients with EIMs were at higher risk of developing pouchitis than were patients who never had EIMs. Furthermore some patients experienced a temporal relationship between flares of EIMs and pouchitis. These results imply that pouchitis may be a novel manifestation of inflammatory bowel disease persisting after operation.

Adult↗