Cost-Effectiveness Analysis of Cholecystectomy During Bariatric Surgery

Background: Surgeons performing bariatric surgery for morbid obesity vary widely in their use of concurrent cholecystectomy. Methods: A decision model was developed to evaluate clinical and economic outcomes of current strategies: routine concurrent cholecystectomy, Roux-en-Y gastric bypass (RYGBP) alone with or without postoperative ursodiol therapy, and selective cholecystectomy based on preoperative ultrasound. Probabilities were obtained from a comprehensive literature review. Costs and hospital days were obtained from the Healthcare Cost and Utilization Project Nationwide Inpatient Sample. One-way sensitivity analyses were performed. Results: The least expensive strategy was to perform RYGBP alone without preoperative ultrasound, with a total cost (over the RYGBP cost) of $536.73 per patient. RYGBP with concurrent cholecystectomy had a cost of $631.35. Performing selective cholecystectomy based on preoperative ultrasound was dominated by the other two strategies. Our model was most sensitive to the probability of developing gallbladder-related symptoms after RYGBP alone. When the incidence of gallbladder-related symptoms was lower than 4.6%, the dominant strategy was to perform a RYGBP without cholecystectomy and no preoperative ultrasound. For values above 6.9%, performing concurrent cholecystectomy at the time of the RYGBP was superior to the other strategies. When ursodiol was used, the least expensive strategy was to perform a concurrent cholecystectomy during RYGBP. Conclusions: The main factor determining the most cost-effective strategy is the incidence of gallbladder-related symptoms after RYGBP. Also, the use of ursodiol was associated with an increase in cost that does not justify its use after RYGBP. Finally, selective cholecystectomy based on preoperative ultrasound was dominated by the other strategies in the scenarios evaluated.