Cost Analysis Comparing Intraoperative Fluorescent Cholangiography with Fluoroscopic Cholangiogram

Fernando Dip, MD, Domenech Asbun, MS, Armando Rosales-Velderrain, MD, Emanuele Lo Menzo, MD, PhD, Conrad H Simpfendorfer, MD, Samuel Szomstein, MD, FACS, Raul Rosenthal, MD, FACS. Cleveland Clinic Florida.

Introduction: Laparoscopic cholecystectomy (LC) remains the gold standard approach for symptomatic cholelithiasis. Despite its standardization, the rate of bile duct injury (BDI) has risen from 0.2 to 0.5% since its introduction. The resulting consequences of BDI significantly affect patients’ well being and leads to economic and legal implications. The routine use of intraoperative cholangiography (IOC) advocated by many as a diagnostic modality to prevent biliary tract injuries, has not been widely accepted, mainly because it is time consuming, costly and there is lack of evidence that it will prevent BDI. Fluorescent cholangiography (FC) is a novel, intraoperative procedure involving infrared visualization of biliary structures. We evaluated the costs and effectiveness of routinely implemented FC and IOC during LC.

Material and methods: We reviewed all patients between February and June 2013 that were enrolled in an IRB approved prospective study, comparing LC with FC and IOC. The procedure time, procedure cost and effectiveness of the two methods were analyzed and compared. The surgeons involved in the cases completed a survey on the usefulness of each method.

Results: A total of 43 patients (21 males and 22 females) were analyzed during the study period. The mean age was 49.53 ± 14.35 yrs and mean body mass index (BMI) was 28.35 ± 8 kg/m2. The overall mean operative time was 64.95 ± 17.43 min. FC was faster than IOC (0.71 ± 0.26 min vs. 7.15 ± 3.76 min; p <0.0001). FC was successfully performed in 43 out of 43 cases (100%), and IOC in 40 out of 43 cases (93.02%). FC was less expensive than IOC (14.10 ± 4.31 vs. 778.43 ± 0.40 dollars; p <0.0001).

FC use generated an additional cost of mean $14 ± 4.25 dollars per LC. Costs of IOC per surgery were found to be in the literature between $100 – $700. According to the survey, all surgeons found the routine use of FC useful.

Conclusion: FC was effective in delineating important anatomic structures during LC. It required less time and expenses when compared to IOC. Additionally it was perceived by the surgeons to be easier to perform and at least as useful as IOC. Further prospective studies are warranted to evaluate the effectiveness of FC in decreasing BDI.