Cost-effectiveness of endoscopic ultrasound-directed transgastric ERCP compared with device-assisted and laparoscopic-assisted ERCP in patients with Roux-en-Y anatomy

Abstract

Background Roux-en-Y gastric bypass (RYGB) surgery is the second most common weight loss surgery in the United States. Treatment of pancreaticobiliary disease in this patient population is challenging due to the altered anatomy, which limits the use of standard instruments and techniques. Both nonoperative and operative modalities are available to overcome these limitations, including device-assisted (DAE) endoscopic retrograde cholangiopancreatography (ERCP), laparoscopic-assisted (LA) ERCP, and endoscopic ultrasound-directed transgastric ERCP (EDGE). The aim of this study was to compare the cost-effectiveness of ERCP-based modalities for treatment of pancreaticobiliary diseases in post-RYGB patients. Methods A decision tree model with a 1-year time horizon was used to analyze the cost-effectiveness of EDGE, DAE-ERCP, and LA-ERCP in post-RYGB patients. Monte Carlo simulation was used to assess a plausible range of incremental cost-effectiveness ratios, net monetary benefit calculations, and a cost-effectiveness acceptability curve. One-way sensitivity analyses and probabilistic sensitivity analyses were also performed to assess how changes in key parameters affected model conclusions. Results EDGE resulted in the lowest total costs and highest total quality-adjusted life-years (QALY) for a total of $5188/QALY, making it the dominant alternative compared with DAE-ERCP and LA-ERCP. In probabilistic analyses, EDGE was the most cost-effective modality compared with LA-ERCP and DAE-ERCP in 94.4 % and 97.1 % of simulations, respectively. Conclusion EDGE was the most cost-effective modality in post-RYGB anatomy for treatment of pancreaticobiliary diseases compared with DAE-ERCP and LA-ERCP. Sensitivity analysis demonstrated that this conclusion was robust to changes in important model parameters.

Endoscopic ultrasound-directed transgastric ERCP (EDGE): a retrospective multicenter study

“…These figures compare favorably to LA-ERCP, for which published LOS varies (1.9 to 3.9 days [25,12,17,24]. In a recent analysis, EDGE was found to be more cost-effective than either LA-ERCP or BAE-ERCP [41]…”

Endoscopic biliary therapy in the era of bariatric surgery

“…EDGE procedures were of shorter duration (73 minutes vs 184 minutes) and patients had a shorter hospital stay (0.8 days vs 2.65 days) (32). EDGE also appears to be a more cost effective modality (34). A retrospective multi-centred review of 30 patients in each arm of EDGE vs BE-ERCP found EDGE to have a statistically significantly higher success rate (100% vs 60%, p<.001), shorter procedure time (49.8 vs 90.7minutes p<.001), shorter length of stay (1 vs 10.5 days p =.02) with similar adverse event rates (10% vs 6.7%) (33).…”

Single-step endoscopic ultrasound-guided gastroenterostomy and ERCP in patient with Roux-en-Y hepaticojejunostomy after right lobe hepatectomy

“…In this report, we wish to demonstrate its feasibility and safety as a single-step pro-cedure. Moreover, despite the high cost of the Hot Axios system, in a comparison with other current alternative strategies for Roux-en-Y anastomosis, EDGE was shown to be the most cost-effective [5]. Thus, shortening the procedure into a single session should reduce even further the cost of patient management.…”