Cost Analysis of Temporarily Placed Covered Self Expandable Metallic Stents Versus Plastic Stents in Biliary Strictures Related to Chronic Pancreatitis

Abstract

Background and Aims: Benign biliary strictures secondary to chronic pancreatitis (CP) are traditionally managed by ERCP with plastic stents insertion. Their potential to occlude and migrate makes them only temporarily efficacious and has led many to consider other options. Temporary placement of CSEMS might offer an alternative in terms of reducing the number of sessions required, but the higher cost associated of CSEMS may be a concern. This study prospectively compared a group of patients treated by CSEMS to a group of patients who received plastic stents and performed a cost analysis to evaluate the overall cost of each modality. Methods: 22 patients with biliary strictures related to CP underwent CSEMS placement (Wallstent, Boston Scientific), and were compared to a set of 27 patients who received plastic stents with 22 of them matched to the CSEMS group by age (51 ± 12 y/o and 52 ± 13 respectively, p = 0.67) gender (20 and 17 male in each group, p = 0.227) and etiology of chronic pancreatitis (15 and 16 alcohol related in each group, p = 0.748). CSEMS were left in place until adequate biliary drainage was achieved, confirmed by clinical improvement, normalization of liver function tests and imaging before removal was effected with snare or rat tooth . Plastic stents were replaced every three months until resolution of stricture. All procedures were performed by 2 dedicated pancreatico-biliary endoscopists (PY and MK). Response to therapy, morbidity, and overall outcome were determined. A cost analysis was performed using decision analysis software (Treeage Data 3.5). Results: 19 patients in the CSEMS group (86%) responded to treatment versus 18 (82%) in the plastic stent group. CSEMS and plastic stents were left in place for a median time of 5 (range: 1-21) versus 8 months (range: 3-35). Median number of session required until resolution of stricture was respectively 2 (range: 1-3) versus 5 (range: 2-12) (p = 0.0001). Complications in the CSEMS group included migration without stricture resolution (1), post sphincterotomy bleed (1), pain (1) and worsening pancreatitis with infected pseudocyst (1). One patient spontaneously passed CSEMS with resolution of the stricture. In this model, the total cost using plastic stents was $17,304.92 per patient. Total cost for CSEMS was $10,137.22. The total cost savings using CSEMS was $7,167.70 per patient. Conclusion: The use of CSEMS in benign biliary strictures related to CP provides substantial cost savings compared to conventional ERCP with plastic stenting. The fewer number of sessions required to achieve resolution of stricture using CSEMS compensates for the initial higher cost of CSEMS placement.