ENDOSCOPIC ULTRASOUND IS A COST-EFFECTIVE STATE-OF-THE-ART REPLACEMENT FOR ERCP IN THE EVALUATION OF PANCREATOBILIARY DISORDERS

Abstract

Purpose: The value of endoscopic ultrasound (EUS) in the evaluation of pancreatobiliary disorders continues to expand. Its safety and diagnostic accuracy are superior to endoscopic retrograde cholangiopancreatography (ERCP), and the information provided frequently obviates the need for ERCP and other diagnostic procedures, resulting in a faster, safer and less costly evaluation of these patients. We describe our experience with EUS ± fine needle aspiration (FNA) and its impact on the costs of managing patients with pancreatobiliary disorders. Methods: We analyzed the clinical and diagnostic aspects as well as the outcome of all patients referred to our EUS center for the evaluation of pancreatobiliary disorders. EUS ± FNA was performed, and patients were managed according to the findings, either medically or with therapeutic ERCP and/or surgery. The estimated cost of the medical care of these patients was obtained and compared with the potential costs if EUS had not been available, mainly considering additional tests, unnecessary ERCPs and surgical interventions. Results: One hundred and nine consecutive patients referred for EUS with a pancreatobiliary indication were prospectively evaluated. Fifty-nine (54.1%) were women, median age 59 yrs (range 7–83). Most EUS (73.4%) were performed on an outpatient basis. Fifty-two procedures (47.7%) were EUS-FNA. Ten EUS-guided celiac plexus neurolysis were performed. The main indications for EUS were jaundice (37.6%), abdominal pain (36.7%), and unexplained pancreatitis (17.4%). The most common EUS findings were pancreatic cancer (30.3%), choledocholithiasis (10.1%), cholelithiasis (8.3%) and cholangiocarcinoma (8.3%). Due to the EUS findings, a total of 64 ERCPs and 28 surgical interventions were avoided. Seven patients underwent exploratory surgery in spite of our EUS-based recommendations. A total of 7 EUS and 2 EUS-FNA procedures were not useful or had no impact on patient's outcome. Only one complication (acute cholangitis) resulted from EUS-FNA. Overall, an approximate total of $688,553 USD ($5247 per patient) was saved in the medical care of these patients. Conclusions: EUS ± FNA is an accurate and cost-effective test to evaluate patients with pancreatobiliary diseases, especially when malignancy is suspected. EUS should replace diagnostic ERCP as a tool in the initial work-up of these patients.