Endoscopic Ultrasound-Guided Versus Percutaneous Transhepatic Biliary Drainage in Patients With Malignant Biliary Obstruction: Which Is the Optimal Cost-Saving Strategy After Failed ERCP?

Won Jae Yoon,Tae Hoon Lee,Do Hyun Park,Ryan Law,Eric D Shah,Sunguk Jang

doi:10.3389/fonc.2022.844083

Abstract

Background and AimAlthough endoscopic ultrasound-guided biliary drainage (EUS-BD) after failed primary ERCP in malignant distal biliary obstruction has similar clinical outcomes compared to percutaneous transhepatic biliary drainage (PTBD), little is known about optimal cost-saving strategy after failed ERCP. We performed a cost analysis of EUS-BD and PTBD after failed ERCP in two countries with different health care systems in the East and West.MethodsFrom an unpublished database nested in a randomized controlled trial, we compared the cost between EUS-BD and PTBD in Korea. The total cost was defined as the sum of the total biliary drainage costs plus the cost of hospital stay to manage adverse events. We also performed a cost-minimization analysis using a decision-analytic model of a US Medicare population.ResultsIn Korea, the median total costs for the biliary intervention ($1,203.36 for EUS-BD vs. $1,517.83 for PTBD; P=.0015) and the median total costs for the entire treatment were significantly higher in PTBD ($4,175.53 for EUS-BD vs. $5,391.87 for PTBD; P=.0496) due to higher re-intervention rate in PTBD. In cost-minimization analysis of US Medicare population, EUS-BD would cost $9,497.03 and PTBD $13,878.44 from a Medicare insurance perspective (average cost-savings in choosing EUS-BD of $4,381.41 in the US). In sensitivity analysis, EUS-BD was favored over PTBD regardless of the expected re-intervention rate in EUS-BD and PTBD.ConclusionsEUS-BD may have an impact on cost-savings due to better clinical outcomes profile compared to PTBD after failed ERCP, even in different medical insurance programs.

Highlights

The standard management of unresectable malignant distal biliary obstruction (MDBO) is endoscopic retrograde cholangiopancreatography (ERCP) with biliary drainage (BD) (1–3)
For percutaneous transhepatic BD (PTBD), initial PTBD may be done on the same day after failed ERCP, subsequent stent insertion is usually done at another session in different day, and the removal of the catheter may need to be done at yet another session (14)
A one-step percutaneous stent insertion has been introduced which may be done the same day after failed ERCP, the external drainage catheter is removed at another session in a different day, after resolution of cholestasis and confirmation of stent patency

Summary

Introduction

The standard management of unresectable malignant distal biliary obstruction (MDBO) is endoscopic retrograde cholangiopancreatography (ERCP) with biliary drainage (BD) (1–3). ERCP fails in about 5% to 7% (35,000–49,000) of 700,000 ERCP cases performed annually in the US (4), and percutaneous transhepatic BD (PTBD) has been the standard procedure for the biliary decompression in such cases with MDBO (5). Salvage interventional procedures with lower costs may result in the reduction of the costs associated with failed ERCPs. Since the first introduction of endoscopic ultrasound (EUS)guided choledochoduodenostomy in 2001 (7), EUS-guided BD (EUS-BD) has gained popularity for biliary decompression when ERCP fails. In 2016, we published the results of a multicenter, randomized controlled clinical trial comparing the efficacy of EUSBD and PTBD after failed primary ERCP in unresectable MDBO. Endoscopic ultrasound-guided biliary drainage (EUSBD) after failed primary ERCP in malignant distal biliary obstruction has similar clinical outcomes compared to percutaneous transhepatic biliary drainage (PTBD), little is known about optimal cost-saving strategy after failed ERCP.

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Results

Conclusion