Original Article
Noninvasive vs. selective invasive biliary imaging for acute biliary pancreatitis: an economic evaluation by using decision tree analysis

https://doi.org/10.1016/S0016-5107(04)02472-1Get rights and content

Background

ERCP is used selectively in patients with acute biliary pancreatitis (ABP). In patients with ABP, ERCP often is difficult and has the potential to cause further damage. In addition, the prevalence of residual choledocholithiasis in ABP is low (<30%). EUS and MRCP accurately diagnose choledocholithiasis, but the performance of MRCP may be inferior in ABP. EUS, with ERCP when a stone is seen, has been shown to be feasible. This study assessed the relative costs and outcomes of EUS and MRCP in patients with ABP compared with standard care involving selective ERCP.

Methods

A decision tree was constructed, modeling standard care for nonsevere ABP (selective ERCP) and severe ABP (ERCP with sphincterotomy and balloon sweep). The other arms included either EUS or MRCP first, with the conversion to or the addition of ERCP when a bile-duct stone was seen. Probabilities and accuracy of EUS and MRCP were taken from published data. Costs were locally quantified in Canadian dollars (CDN), including nursing/technical/professional personnel, equipment maintenance, and disposable equipment. The robustness of assumptions was tested by sensitivity analyses.

Results

Overall, EUS in all patients with ABP was marginally dominant compared with standard care with selective ERCP ($58 CDN per patient less expensive; 0.9% fewer cases of pancreatitis [ERCP-related or recurrent]). In the severe ABP subgroup, EUS was more clearly dominant ($742 CDN per patient less expensive; 3% fewer cases of pancreatitis), and the nonsevere subgroup had an incremental cost-effectiveness ratio of $17,000 per case of pancreatitis avoided. MRCP was more expensive than EUS in both subgroups.

Conclusions

EUS is dominant in severe ABP. In nonsevere ABP, it is slightly more costly but is associated with fewer ERCPs and ERCP-related complications. A randomized trial would help to quantify the benefits of avoiding ERCP in these patients.

Section snippets

Patients

The hypothetical cohort considered in the model comprised nonpregnant adult patients presenting within 48 hours of the clinical onset of acute pancreatitis, associated with cholelithiasis or a history of gallstones, with or without prior cholecystectomy, who did not have another identifiable cause for pancreatitis, especially recent heavy consumption of alcohol, and who were not suspected to have cholangitis. Patients who already had transabdominal US before entering the model with a US

Results

The main results are summarized in Table 3. The EUS-first strategy was less costly (on average $58 CDN less per patient) than standard care and less costly than MRCP (on average $130 CDN less per patient). The average number of ERCPs needed per patient was 0.23 fewer per patient in the EUS-first arm compared with the standard care arm (also with 1.2 fewer ERCP-related deaths per 1000 patients). There were 0.25% more cases of recurrent pancreatitis, giving a total rate for pancreatitis,

Discussion

Although ABP is a common clinical problem, optimal management is not entirely clear. It appears that a subgroup of patients (those with severe ABP or those with residual bile-duct stones) benefits from early ductal clearance at ERCP. A noninvasive test with high accuracy for detecting bile-duct obstruction that could be easily converted to an invasive therapeutic procedure when a stone is identified, would be ideal; EUS-guided ERCP potentially meets these criteria. Same-site MRCP and ERCP is

References (50)

  • M.I. Canto et al.

    Endoscopic ultrasonography versus cholangiography for the diagnosis of choledocholithiasis

    Gastrointest Endosc Clin N Am

    (1998)
  • A.R. Gillams et al.

    Recent developments in biliary tract imaging

    Gastrointest Endosc Clin N Am

    (1996)
  • J. Lachter et al.

    Linear EUS for bile duct stones

    Gastrointest Endosc

    (2000)
  • M. Sugiyama et al.

    Endoscopic ultrasonography for diagnosing choledocholithiasis: a prospective comparative study with ultrasonography and computed tomography

    Gastrointest Endosc

    (1997)
  • A. Chak et al.

    Prospective assessment of the utility of EUS in the evaluation of gallstone pancreatitis

    Gastrointest Endosc

    (1999)
  • V. de Ledinghen et al.

    Diagnosis of choledocholithiasis: EUS or magnetic resonance cholangiography? A prospective controlled study

    Gastrointest Endosc

    (1999)
  • M.I. Canto et al.

    Endoscopic ultrasonography versus cholangiography for the diagnosis of choledocholithiasis

    Gastrointest Endosc

    (1998)
  • L. Palazzo et al.

    Value of endoscopic ultrasonography in the diagnosis of common bile duct stones: comparison with surgical exploration and ERCP

    Gastrointest Endosc

    (1995)
  • F. Prat et al.

    Early EUS of the bile duct before endoscopic sphincterotomy for acute biliary pancreatitis

    Gastrointest Endosc

    (2001)
  • F.C. Ramirez et al.

    Success of repeat ERCP by the same endoscopist

    Gastrointest Endosc

    (1999)
  • J.C. Gregor et al.

    Should ERCP be routine after an episode of “idiopathic” pancreatitis? A cost-utility analysis

    Gastrointest Endosc

    (1996)
  • D. Boerma et al.

    Wait-and-see policy or laparoscopic cholecystectomy after endoscopic sphincterotomy for bile-duct stones: a randomised trial

    Lancet

    (2002)
  • M. Rhodes et al.

    Randomised trial of laparoscopic exploration of common bile duct versus postoperative endoscopic retrograde cholangiography for common bile duct stones

    Lancet

    (1998)
  • M.E. Cohen et al.

    Prediction of bile duct stones and complications in gallstone pancreatitis using early laboratory trends

    Am J Gastroenterol

    (2001)
  • S. Kumar et al.

    Success and yield of second attempt ERCP

    Gastrointest Endosc

    (1995)
  • Cited by (68)

    • ASGE guideline on the role of endoscopy in the evaluation and management of choledocholithiasis

      2019, Gastrointestinal Endoscopy
      Citation Excerpt :

      Among patients at indeterminate risk, EUS before ERCP may obviate the need for the latter.31,32 MRCP overcomes the limitations of transabdominal US, particularly the obfuscation of the distal bile duct because of intraductal air.19 In the meta-analysis of head-to head studies by Meeralam et al,24 the specificities of both EUS and MRCP were very high (.97 vs .92), consistent with a Cochrane meta-analysis,33 which primarily used indirect comparison of the 2 tests.

    • EUS in Bile Duct, Gallbladder, and Ampullary Lesions

      2014, Endosonography, Third edition
    • Endoscopic retrograde cholangiopancreatography for suspected choledocholithiasis: Testing the current guidelines

      2013, Digestive and Liver Disease
      Citation Excerpt :

      MRCP is an option to consider in those institutions where the expertise and/or equipment for EUS are not available, as a recent systematic review and prospective study have demonstrated that both techniques have statistically similar diagnostic accuracy, sensitivity and specificity [16,17]. Unfortunately, MRCP has been shown to be more expensive than EUS and would add significant amount of cost to the patients hospital stay and care [18]. In our view in institutions without EUS capabilities, laparoscopic cholecystectomy and intraoperative cholangiogram may be the best approach as all patients will eventually require surgical removal of their gallbladder.

    View all citing articles on Scopus

    Presentation at the Canadian Annual Gastroenterology Meeting, February 27, 2004, Banff, Alberta, Canada (Can J Gastroenterol 2003;17:95A [Abstract]) and at Digestive Diseases Week (DDW), Annual Meeting of the AGA, Orlando, Fla, 2003, May 15, 2004 (Gastrointest Endosc 2003;57:AB112 [Abstract]).

    Drs. Romagnuolo and Currie are population health investigators funded by the Alberta Heritage Foundation for Medical Research.

    View full text