Endoscopic ultrasound versus endoscopic retrograde cholangiopancreatography for primary palliation of malignant distal biliary obstruction: a cost-effectiveness modeling analysis.

BACKGROUND

Endoscopic retrograde cholangiopancreatography-guided transpapillary biliary drainage (ERCP-BD) is the standard for primary palliation of malignant distal biliary obstruction (MDBO), but endoscopic ultrasound-guided choledochoduodenostomy (EUS-CDS) has demonstrated improved technical success, efficiency, and safety in randomized trials. However, cost-effectiveness data are lacking. In this modeling study, we analyzed the cost-effectiveness of EUS-CDS with lumen-apposing metal stent (LAMS) and ERCP-BD with self-expandable metal stent (SEMS) for primary MDBO palliation.

METHODS

A state-transition Markov model compared EUS-CDS and ERCP-BD over a 1-year time horizon from a US healthcare perspective. The base case was a 70-year-old with locally advanced, unresectable pancreatic cancer, common bile duct dilation >15 mm, and MDBO. Probabilities were derived from meta-analyses of randomized trials. Outcomes were incremental cost-effectiveness ratios (ICERs), with a willingness-to-pay (WTP) threshold of $100 000/quality-adjusted life year (QALY). Extensive sensitivity analyses were performed.

RESULTS

EUS-CDS with LAMS was cost effective versus ERCP-BD with SEMS for primary treatment of MDBO at an ICER of $47 711/QALY. In one-way sensitivity analyses, EUS-CDS remained cost effective if it cost <$15 502 or if ERCP-BD cost >$11 174. ERCP-BD would become cost effective if technical success was >91%, reintervention <11%, or postprocedural pancreatitis <4%. Probabilistic sensitivity analysis showed EUS-CDS remained cost effective in 74.1% of iterations at a $100 000/QALY WTP threshold.

CONCLUSIONS

In patients with MDBO and biliary dilation >15 mm, EUS-CDS with LAMS may be not only a clinically preferred option but also an economically viable primary approach. Continued efforts to minimize LAMS costs, decrease stent dysfunction, and identify optimal anatomic indications are warranted to facilitate wider adoption.