Cost-effectiveness analysis of palliative treatment for periampullary cancer: a comparison of surgical and endoscopic approaches.

BACKGROUND

Endoscopic biliary stenting is the standard palliative approach for biliary obstruction in unresectable periampullary cancer (PAC). However, stent dysfunction and complications can impact treatment outcomes. This study aimed to evaluate the influence of surgical (laparotomy) versus endoscopic approaches on the cost-effectiveness of palliative treatment for biliary obstruction in PAC using real-world data.

METHODS

Data from consecutive patients with malignant obstructive jaundice undergoing either endoscopic biliary stenting (plastic and/or metal stents) or surgical biliary-digestive bypass via laparotomy with palliative intent from January 2002 to December 2013 at a tertiary public teaching hospital were retrospectively collected. Epidemiological and clinical variables, complications, survival, and total treatment costs and costs per procedure were analyzed.

RESULTS

Of 150 patients included, 58 (38.66%) underwent endoscopic treatment (ET group) and 92 (61.33%) underwent laparotomy treatment (LT group). The groups were homogenous regarding preoperative anesthetic risk. Early complications were similar in both groups (55.17% for ET and 40.10% for LT), but late complications were more frequent in the ET group (20.68% vs. 10.34%, p < 0.05), mainly associated with persistent cholestasis, recurrent cholangitis, and difficulty with chemotherapy. The ET group also had significantly worse survival curves. While there was no significant difference in the mean cost per procedure between the ET (US$1217) and LT (US$1458) groups (p > 0.05), the mean total cost of treatment was significantly lower in the ET group (US$3653 vs. US$5451, p < 0.05).

CONCLUSION

Endoscopic treatment was associated with a higher occurrence of adverse events and, consequently, worse survival curves, despite a lower mean total cost. Despite this, combining the advantages of both modalities may guide the planning of future cost-effectiveness studies comparing minimally invasive approaches (surgical and endoscopic), particularly in patients with a better prognosis.