Partially covered self-expandable metal stents versus polyethylene stents for malignant biliary obstruction: a cost-effectiveness analysis

Intraluminal brachytherapy using 125I seed strand combined with PTBD and Hepatic arterial infusion chemotherapy for unresectable Bismuth-Corlette III and IV stage hilar cholangiocarcinoma

PURPOSE

To evaluate the safety and efficacy of 125I seed strand combined with percutaneous transhepatic biliary drainage (PTBD) and hepatic arterial infusion chemotherapy (HAIC) for unresectable Bismuth-Corlette III and IV stage hilar cholangiocarcinoma (HCCA).

METHODS

From January 2018 to December 2021, a total of 128 Bismuth-Corlette III and IV stage HCCA patients with obstructive jaundice were included in this single-center retrospective study. Forty-eight patients underwent 125I seed strand combined with PTBD and HAIC (group A). The mean intended dose (r = 10 mm; z = 0; 240 days) in group A was 63.8 ± 0.6 Gy. Eighty cases underwent PTBD plus HAIC (group B). Median overall survival (OS) and median bile duct patency time (BDPT) were compared between the two groups.

RESULTS

In the propensity-score matched (PSM) cohort, the median OS and median BDPT were significantly longer in group A than in group B (44 PSM pairs; OS, 13.6 ± 0.4 vs. 8.7 ± 1.4 months, p < 0.001; BDPT, 12.1 ± 0.5 vs. 6.4 ± 0.7 months, p < 0.001). Multivariate analysis revealed that the treatment regimen was an independent prognostic factor of OS. There were no serious complications related to 125I seed strand implantation.

CONCLUSIONS

125I seed strand combined with PTBD and HAIC for unresectable Bismuth-Corlette III and IV stage HCCA is safe and effective.

Contemporary Landscape of Medical Technology in Gastroenterology Between 2013 and 2023

Medical technology in gastroenterology spans devices, point-of-care diagnostics, digital health, and artificial intelligence. We conducted a narrative review of US Food and Drug Administration (FDA)-reviewed medical technology on the available evidence base to support uptake in clinical practice. Seven hundred thirteen new gastrointestinal devices were FDA approved or cleared between 2013 and 2023. The most frequent technologies had indications for use in general endoscopy (442 or 62.0% of all new technologies) with advanced endoscopy technologies being the second most common (172 or 24.1%). Ninety-nine new technologies had indications for use outside of the endoscopy suite. Ninety-nine percent of new technologies were FDA cleared against existing technologies through the 510(k) pathway rather than approved on new clinical data. Among the 19 devices with clinical trial data, trials were limited in sample size and generally evaluated disease-related changes or technical success rather than patient-reported outcomes that anchor drug trials. Twelve devices (63.2%) had favorable, published cost-effective data. To promote evidence-based discussion and uptake of new technology, and especially disruptive or high-risk technology, we propose a practical framework informed by balancing probable efficacy and safety and considering cost-effectiveness.

Endoscopic Ultrasound-Guided Biliary Drainage of First Intent With a Lumen-Apposing Metal Stent vs Endoscopic Retrograde Cholangiopancreatography in Malignant Distal Biliary Obstruction: A Multicenter Randomized Controlled Study (ELEMENT Trial)

BACKGROUND & AIMS

Endoscopic ultrasound-guided choledochoduodenostomy with a lumen-apposing metal stent (EUS-CDS) is a promising modality for management of malignant distal biliary obstruction (MDBO) with potential for better stent patency. We compared its outcomes with endoscopic retrograde cholangiopancreatography with metal stenting (ERCP-M).

METHODS

In this multicenter randomized controlled trial, we recruited patients with MDBO secondary to borderline resectable, locally advanced, or unresectable peri-ampullary cancers across 10 Canadian institutions and 1 French institution. This was a superiority trial with a noninferiority assessment of technical success. Patients were randomized to EUS-CDS or ERCP-M. The primary end point was the rate of stent dysfunction at 1 year, considering competing risks of death, clinical failure, and surgical resection. Analyses were performed according to intention-to-treat principles.

RESULTS

From February 2019 to February 2022, 144 patients were recruited; 73 were randomized to EUS-CDS and 71 were randomized to ERCP-M. The mean (SD) procedure time was 14.0 (11.4) minutes for EUS-CDS and 23.1 (15.6) minutes for ERCP-M (P < .01); 40% of the former was performed without fluoroscopy. Technical success was achieved in 90.4% (95% CI, 81.5% to 95.3%) of EUS-CDS and 83.1% (95% CI, 72.7% to 90.1%) of ERCP-M with a risk difference of 7.3% (95% CI, -4.0% to 18.8%) indicating noninferiority. Stent dysfunction occurred in 9.6% vs 9.9% of EUS-CDS and ERCP-M cases, respectively (P = .96). No differences in adverse events, pancreaticoduodenectomy and oncologic outcomes, or quality of life were noted.

CONCLUSIONS

Although not superior in stent function, EUS-CDS is an efficient and safe alternative to ERCP-M in patients with MDBO. These findings provide evidence for greater adoption of EUS-CDS in clinical practice as a complementary and exchangeable first-line modality to ERCP in patients with MDBO.

CLINICALTRIALS

gov, Number: NCT03870386.

Efficacy Analysis of Suprapapillary versus Transpapillary Self-Expandable Metal Stents According to the Level of Obstruction in Malignant Extrahepatic Biliary Obstruction

Background/Aims

The use of a self-expandable metal stent (SEMS) is recommended for unresectable malignant biliary obstruction (MBO). Stent-related adverse events might differ according to the position of the stent through the ampulla of Vater (AOV). We retrospectively evaluated SEMS patency and adverse events according to the position of the SEMS.

Methods

In total, 280 patients who underwent endoscopic SEMS placement due to malignant distal biliary obstruction were analyzed retrospectively. Suprapapillary and transpapillary SEMS insertions were performed on 51 patients and 229 patients, respectively.

Results

Between the suprapapillary group (SPG) and transpapillary group (TPG), the stent patency period was not significantly different (median [95% confidence interval]: 107 days [82.3 to 131.7] vs 120 days [99.3 to 140.7], p=0.559). There was also no significant difference in the rate of adverse events. In subgroup analysis, the stent patency for an MBO located within 2 cm from the AOV was found to be significantly shorter than that for an MBO located more than 2 cm from the AOV in the SPG (64 days [0 to 160.4] vs 127 days [82.0 to 171.9], p<0.001) and TPG (87 days [52.5 to 121.5] vs 130 [97.0 to 162.9], p<0.001). Patients with an MBO located within 2 cm from the AOV in both groups had a higher percentage of duodenal invasion (SPG: 40.0% vs 4.9%, p=0.002; TPG: 28.6% vs 2.9%, p<0.001) than patients with an MBO located more than 2 cm from the AOV.

Conclusions

The SPG and TPG showed similar results in terms of stent patency and rate of adverse events. However, patients with an MBO located within 2 cm from the AOV had a higher percentage of duodenal invasion with shorter stent patency than those with an MBO located more than 2 cm from the AOV, regardless of stent position.

Utilizing 4D Printing to Design Smart Gastroretentive, Esophageal, and Intravesical Drug Delivery Systems

The breakthrough of 3D printing in biomedical research has paved the way for the next evolutionary step referred to as four dimensional (4D) printing. This new concept utilizes the time as the fourth dimension in addition to the x, y, and z axes with the idea to change the configuration of a printed construct with time usually in response to an external stimulus. This can be attained through the incorporation of smart materials or through a preset smart design. The 4D printed constructs may be designed to exhibit expandability, flexibility, self-folding, self-repair or deformability. This review focuses on 4D printed devices for gastroretentive, esophageal, and intravesical delivery. The currently unmet needs and challenges for these application sites are tried to be defined and reported on published solution concepts involving 4D printing. In addition, other promising application sites that may similarly benefit from 4D printing approaches such as tracheal and intrauterine drug delivery are proposed.

EUS-guided biliary drainage in malignant distal biliary obstruction: An international survey to identify barriers of technology implementation

Background and Objectives

EUS-guided biliary drainage (EUS-BD) is a promising alternative to ERCP in malignant distal biliary obstruction (MDBO). Despite accumulating data, however, its application in clinical practice has been impeded by undefined barriers. This study aims to evaluate the practice of EUS-BD and its barriers.

Methods

An online survey was generated using Google Forms. Six gastroenterology/endoscopy associations were contacted between July 2019 and November 2019. Survey questions measured participant characteristics, EUS-BD in different clinical scenarios, and potential barriers. The primary outcome was the uptake of EUS-BD as a first-line modality, without previous ERCP attempts, in patients with MDBO.

Results

Overall, 115 respondents completed the survey (2.9% response rate). Respondents were from North America (39.2%), Asia (28.6%), Europe (20%), and other jurisdictions (12.2%). Regarding the uptake of EUS-BD as first-line treatment for MDBO, only 10.5% of respondents would consider EUS-BD as a first-line modality regularly. The main concerns were the lack of high-quality data, fear of adverse events, and limited access to EUS-BD dedicated devices. On multivariable analysis, lack of access to EUS-BD expertise was an independent predictor against the use of EUS-BD, odds ratio 0.16 (95% confidence interval, 0.04-0.65). In salvage situations following failed ERCP, most favored EUS-BD (40.9%) over percutaneous drainage (21.7%) in unresectable cancer. In borderline resectable or locally advanced disease, however, most favored the percutaneous approach due to fear of EUS-BD complicating future surgery.

Conclusions

EUS-BD has not reached widespread clinical adoption. Identified barriers include lack of high-quality data, fear of adverse events, and lack of access to EUS-BD dedicated devices. Fear of complicating future surgery was also identified as a barrier in potentially resectable disease.

Use of stents in patients undergoing chemotherapy for borderline resectable pancreatic cancer-causing biliary obstruction while awaiting surgery: A cost-effectiveness analysis

Background and study aims  Biliary stenting is indicated to relieve obstruction from borderline resectable pancreatic cancer while patients receive preoperative neoadjuvant therapy. We compared the cost-effectiveness of plastic versus metal biliary stenting in this setting. Methods  A decision tree analysis compares two competing types of biliary stents (initially metal vs. initially plastic) to treat malignant distal biliary obstruction while receiving neoadjuvant therapy with different scenarios including possible complications as bridge till the patient undergoes curative surgical attempt. Using published information, effectiveness was chosen as the probability of successfully reaching a state of being ready for surgery once chemotherapy was completed. Costs (2018 US$) were based on national data. A third-party payer perspective was adopted, and sensitivity analyses were performed over a time-horizon of one year. Results  Initially inserting a metal versus a plastic biliary stent was more efficacious with a higher probability of reaching the readiness for surgery endpoint (96 % vs. 85 %), on average 18 days earlier while also being less expensive (US$ 9,304 vs. US$ 11,538). Sensitivity analyses confirmed robustness of these results across varying probability assumptions of plausible ranges and remained a dominant strategy even when lowering the willingness-to-pay threshold to US$ 1,000. Conclusions  Initial metal stenting to relieve malignant biliary obstruction from borderline resectable pancreatic cancer in patients undergoing neoadjuvant therapy prior to surgery is a dominant intervention in economic terms, when compared to initially inserting a plastic biliary stent as it results in a greater proportion of patients being fit for surgery earlier and at a lower cost.

Survival, stent patency, and cost-effectiveness of plastic biliary stent versus metal biliary stent for palliation in malignant biliary obstruction in a developing country tertiary hospital

BACKGROUND AND AIM

Patients with advanced malignant obstructive jaundice often require biliary drainage. Resources restraint makes clinicians need to outweigh effectiveness of each biliary stents and their costs. Hence, a cost-effectiveness analysis is necessary.

METHODS

A retrospective cohort study was done on malignant biliary obstruction patients undergoing palliative biliary stenting between January 2015 and December 2018. We evaluated 180-day survival rate using log-rank test and stent patency duration using Mann-Whitney U test. Effectiveness was defined as stent patency, while cost was calculated using hospital perspective using decision tree model and reported as incremental cost-effectiveness ratio.

RESULTS

A total of 81 men and 83 women were enrolled in this study. One hundred and eighty days survival rate was 35.9% (median 76 days, 95% confidence interval [CI] 50-102 days) and 33.3% (median 55 days, 95% CI 32-78 days), while average stent patency was 123 (8) days versus 149 (13) days for plastic and metal stent groups, respectively (P > 0.05). Metal stent could save Indonesian Rupiah (IDR) 1 217 750 to get additional 26 days of patency.

CONCLUSION

There were no differences in survival and stent patency between the two groups. Metal biliary stent is more cost-effective than plastic stent for palliation in malignant biliary obstruction.

Early cholangioscopy-assisted electrohydraulic lithotripsy in difficult biliary stones is cost-effective

BACKGROUND AND AIMS

Single-operator cholangioscopy-assisted electrohydraulic lithotripsy (SOC-EHL) is effective and safe in difficult choledocholithiasis. The optimal timing of SOC-EHL use, however, in refractory stones has not been elucidated. The following aims to determine the most cost-effective timing of SOC-EHL introduction in the management of choledocholithiasis.

METHODS

A cost-effectiveness model was developed assessing three strategies with a progressively delayed introduction of SOC-EHL. Probability estimates of patient pathways were obtained from a systematic review. The unit of effectiveness is complete ductal clearance without need for surgery. Cost is expressed in 2018 US dollars and stem from outpatient US databases.

RESULTS

The three strategies achieved comparable ductal clearance rates ranging from 97.3% to 99.7%. The least expensive strategy is to perform SOC-EHL during the first endoscopic retrograde cholangiography pancreatography (ERCP) (SOC-1: 18,506$). The strategy of postponing the use of SOC-EHL to the third ERCP (SOC-3) is more expensive (US$18,895) but is 2% more effective. (0.9967). SOC-EHL during the second ERCP in the model (SOC-2) is the least cost-effective. Sensitivity analyses show altered conclusions according to the cost of SOC-EHL, effectiveness of conventional ERCP, and altered willingness-to-pay (WTP) thresholds with early SOC-1 being the most optimal approach below a WTP cut-off of US$20,295.

CONCLUSIONS

Early utilization of SOC-EHL (SOC-1) in difficult choledocholithiasis may be the least costly strategy with an effectiveness approximating those achieved with a delayed approach where one or more conventional ERCP(s) are reattempted prior to SOC-EHL introduction.

Interventional Treatment for Cholangiocarcinoma

Cholangiocarcinoma (CCA) is the second most common type of primary liver malignancy. The latest classification includes intrahepatic cholangiocarcinoma and extrahepatic cholangiocarcinoma, with the latter one further categorized into perihilar and distal cholangiocarcinoma. Although surgical resection is the preferred treatment for CCA, less than half of the patients are actually eligible for radical surgical resection. Interventional treatment, such as intra-arterial therapies, ablation, and brachytherapy (iodine-125 seed implantation), has become an acceptable palliative treatment for patients with unresectable CCA. For these patients, interventional treatment is helpful for locoregional control, symptom relief, and improving quality of life. Herein, in a timely and topical manner, we will review these advances and highlight future directions of research in this article.

Antireflux metal stent for biliary obstruction: Any benefits?

Endoscopic retrograde cholangiopancreatography with stent placement has been utilized as standard palliative management of distal malignant biliary obstruction (MBO). Compared to plastic stents, metal stents can provide longer-term relief of symptoms. When a large-bore metal stent is placed across the ampulla, patients are predisposed to the risk of cholangitis or stent dysfunction due to reflux of duodenal contents. To mitigate the risk of adverse events associated with the duodenobiliary reflux, efforts have been directed to development of antireflux metal stents (ARMSs). The antireflux property has been introduced through adding of an antireflux valve to the duodenal stent end. Evidence from clinical studies indicates that ARMSs may not only reduce the risk of ascending cholangitis during follow-up but also prolong stent patency time. However, the results of clinical studies testing ARMSs are inconsistent owing to heterogeneous designs of antireflux valves and stent bodies. Metal stents are increasingly indicated for benign biliary strictures and MBO in the setting of neoadjuvant chemotherapy, and therefore, research is warranted to evaluate ARMSs for those indications. Given that endoscopic ultrasound (EUS)-guided transmural biliary drainage has gained popularity, the optimal timing of placing an ARMS in relation to EUS-guided and percutaneous drainage should be investigated. Development and evaluation of ARMSs require an integrative approach utilizing phantom and animal models, measurements of stent mechanical properties, and in vivo functional study after stent placement. In this review article, we summarize updated evidence on ARMSs for MBO and discuss issues that should be addressed in future studies.

Telepresence-teleguidance to facilitate training and quality assurance in ERCP: a health economic modeling approach

Background and study aims  The aims of this study was to document the clinical and training relevance of endoscopic retrograde cholangiopancreaticography (ERCP) teleguidance (as a clinical model for applied telemedicine) with health economic modeling methodologies. Methods  Probabilities and consequences of complications after ERCP performed by either a novice-trainee or supported through teleguidance (TM) by an expert formed the basis of the health economic model. Results  The main clinical and economic outcomes originated from the base case scenario representing a low-volume center. In the cohort the patient age was 62 years, 58 % were females, the expert was doing ≥ 250 ERCPs per year and 50 for the novice-trainee. The expert knowledge transferred was set to 50 % and the average complexity grade to 1.98. Given a willingness to pay threshold of 56,180 USD/ quality-adjusted life years (QALY), the probability of cost-effectiveness of TM assistance was 98.9 %. The probability of a QALY gain for patients having an ERCP, to which was added TM, was 91.6 %. Adding TM saved on an average 111.2 USD (95 % CI 959 to 1021 SEK) per patient, and remained cost-effective basically insensitive to the level of willingness to pay. Conclusion  Teleguidance during an ERCP procedure has the potential to be the prefered option in many low- to medium-volume hospitals. The main mechanisms behind these effects are positive impact on several adverse patient outcomes, QALY increase, and decreased costs. TM should be considered for integration into future teaching curriculums in advanced upper gastrointestinal endoscopy.

Endoscopic ultrasound-guided biliary drainage for distal malignant obstruction: a systematic review and meta-analysis of randomized trials

Background and study aims  Endoscopic ultrasound (EUS)-guided biliary drainage (BD) is increasingly used for distal malignant biliary obstruction, yet its safety and efficacy compared to endoscopic retrograde cholangiopancreatography (ERCP) or percutaneous transhepatic biliary drainage (PTBD) remain unclear. We performed a meta-analysis to improve our understanding of the role of EUS-BD in this patient population. Methods  We searched Embase, MEDLINE, CENTRAL, and ISI Web of Knowledge through September 2018 for randomized controlled trials (RCTs) comparing EUS-BD to ERCP-BD or PTBD as treatment of distal malignant biliary obstruction. Risk ratios (RRs) with 95 % confidence intervals (CIs) were combined using random effects models. The primary outcome was risk of stent/catheter dysfunction requiring reintervention. Results  Of six trials identified, three (n = 222) compared EUS-BD to ERCP-BD for first-line therapy; three others (n = 132) evaluated EUS-BD versus PTBD after failed ERCP-BD. EUS-BD was associated with a decreased risk of stent/catheter dysfunction overall (RR, 0.39; 95 %CI 0.27 - 0.57) and in planned subgroup analysis when compared to ERCP (RR, 0.41; 95 %CI 0.23 - 0.74) or PTBD (RR, 0.37, 95 %CI 0.22 - 0.61). Compared to ERCP, EUS was associated with a decreased risk of post-procedure pancreatitis (RR, 0.12; 95 %CI 0.01 - 0.97). No differences were noted in technical or clinical success. Conclusions  In a meta-analysis of randomized trials comparing EUS-BD to conventional biliary drainage modalities, no difference in technical or clinical success was observed. Importantly, EUS-BD was associated with decreased risks of stent/catheter dysfunction when compared to both PTBD and ERCP, and decreased post-procedure pancreatitis when compared to ERCP, suggesting the potential role for EUS-BD as an alternative first-line therapy in distal malignant biliary obstruction.

Use of Doppler Probe in Nonvariceal Upper-Gastrointestinal Bleeding Is Less Costly and More Effective Than Standard of Care

BACKGROUND & AIMS

Upper gastrointestinal bleeding is a common emergency and rebleeding is associated with an increased risk of death. Proper assessment of high-risk lesions and appropriate endoscopic hemostasis are required for the best outcomes. The endoscopic Doppler probe examination (DPE) allows for a more complete assessment of the stigmata of hemorrhage, providing better evaluation of the need for endoscopic hemostasis and determination of its completeness. We aimed to evaluate whether use of the DPE provides an additional advantage in cost and effectiveness compared with traditional endoscopic visual assessment (TEA) of high-risk stigmata in patients with nonvariceal upper gastrointestinal bleeding.

METHODS

We drew a decision tree representing the choice between DPE and TEA approaches for patients undergoing an index endoscopy for active nonvariceal upper gastrointestinal bleeding. Clinical probabilities were retrieved from randomized controlled trial data. Costs were expressed in 2017 US dollars. A third-party payer perspective was adopted. We performed deterministic and probabilistic sensitivity analyses. The adopted time horizon was 30 days after the index endoscopy.

RESULTS

We found that DPE is a dominant strategy over the TEA, in that DPE is more efficacious (92.6% of patients avoiding rebleeding vs 78.6% for TEA) and less expensive ($8502 vs $9104 for TEA). The economic dominance of DPE over TEA was robust to sensitivity analyses across all assumptions of the model when varied among ranges spanning 30% of their respective baseline values.

CONCLUSIONS

In a cost-effectiveness analysis, we found DPE to be an economically dominant strategy to TEA (the traditional approach) in the management of high-risk lesions in patients with nonvariceal upper gastrointestinal bleeding. DPE was less costly and more effective.

Endoscopic biliary drainage in patients with cholangiocarcinoma - self-expanding metal versus polyethylene stents

Background: Endoscopic biliary drainage is the standard of care for patients with cholangiocarcinoma (CCA)-induced, obstructive jaundice. Self-expanding metal stents are supposed to be superior to polyethylene stents in terms of reduction of interventions and costs. So far, there are only few real-life data with respect to stent selection and survival in this patient cohort. Methods: In this study, we retrospectively analyzed patients with CCA treated with endoscopic biliary drainage from 2000 to 2015 at Hannover Medical School, Germany. The aim of this study was to analyze whether metal stenting reduces the frequency of interventions and influences survival in a large, real-life cohort. Results: Overall, 422 patients with CCA were included in this study. Indication for endoscopic biliary drainage was most often obstructive jaundice (n = 397; 94.1%). Among these patients, 20 patients (5%) were initially treated with a metal stent and 38 (9.6%) received a metal stent in the subsequent course. Median number of interventions per month was 2.4-fold reduced following metal stenting. Patients first treated with a metal stent had a more advanced tumor stage and a significantly shorter median overall survival (mOS) compared to patients who received a metal stent subsequently (7.5 months vs. 15.2 months; p=.019). There was no difference in mOS for metal vs. polyethylene stenting following a propensity score match for the confounders curative resection and chemotherapy (13.2 vs. 13.7 months, p=.555). Conclusions: Our data confirm that metal stenting reduces the frequency of interventions, but does not influence OS. Metal stenting should be considered specifically in younger patients who are suitable for chemotherapy.

3D-printed flexible polymer stents for potential applications in inoperable esophageal malignancies

Palliation therapy for dysphagia using esophageal stents is the current treatment of choice for those patients with inoperable esophageal malignancies. However, the metallic and plastic stents currently used in the clinical setting may cause complications, such as tumor ingrowth and stent migration into the stomach. To effectively reduce/overcome these complications, we designed a tubular, flexible polymer stent with spirals. The parameters of the spirals were computationally optimized by using a finite element analysis. The designed polymer stents with optimized spirals were then printed by a 3D printing technique. 3D-printed tubular polymer stents without spirals served as controls. The self-expansion and anti-migration properties of the printed stent were characterized in an ex vivo normal porcine esophagus. The biodegradability test of the stent was performed in a neutral buffer and acidic gastric buffer. The cytotoxicity of the new stent was examined through the viability test of human esophagus epithelial cells. Results showed the self-expansion force of the 3D-printed polymer stent with spirals was higher than the stent without spirals. The anti-migration force of the 3D-printed stent with spirals was significantly higher than that of the stent without spirals. Furthermore, the stent with spirals significantly decreased the migration distance compared to the non-spiral 3D-printed polymer stent. Degradation study showed that the polymer materials started to degrade after six weeks and the compressive strength of the stent was not significantly decreased with time. In vitro cell viability results further indicated that the polymer stent does not have any cytotoxicity. Together, these results showed that the 3D-printed stent with spirals has potential applications in the treatment of inoperable esophageal malignancies. STATEMENT OF SIGNIFICANCE: In this study, we developed a new 3D-printed flexible tubular polymeric stent with spirals. The mechanical properties of the 3D-printed polymer stent are modulated by changing the ratios of PLA to TPU. The stent is flexible enough to be compressed in a clinically available stent delivery system, and can self-expand after it is released. The self-expansion force of the stent with spirals is higher than that of non-spiral stents. The spirals on the outside of the stent significantly increased the anti-migration force compared to non-spiral stents in an ex vivo normal pig esophagus. Together, the 3D-printed stent with spirals will bring promising potential in the treatment of inoperable esophagus malignancies or benign strictures.

Inflammation-based prognostic scores in patients with extrahepatic bile duct lesions treated by percutaneous transhepatic biliary stenting combined with 125I seeds intracavitary irradiation

PURPOSE

This study aimed at investigating the efficacy of percutaneous transhepatic biliary stenting (PTBS) combined with ¹²⁵I seeds intracavitary irradiation in the treatment of extrahepatic cholangiocarcinoma (EHC) and to preliminarily explore the prognostic values of inflammation-based scores in these patients.

METHODS

A total of 113 clinically/pathologically diagnosed cases of EHC who received PTBS combined with ¹²⁵I seeds implantation were retrospectively analyzed. The postoperative changes of clinical symptoms and serum levels of alanine aminotransferase (ALT), aspartate aminotransferase (AST), alkaline phosphatase (ALP), total serum bilirubin (TBIL), direct bilirubin (DBIL), and albumin (ALB) were observed. Preoperative clinical data were extracted to calculate inflammation-based scores, including systemic immune-inflammation index (SII), neutrophil-to-lymphocyte ratio (NLR), and platelets-to-lymphocyte ratio (PLR). Kaplan-Meier survival curves and Cox regression analyses were used to evaluate the prognostic significance of inflammation-based scores.

RESULTS

After operation, clinical symptoms such as jaundice and fever significantly improved in all patients. At 1 month and 3 months postoperatively, serum levels of ALT, AST, ALP, TBIL, and DBIL significantly reduced, and ALB significantly increased, compared with preoperative values. The median survival time of the patients was 12 months and the 1-year survival rate was 56.8%. Univariate analysis revealed that factors related to overall survival were CA19-9, TBIL, ALB, SII, and NLR. Multivariate analysis further identified SII and NLR as independent prognostic models.

CONCLUSION

The combination of PTBS and ¹²⁵I seeds intracavitary irradiation is an effective palliative treatment for advanced EHC. Elevated SII and NLR can be used to predict poor survival.

Cost-effectiveness analysis comparing lumen-apposing metal stents with plastic stents in the management of pancreatic walled-off necrosis

BACKGROUND AND AIMS

EUS-guided transmural drainage is effective in the management of pancreatic walled-off necrosis (WON). A lumen-apposing metal stent (LAMS) has recently been developed specifically for the drainage of pancreatic fluid collections that shows promising results. However, no cost-effectiveness data have been published in comparison with endoscopic drainage with traditional plastic stents (PSs). Our aim here was to compare the cost-effectiveness of LAMSs to PSs in the management of WON.

METHODS

A decision tree was developed to assess both LAMSs and PSs over a 6-month time horizon. For each strategy, after the insertion of the respective stents, patients were followed for subsequent need for direct endoscopic necrosectomy, adverse events requiring unplanned endoscopy, percutaneous drainage (PCD), or surgery using probabilities obtained from the literature. The unit of effectiveness was defined as successful endoscopic drainage without the need for PCD or surgery. Costs in 2016 U.S.$ were based on inpatient institutional costs. Sensitivity analyses were performed. An a priori willingness-to-pay threshold of U.S.$50,000 was established.

RESULTS

LAMSs were found to be more efficacious than PSs, with 92% and 84%, respectively, of the patients achieving successful endoscopic drainage of WON. LAMSs, however, were more costly: the average cost per patient of U.S.$20,029 compared with U.S.$15,941 for PSs. The incremental cost-effectiveness ratio favored LAMSs at U.S.$49,214 per additional patient successfully treated. Sensitivity analyses confirmed the robustness of the results.

CONCLUSION

LAMSs are more effective but also more costly than PSs in managing WON. Data from high-quality, adequately controlled, prospective, randomized trials are needed to confirm our findings.

Plastic stents are more cost-effective than lumen-apposing metal stents in management of pancreatic pseudocysts

BACKGROUND AND STUDY AIMS

 Endoscopic ultrasound-guided drainage is an effective and accepted primary modality for management of pancreatic pseudocyst (PP). A lumen-apposing metal stent (LAMS) has recently been developed specifically for drainage of pancreatic fluid collections which may be superior to using traditional plastic stents (PS) but is more expensive. Because use of a stent involves a risk of unplanned endoscopy, percutaneous drainage (PCD) and surgery, their costs should also be included in the comparison and a cost-effectiveness analysis of LAMS and PS should therefore be performed.

PATIENTS AND METHODS

 A decision tree was developed assessing both endoscopic drainage strategies for patients with PP: LAMS and PS over a 6-month time horizon. For each strategy, inpatients received a stent and were followed for subsequent need for direct further interventions or adverse events leading to unplanned endoscopy, PCD, surgery, or successful endoscopic drainage using probabilities obtained from the literature. The unit of effectiveness was successful endoscopic drainage without need for PCD or surgery. Sensitivity analyses were performed.

RESULTS

Success rates were 93.9 % for LAMS and 96.96 % for PS. Respective costs per successful drainage were US $ 18,129 (LAMS) and US $ 10,403 (PS). The LAMS strategy was thus characterized as dominated by the PS approach because it was costlier and less effective than PS. Both deterministic and probabilistic sensitivity analyses confirmed the robustness of these findings.

CONCLUSION

 Use of LAMS is not less effective and more costly than PS in management of patients with PP. As such, PS should be preferred over LAMS as initial management of these patients.

Nutritional prognostic scores in patients with hilar cholangiocarcinoma treated by percutaneous transhepatic biliary stenting combined with 125I seed intracavitary irradiation: A retrospective observational study

We mainly aimed to preliminarily explore the prognostic values of nutrition-based prognostic scores in patients with advanced hilar cholangiocarcinoma (HCCA).We retrospectively analyzed 73 cases of HCCA, who underwent percutaneous transhepatic biliary stenting (PTBS) combined with I seed intracavitary irradiation from November 2012 to April 2017 in our department. The postoperative changes of total bilirubin (TBIL), direct bilirubin (DBIL), alanine aminotransferase (ALT), aspartate aminotransferase (AST), alkaline phosphatase (ALP), and albumin (ALB) were observed. The preoperative clinical data were collected to calculate the nutrition-based scores, including controlling nutritional status (CONUT), C-reactive protein/albumin ratio (CAR), and prognostic nutritional index (PNI). Kaplan-Meier curve and Cox regression model were used for overall survival (OS) analyses.The serum levels of TBIL, DBIL, ALT, AST, and ALP significantly reduced, and ALB significantly increased at 1 month and 3 months postoperatively. The median survival time of the cohort was 12 months and the 1-year survival rate was 53.1%. Univariate analysis revealed that the statistically significant factors related to OS were CA19-9, TBIL, ALB, CONUT, and PNI. Multivariate analysis further identified CA19-9, CONUT, and PNI as independent prognostic factors.Nutrition-based prognostic scores, CONUT and PNI in particular, can be used as predictors of survival in unresectable HCCA.

Using Hemospray Improves the Cost-effectiveness Ratio in the Management of Upper Gastrointestinal Nonvariceal Bleeding

GOALS

We compared the cost-effectiveness of traditional recommended endoscopic hemostatic therapies and Hemospray alone or in combination when treating nonvariceal upper gastrointestinal bleeding (NVUGIB).

BACKGROUND

Hemospray (TC-325) is a novel endoscopic hemostatic powder, achieving hemostasis through adherence to actively bleeding biological surfaces.

STUDY

A decision tree of patients with NVUGIB assessed 4 possible treatment strategies: traditional therapy alone (T), Hemospray alone (H), traditional therapy completed by Hemospray if needed (T+H), or Hemospray completed by traditional therapy if needed (H+T). Using published probabilities, effectiveness was the likelihood of avoiding rebleeding over 30 days. Costs in 2014 US$ were based on the US National Inpatient Sample. A third-party payer perspective was adopted. Sensitivity and subgroup analyses were performed.

RESULTS

For all patients, T+H was more efficacious (97% avoiding rebleeding) and less expensive (average cost per patient of US$9150) than all other approaches. The second most cost-effective approach was H+T (5.57% less effective and US$635 more per patient). Sensitivity analyses showed T+H followed by a strategy of H+T remained more cost-effective than H or T alone when varying all probability assumptions across plausible ranges. Subgroup analysis showed that the inclusion of H (especially alone) was least adapted for ulcers and was more cost-effective when treating lesions at low risk of delayed rebleeding.

CONCLUSIONS

Hemospray improves the effectiveness of traditional hemostasis, being less costly in most NVUGIB patient populations. A Hemospray first approach is most cost-effective for nonulcer bleeding lesions at low risk of delayed hemorrhage.

Plastic vs. Self-Expandable Metal Stents for Palliation in Malignant Biliary Obstruction: A Series of Meta-Analyses

OBJECTIVES

Self-expandable metal stents (SEMS) are thought to have an advantage over plastic stents in achieving biliary drainage.

METHODS

We performed a systematic search of MEDLINE, EMBASE, Scopus, CENTRAL, and ISI Web of knowledge databases, from January 1980 to September 2015, for randomized-controlled trials (RCTs) comparing SEMS vs. plastic stents in the palliation of malignant biliary obstruction. Primary outcomes were durations of stent patency, patient survival, and 30-day mortality. Numerous secondary outcomes were assessed, and extensive sensitivity and subgroup analyses were performed.

RESULTS

In all, 20 RCTs totaling 1,713 patients yielded a weighted mean difference (WMD) in time to stent patency (4 studies) of 4.45 months (95% confidence interval (CI), 0.31, 8.59; GRADE=moderate) favoring SEMS. There were no differences in overall patient survival (5 studies) WMD=0.67 months (95% CI, -0.66, 1.99; GRADE=moderate), or 30-day mortality (8 studies) odds ratio (OR)=0.80 (95% CI, 0.52, 1.24; GRADE=moderate) but there was a higher symptom-free survival at 6 months (4 studies) OR=5.96 (95% CI, 1.71, 20.81; GRADE=moderate). SEMS use resulted in lower rates of late complications (11 studies) OR=0.43 (95% CI, 0.26, 0.71; GRADE=moderate), sepsis or cholangitis (14 studies) OR=0.53 (95% CI, 0.37, 0.77; GRADE=high), blocking from sludge (8 studies) OR=0.11(95% CI, 0.07, 0.17; GRADE=moderate), and mean number of re-interventions (8 studies) WMD=-0.83 interventions (95% CI, -1.64, -0.02; GRADE=moderate). There was a longer patency of SEMS for those without a prior drainage attempt (2 studies) WMD 7.70 months (95% CI, 7.14, 8.25; GRADE=high). Although a survival advantage was found when an uncovered SEMS was used (3 studies) WMD 1.31 months (95% CI, 0.30, 2.32; GRADE=high), but not partially or fully covered SEMS (2 studies) WMD -0.66 months (95% CI, -1.02, -0.30; GRADE=high) vs. plastic stents, and for SEMS in the setting of pre- or post-procedural antibiotic administration (2 studies) WMD 1.49 months (95% CI, 0.27, 2.70; GRADE=high), and performance of a sphincterotomy (2 studies) WMD 1.63 months (95% CI, 0.42, 2.84; GRADE=high).

CONCLUSIONS

Keeping in mind the noted risk of bias in source data, the use of SEMS compared with plastic stents, in the palliation of patients with malignant biliary obstruction results in longer stent patency, lower complications rates, and fewer re-interventions, whereas exhibiting survival benefits in selected subgroups of patients.

Endoscopic ultrasound-guided antegrade stenting in an occluded biliary self-expandable metal stent

Endoscopic ultrasound-guided biliary drainage (EUS-BD) is an attractive option for patients who cannot undergo conventional endoscopic retrograde cholangiopancreatography (ERCP) and do not want surgery or percutaneous drainage procedures. We present the use of EUS-antegrade (EUS-AG) insertion of a self-expandable metal stent (SEMS) in a patient with a common hepatic duct cholangiocarcinoma, as well as a huge gastric lipoma, after recurrent biliary obstruction of a prior SEMS inserted via ERCP in the same session as a duodenal stent insertion for gastric outlet obstruction.