Comparing cost-effectiveness between endoscopic ultrasound and endoscopic retrograde cholangiopancreatography in diagnosis of common bile duct stone in patients with predefined risks: A study from a developing country

Assessing the impact of center volume on the cost-effectiveness of centralizing ERCP

BACKGROUND AND AIMS

ERCP is a complex endoscopic procedure in which the center's procedure volume influences outcomes. With the increasing healthcare expenses and limited resources, promoting cost-effective care becomes essential for healthcare provision. This study was a cost-effectiveness analysis to evaluate the hypothesis that high-volume (HV) centers perform ERCP with higher quality at lower costs than low-volume (LV) centers.

METHODS

A baseline case compared the current distribution of ERCPs among HV and LV centers with a hypothetical scenario in which all ERCPs are performed at HV centers. A cost-effectiveness analysis was constructed, followed by 1- and 2-way sensitivity analyses, and probabilistic sensitivity analysis using Monte Carlo simulations.

RESULTS

In the baseline case, the incremental cost-effectiveness ratio was -$151,270 per year, due to the hypothetical scenario's lower costs and slightly higher quality-adjusted life years. The model was most sensitive to changes in transportation costs (109.34%), probability of significant adverse events (AEs) after successful ERCP at LV centers (42.12%), utility after ERCP with significant AEs (30.10%), and probability of significant AEs after successful ERCP at HV centers (23.53%); only transportation costs above $3655 changed the study outcome, however. The current ERCP distribution would only be cost-effective if LV centers achieved higher success (≥92.4% vs 89.3%), with much lower significant AEs (≤.5% vs 6.7%). The study's main findings remained unchanged while combining all model parameters in the probabilistic sensitivity analysis.

CONCLUSIONS

Our findings show that HV centers have high-performance rates at lower costs, raising the need to consider the principle of centralization of ERCPs into HV centers to improve the quality of care.

Comparison of Endoscopic Ultrasound and Transabdominal Ultrasound in the Detection of Gallbladder and Common Bile Duct Microlithiasis

OBJECTIVE

Endoscopic ultrasonography (EUS) is an emerging method with a wide range of potential uses in gastroenterology, including the detection of bile duct stones and the identification of early ductal alterations in suspected patients. This study was designed to compare the diagnostic yield of EUS and transabdominal ultrasound (TUS) in the detection of gallbladder and common bile duct (CBD) microlithiasis.

METHOD

Patients with biliary colic with normal initial TUS were the subjects of this prospective study. EUS scan was performed on all recruited patients and linear endoscopes were used for the EUS examination. Cholecystectomy and histological analysis were done in patients within two weeks after EUS revealing cholelithiasis whereas the cases of CBD stone/microlithiasis were confirmed by endoscopic retrograde cholangiopancreatography (ERCP). The mean values of all hematological characteristics were independently determined for males and females and then compared using Student's t-test. For statistical significance, a p-value of 0.05 or below was used.

RESULTS

A total of 131 patients, including 77 females and 54 males, with a mean age of 38.41 ± 14.78 years were examined. All 78 (59.5%) individuals who had cholecystectomy were found to have gallstones or microlithiasis as successfully diagnosed by EUS. The sensitivity and specificity of EUS were 92.9% and 100%, respectively, for CBD stones and 98.8% and 100%, respectively, for the detection of gallbladder microlithiasis. The agreement between EUS and TUS was fair for CBD stones (κ = 0.214) and very weak for microlithiasis (κ = -0.093).

CONCLUSION

EUS demonstrates a superior yield over TUS in detecting gallbladder stones and CBD microlithiasis, offering a more reliable diagnostic modality.

LIMITATION

This was a single-center study.

Comparing the efficacy of EUS versus MRCP with ERCP as gold standard in patients presenting with partial biliary obstruction - finding a better diagnostic tool

Objective

To evaluate the diagnostic accuracy of different imaging modalities in patients with partial biliary obstruction with no obvious aetiology on initial imaging.

Methods

This is a prospective single-centre cohort study carried out at Pak Emirates Military Hospital, Rawalpindi from June 2019 to June 2021 with non-probability consecutive sampling. Patients with ages 16 to 75 years, presenting with partial biliary obstruction and undetermined aetiology on initial imaging (TUS and MRCP) were enrolled. EUS was performed for each of these patients and the case was regarded as "true positive" or "true negative" if the findings of imaging modality correlated to those of ERCP. ROC curve, sensitivity, specificity, PPV, NPV and AUC (with 95% confidence interval) were drawn for all the diagnostic tools using SPSS V. 21.

Results

A total of 65 patients were enrolled over a period of two years with male to female ratio of 1.4:1. Forty-four patients had an intermediate risk of choledocholithiasis upon preliminary evaluation whereas, 48(74%) of the participants had CBD calculi or sludge confirmed upon subsequent ERCP. Trans-abdominal ultrasound showed the lowest sensitivity (29.2%), specificity (85%), NPV 12% and PPV 93% for diagnosing CBD calculi. This was followed by MRCP with a sensitivity of 37.5%, specificity of 100%, NPV of 36.2% and PPV of 100%. EUS showed the maximum diagnostic accuracy with AUC of 1.0 and a 100% sensitivity and specificity when compared with ERCP as gold standard.

Conclusion

EUS is superior to MRCP in terms of diagnostic accuracy as minimally invasive diagnostic tool and EUS superiority is particularly relevant in patients with intermediate risk of choledocholithiasis.

The value of endoscopic ultrasonography for differential diagnosis in obstructive jaundice of the distal common bile duct

INTRODUCTION

Obstructive jaundice is a common clinical disease of great significance; however, diagnosing it according to etiology, especially in patients with distal obstructive jaundice is difficult. The development of endoscopic ultrasonography has improved diagnostic methods. Endoscopic ultrasonography not only improves the accuracy of conventional endoscopic ultrasound technology in etiological diagnosis, but also offers several special endoscopic ultrasound technologies for diagnosing distal obstructive jaundice of the common bile duct. What's more, endoscopic ultrasonography can be used to treat distal obstructive jaundice of common bile duct.

AREAS COVERED

This review discusses the diagnostic value and applications of endoscopic ultrasonography for obstructive jaundice of the distal common bile duct.

EXPERT OPINION

This article summarizes the value of endoscopic ultrasonography in the etiological diagnosis, relevant treatment applications of distal obstructive jaundice and the limitations of endoscopic ultrasonography in some etiologies due to the lack of clear comparison with other imaging methods. We also provide new data for the future research direction of endoscopic ultrasonography in distal obstructive jaundice.

Nonradiation-to-endoscopist ERCP is non-inferior to standard ERCP

Background

Radiation exposure is inherently involved in endoscopic retrograde cholangiopancreatography (ERCP), which could cause radiation-induced injury to endoscopists with long-term exposure. Nonradiation ERCP has been applied to pregnant patients. Conceivably, the same techniques could be used to benefit endoscopists. This study was designed to evaluate the effectiveness and safety of nonradiation-to-endoscopist (NRE) ERCP, compared with standard ERCP.

Methods

A retrospective, single-center study was conducted from August 2010 to December 2015. Patients aged 18–90 years and with choledocholithiasis (< 15 mm) or distal biliary stricture were eligible. Pre-ERCP evaluation with magnetic resonance cholangiopancreatography was mandatory. To overcome selection bias, we performed 1:2 match using propensity score matching (PSM) between NRE and standard groups. The primary endpoint was overall ERCP success rate. Secondary endpoints were cannulation success rate, stone clearance rate, complication rate, and duration of hospitalization.

Results

A total of 329 patients met inclusion criteria. After PSM, 73 patients were included in the NRE group and 146 in the standard group. The ERCP overall success rate for NRE and standard groups was equivalent (94.5% vs. 93.2%, P = 0.70). There was no difference in cannulation success rates between the two groups (95.6% vs. 97.8%, P = 0.39). A total of 88.3% of patients in the NRE group and 93.9% of patients in the standard group had stones cleared at initial ERCP (P = 0.57). No difference in overall stone clearance rate between the two groups (95.0% vs. 93.9%, P = 0.77) was found after second ERCP. The complication rate (1.4% vs. 1.4%, P = 1.00) and hospital duration (8.3 ± 5.1 vs. 10.2 ± 8.8 days, P = 0.07) were not different between the two groups.

Conclusion

Although technically demanding, NRE-ERCP is both safe and feasible in selected patients compared with standard ERCP.

Diagnostic Accuracy of Endoscopic Ultrasonography Versus the Gold Standard Endoscopic Retrograde Cholangiopancreatography in Detecting Common Bile Duct Stones

Background and objectives Stone in the biliary tract is one of the most common causes of hospitalization. However, it is difficult to determine the prevalence of gallstones in the general population because they are often asymptomatic. Thus, management lies in the proper clearance of the common bile duct (CBD) along with the removal of the gallbladder, for which it must be diagnosed on time with proper accuracy. Imaging modalities including magnetic resonance cholangiopancreatography (MRCP), endoscopic ultrasound (EUS), and endoscopic retrograde cholangiopancreatography (ERCP) provide true visualization of choledocholithiasis with comparable sensitivities. The gold standard ERCP is an invasive procedure and may cause complications, such as pancreatitis, perforation, and bleeding. EUS is a minimally invasive procedure to assess the biliary tract using high-frequency sound waves. Until now the EUS has not been addressed much in our local tertiary care setups and this study was conducted to evaluate its accuracy in the diagnosis of choledocholithiasis. The objective of our study is to determine the diagnostic accuracy (specificity and sensitivity) of EUS versus ERCP for the diagnosis of choledocholithiasis. Materials and methods This retrospective study was conducted on patients suspected of having choledocholithiasis undergoing both EUS and ERCP based on their history, clinical symptoms, and laboratory test results including upper abdominal pain, deranged liver function enzymes, and a dilated CBD on radiology. EUS was initially performed for the diagnosis of extrahepatic biliary obstruction followed by one or more of the confirmatory criterion standard tests (including ERCP). In order to reduce the chances of passage of stone resulting in negative analysis, only those patients were included in which both procedures were conducted temporally close together (24-72 hours in most instances). The main outcome measures were diagnostic accuracy with the help of sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) using a receiver operating characteristic curve. A total of 123 patients met the inclusion criteria via non-probability consecutive sampling methods. Results The mean age of our study population was 50.30 ± 13.91. We included 63 males (51.2%) and 60 females (48.8%). The most frequent indication for undergoing diagnostic procedures was deranged liver function tests (67.47%). The frequent comorbidities reported were hypertension (29.26%), diabetes (21.95%), chronic liver disease (16.26%), and ischemic heart disease (4.87%). Mean alkaline phosphatase and gamma-glutamyl transferase levels were markedly raised from the baseline in the study population. Post-ERCP complications were also reported in some of the study participants. About 85 patients (69.10%) were diagnosed with choledocholithiasis among the study participants. The diagnostic accuracy of EUS was compared with ERCP revealed an area under the curve (AUC) of 0.930, standard error of 0.031, 95% confidence interval of 0.868-0.991, the sensitivity of 89.5%, specificity of 96.5%, positive predictive value of 91.9%, and negative predictive value of 95.3%. Conclusion It is recommended that ERCP can be selectively conducted or excluded in patients with biliary obstruction in case of EUS negative, thus minimizing the complications and morbidity associated with an invasive procedure, with our results showing a comparative diagnostic accuracy of EUS.

A validated score predicting common bile duct stone in patients hospitalized with acute calculus cholecystitis: a multi-center retrospective study

BACKGROUND

Concomitant common bile duct (CBD) stone in the setting of acute calculous cholecystitis (ACC) should be suspected once abnormal liver indices are noticed.

AIM

We aimed to identify predictors of CBD stone in patients hospitalized with ACC.

METHODS

We performed a retrospective multi-center, case-controlled, study from 1st of January 2016 until the 31th of December 2018. Inclusion criteria included patients with an established diagnosis of ACC based on clinical, laboratory and radiological criteria and who had an endoscopic ultrasound (EUS) for suspected CBD stone. One-hundred and twelve patients were included, of these fifty-three patients (47.3%) were diagnosed with CBD stone by EUS.

RESULTS

In univariate analysis, Age (OR 1.038, P = 0.001), total bilirubin (mg/dl) (OR 1.429, P = 0.02) and CBD width (mm) by US (OR 1.314, P = 0.01) were statistically significant in predicting CBD stone and remained significant in multivariate regression analysis. We developed a diagnostic score that included these three parameters, with assignment of weights for each variable according to the coefficient estimate. A low cut-off score of 0 was associated with sensitivity of 100% for CBD stone, whereas a high cut-off score of 3 was associated with sensitivity of 10% and specificity of 96.6% with a positive predictive value of 67% (ROC of 0.7558). We validated this score with an independent cohort (ROC of 0.7416) with a sensitivity of 46.6%, a specificity of 91.5% and a PPV of 87.1%.

CONCLUSION

We recommend incorporating this score as an aid for stratifying patients with ACC into low or high probability for concomitant CBD stone.

Preoperative predictors of choledocholithiasis in patients presenting with acute calculous cholecystitis

BACKGROUND AND AIMS

Markedly increased liver chemistries in patients presenting with acute calculous cholecystitis (AC) often prompt an evaluation for concomitant choledocholithiasis (CDL). However, current guidelines directing the workup for CDL fail to address this unique population. The aims of this study are to define the range of presenting laboratory values and imaging findings in AC, develop a model to predict the presence of concurrent CDL, and develop a management algorithm that can be easily applied on presentation.

METHODS

We conducted a retrospective review of patients presenting with AC to a large tertiary hospital over a 3.5-year period. CDL was defined as common bile duct (CBD) stone(s), sludge, or debris seen on any of the following studies: US, CT, magnetic resonance imaging/MRCP, EUS, ERCP, or intraoperative cholangiogram. A multivariable model to predict CDL was developed on 70% of the patients and validated on the remaining 30%.

RESULTS

A total of 366 patients were identified and 65 (17.8%) had concurrent CDL. Univariable analysis was used to predict CDL and demonstrated statistically significant odds ratios for transaminases >3 times the upper limit of normal, alkaline phosphatase (AlkPhos) above normal, lipase >3 times the upper limit of normal, total bilirubin ≥1.8 mg/dL, and CBD diameter >6 mm. In the validation cohort, an optimal model containing alanine transaminase (ALT) >3 times the upper limit of normal, abnormal AlkPhos, and CBD diameter >6 mm was found to have an area under the receiver operating curve of 0.91. When 0 or 1 risk factors were present, 98.6% of patients did not have CDL. When all 3 risk factors were present, 77.8% were found to have CDL.

CONCLUSIONS

The prevalence of CDL is high among patients with AC. When a validated model is used, application of cutoffs for ALT, AlkPhos, and CBD diameter can effectively triage patients with low and high likelihood for CDL to surgery or ERCP, respectively.

Prospective randomized trial of EUS-assisted ERCP without fluoroscopy versus ERCP in common bile duct stones

BACKGROUND AND AIMS

ERCP with stone removal is the standard treatment for common bile duct stones (CBDSs). Radiation exposure is a risk to the endoscopist and patient. EUS-guided ERCP without fluoroscopy (EGEWF) in patients with CBDSs is feasible, but the efficacy and safety compared with ERCP is unknown. We aimed to compare the efficacy and safety of EGEWF with ERCP in CBDS removal.

METHODS

A prospective randomized study was done in 114 patients with CBDSs who met inclusion criteria. These patients were equally randomized into the EGEWF and ERCP groups. In the EGEWF group, ERCP was performed by cannulation without fluoroscopy. Balloon sweeping was done after sphincterotomy to clear the stones until the number of stones matched the number detected by EUS and the stone clearance (SC) was confirmed by cholangiography. In the ERCP group, ERCP was performed in the standard manner. The cannulation rates, SC rates, total procedure and fluoroscopic times, and adverse event rates were analyzed.

RESULTS

After exclusion of 3 patients, 55 were in the EGEWF group and 56 in the ERCP group. Demographic data, laboratory data, stone characteristics, CBD diameter, and number of patients with periampullary diverticulum were not different between the 2 groups. The cannulation success rates in the EGEWF (96.35%) and ERCP (100%) groups were similar (P = .243). The SC rate in the EGEWF group (85.5%) was inferior to the ERCP group (100%) (P = .002). The SC rate based on the number of stones retrieved that matched the number by EUS was correct in 94%. More than 2 stones may increase the failure rate of SC in EGEWF. The adverse event rates and the total procedure times were not different between the groups.

CONCLUSIONS

EGEWF was inferior to ERCP in terms of SC; however, no radiation exposure is beneficial for selected patients. (Clinical trial registration number: NCT02870686.).