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Tu1536 Single-Operator Cholangioscopy Is More Cost-Effective Than Bile Duct Exploration for Management of Difficult Common Bile Duct Stones After Failed Conventional ERCP
Abstracts
physician reimbursement rates, including pathologic, radiographic, procedural and pharmacologic elements. Indirect patient costs such as time lost from work were not considered in this evaluation. Results: Nineteen patients were enrolled in each study period, for a total of 38 patients. All patients completed the follow-up period of 12 months. Patient characteristics were similar across both study periods. The novel algorithm performed well compared to the traditional algorithm, with a sensitivity of 100.0% (95% CI 19.8% – 100.0%) and a specificity of 100.0% (95% CI 77.1% – 100.0%). Technical success was achieved in all but one patient investigated with SOC. Adverse events were similar across both study periods. The mean overall cost per patient (USD) when applying the traditional algorithm was $4374.32 compared with $3006.24 for the novel algorithm (p Z 0.004). This resulted in a mean cost savings of $1368.08 per patient. Conclusions: Our study showed that SOC is diagnostically accurate, safe and cost effective for the detection of CCA in the PSC population. When utilized as part of our novel algorithm, SOC outperformed a traditional approach. Further studies are needed to further evaluate the definitive current and future role of SOC in this patient population.
Figure 1. Traditional algorithm for assessment of suspected CCA, observed in study period I.
Figure 2. Novel algorithm for assessment of suspected CCA, observed in study period II.
Tu1535 Safety and Efficacy of Trans-Luminal Biliary Drainage Using the Choledochduodenostomy vs Hepaticogastrostomy After Failed ERCP. Systemic Review and Meta-Analysis Mohamed M. Abdelfatah*1, Glenn Harvin1, Eslam G. Ali1, Hossein Movahed1, Paul Vos2, Amit Raina1 1 Division of Gastroenterology, Hepatology and Nutrition, East carolina University, Greenville, NC; 2Department of Biostatistics, East carolina University, Greenville, NC Introduction: percutaneous trans-hepatic biliary drainage (PTBD) was the only nonsurgical alternative after failing endoscopic retrograde cholangiopancreatography (ERCP). However, this procedure is associated with substantial morbidity and low
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quality of life. Choledocoduodenostomy (CDS) and hepaticogastrostomy (HGS) are recently described endoscopic ultrasound guided, trans-luminal biliary drainage procedures. We aimed to review literature and conduct a meta-analysis evaluating cumulative success rate and safety of CDS and HGS. We then compared the success rate and safety of CDS and HGS approach. Methods: We searched Medline, EMBASE, Cochrane database, ISI Web of Science and Scopus from January 1, 2001 through November 20, 2015, to identify studies. After excluding case reports and EUSrendezvous technique, 46 studies were included. We calculated the cumulative (CDS and HGS) pooled technical success rate and post procedure adverse events. Subsequently, we calculated and compared the pooled technical success rate and postprocedure adverse events for CDS and HGS. We excluded Studies investigating rendezvous technique from our study. Case reports and small case series were excluded. Results: Combining all studies that reported on CDS (nZ410) and HGS (nZ368) resulted in 727 successes and 140 post-procedure adverse events from a total of 778 procedures. Overall technical success rate was 93.4% and overall complication percentage was 18 %. In the CDS group technical success rate was 93.7% (384/410) with and post-procedure adverse events was 17.3%(71/410). In the HGS group technical success rate was 93.2%(343/368) and post-procedure adverse events was 18.8% (69/368). HGS and CDS were compared in terms of success and complications using Fisher’s exact test. The odds of success for CDS were 1.08 times the odds for HGS (pZ.90, 95% CI for the odds ratio .584 to 1.980). The odds of complications for CDS were .91 times the odds for HGS (pZ.60, 95% CI .619 to 1.332). Conclusion: Trans luminal biliary drainage using HGS/CDS is a relatively new technique with promising results and might be the go-to future alternative option after failed ERCP. According to our meta-analysis Differences in technical success and differences in complications between HGS VS CDS were not statistically significant.
Tu1536 Single-Operator Cholangioscopy Is More Cost-Effective Than Bile Duct Exploration for Management of Difficult Common Bile Duct Stones After Failed Conventional ERCP Jaskiran Sandha*, Gurpal S. Sandha Medicine, University of Alberta, Edmonton, AB, Canada Background: Common bile duct (CBD) stones are currently managed by ERCP with sphincterotomy and stone extraction with a balloon catheter or basket. However, some stones are difficult to extract by conventional means. These include multiple, large, impacted, or faceted stones, or those proximal to a stricture. Cholangioscopy with electro-hydraulic lithotripsy (EHL) is a modality to treat these difficult stones. Aims: The aim of this study was to describe the clinical efficacy of a single-operator cholangioscopy system (SpyGlassÔ, Boston Scientific Corporation, Marlborough, MA, USA) for difficult stones and discuss possible cost savings by avoiding surgical intervention. Methods: We performed a retrospective chart review of all patients referred for SpyGlassÔ cholangioscopy with EHL for difficult stones. Clinical efficacy was defined as the successful clearance of the CBD of all stones. The total cost (based on Alberta Health Services reimbursement codes) was calculated by adding all costs associated with cholangioscopy, including any subsequent procedures, surgery, hospital stay, or treatment of any complications. This cost was compared with the projected cost of open and laparoscopic CBD exploration (OCBDE, LCBDE). Results: A total of 51 patients with difficult CBD stones (35 female, median age 68 16.4 years [range 30-88 years]) with 108 prior ERCPs (average 2.1/patient) were referred. They underwent 58 SpyGlassÔ cholangioscopy ERCPs and 7 additional ERCPs (average 1.3/patient). The average procedure time was 67 minutes (range 24-124 minutes). The CBD was successfully cleared in 47/51 patients (93% clinical efficacy). Minor complications were seen in 7 patients (14%). These included mild EHL-induced CBD wall trauma in 4 patients, wire-induced cystic duct stump leak in 1 patient, mild post-ERCP pancreatitis in 1 patient and mild mucosal tearing at gastro-esophageal junction during extraction of a plastic stent in 1 patient. The average cost of all procedures was $4550. This compares to a projected cost of $7766 and $6175 for OCBDE and LCBDE, respectively. The average cost saving per patient using SpyGlassÔ cholangioscopy instead of OCBDE or LCBDE was $3216 and $1625, respectively. The published rate of complications (bile leak, hemorrhage, and abscess) for CBDE is 3.2%. Treatment of these complications added $4977, $5216, and $3701 to the cost of CBDE. Conclusion: Single-operator SpyGlassÔ cholangioscopy with EHL is highly effective for the treatment of difficult CBD stones. By adopting this modality as primary treatment for these difficult stones, significant cost savings may be realised by avoiding surgical intervention.
Tu1537 Clinical risk factors for complications in patients undergoing percutaneous transhepatic cholangioscopy Dong Hoon Baek*, Dong Uk Kim, Geun Am Song, Tae Wook Kim, Seong Jun Lee Internal Medicine, Gastroenterology, Pusan National University Hospital, Busan, Korea (the Republic of) Background: Percutaneous transhepatic cholangioscopy (PTCS) has been widely used for the diagnosis and treatment of intrahepatic duct stones, strictures, and
Volume 83, No. 5S : 2016 GASTROINTESTINAL ENDOSCOPY AB599
physician reimbursement rates, including pathologic, radiographic, procedural and pharmacologic elements. Indirect patient costs such as time lost from work were not considered in this evaluation. Results: Nineteen patients were enrolled in each study period, for a total of 38 patients. All patients completed the follow-up period of 12 months. Patient characteristics were similar across both study periods. The novel algorithm performed well compared to the traditional algorithm, with a sensitivity of 100.0% (95% CI 19.8% – 100.0%) and a specificity of 100.0% (95% CI 77.1% – 100.0%). Technical success was achieved in all but one patient investigated with SOC. Adverse events were similar across both study periods. The mean overall cost per patient (USD) when applying the traditional algorithm was $4374.32 compared with $3006.24 for the novel algorithm (p Z 0.004). This resulted in a mean cost savings of $1368.08 per patient. Conclusions: Our study showed that SOC is diagnostically accurate, safe and cost effective for the detection of CCA in the PSC population. When utilized as part of our novel algorithm, SOC outperformed a traditional approach. Further studies are needed to further evaluate the definitive current and future role of SOC in this patient population.
Figure 1. Traditional algorithm for assessment of suspected CCA, observed in study period I.
Figure 2. Novel algorithm for assessment of suspected CCA, observed in study period II.
Tu1535 Safety and Efficacy of Trans-Luminal Biliary Drainage Using the Choledochduodenostomy vs Hepaticogastrostomy After Failed ERCP. Systemic Review and Meta-Analysis Mohamed M. Abdelfatah*1, Glenn Harvin1, Eslam G. Ali1, Hossein Movahed1, Paul Vos2, Amit Raina1 1 Division of Gastroenterology, Hepatology and Nutrition, East carolina University, Greenville, NC; 2Department of Biostatistics, East carolina University, Greenville, NC Introduction: percutaneous trans-hepatic biliary drainage (PTBD) was the only nonsurgical alternative after failing endoscopic retrograde cholangiopancreatography (ERCP). However, this procedure is associated with substantial morbidity and low
www.giejournal.org
quality of life. Choledocoduodenostomy (CDS) and hepaticogastrostomy (HGS) are recently described endoscopic ultrasound guided, trans-luminal biliary drainage procedures. We aimed to review literature and conduct a meta-analysis evaluating cumulative success rate and safety of CDS and HGS. We then compared the success rate and safety of CDS and HGS approach. Methods: We searched Medline, EMBASE, Cochrane database, ISI Web of Science and Scopus from January 1, 2001 through November 20, 2015, to identify studies. After excluding case reports and EUSrendezvous technique, 46 studies were included. We calculated the cumulative (CDS and HGS) pooled technical success rate and post procedure adverse events. Subsequently, we calculated and compared the pooled technical success rate and postprocedure adverse events for CDS and HGS. We excluded Studies investigating rendezvous technique from our study. Case reports and small case series were excluded. Results: Combining all studies that reported on CDS (nZ410) and HGS (nZ368) resulted in 727 successes and 140 post-procedure adverse events from a total of 778 procedures. Overall technical success rate was 93.4% and overall complication percentage was 18 %. In the CDS group technical success rate was 93.7% (384/410) with and post-procedure adverse events was 17.3%(71/410). In the HGS group technical success rate was 93.2%(343/368) and post-procedure adverse events was 18.8% (69/368). HGS and CDS were compared in terms of success and complications using Fisher’s exact test. The odds of success for CDS were 1.08 times the odds for HGS (pZ.90, 95% CI for the odds ratio .584 to 1.980). The odds of complications for CDS were .91 times the odds for HGS (pZ.60, 95% CI .619 to 1.332). Conclusion: Trans luminal biliary drainage using HGS/CDS is a relatively new technique with promising results and might be the go-to future alternative option after failed ERCP. According to our meta-analysis Differences in technical success and differences in complications between HGS VS CDS were not statistically significant.
Tu1536 Single-Operator Cholangioscopy Is More Cost-Effective Than Bile Duct Exploration for Management of Difficult Common Bile Duct Stones After Failed Conventional ERCP Jaskiran Sandha*, Gurpal S. Sandha Medicine, University of Alberta, Edmonton, AB, Canada Background: Common bile duct (CBD) stones are currently managed by ERCP with sphincterotomy and stone extraction with a balloon catheter or basket. However, some stones are difficult to extract by conventional means. These include multiple, large, impacted, or faceted stones, or those proximal to a stricture. Cholangioscopy with electro-hydraulic lithotripsy (EHL) is a modality to treat these difficult stones. Aims: The aim of this study was to describe the clinical efficacy of a single-operator cholangioscopy system (SpyGlassÔ, Boston Scientific Corporation, Marlborough, MA, USA) for difficult stones and discuss possible cost savings by avoiding surgical intervention. Methods: We performed a retrospective chart review of all patients referred for SpyGlassÔ cholangioscopy with EHL for difficult stones. Clinical efficacy was defined as the successful clearance of the CBD of all stones. The total cost (based on Alberta Health Services reimbursement codes) was calculated by adding all costs associated with cholangioscopy, including any subsequent procedures, surgery, hospital stay, or treatment of any complications. This cost was compared with the projected cost of open and laparoscopic CBD exploration (OCBDE, LCBDE). Results: A total of 51 patients with difficult CBD stones (35 female, median age 68 16.4 years [range 30-88 years]) with 108 prior ERCPs (average 2.1/patient) were referred. They underwent 58 SpyGlassÔ cholangioscopy ERCPs and 7 additional ERCPs (average 1.3/patient). The average procedure time was 67 minutes (range 24-124 minutes). The CBD was successfully cleared in 47/51 patients (93% clinical efficacy). Minor complications were seen in 7 patients (14%). These included mild EHL-induced CBD wall trauma in 4 patients, wire-induced cystic duct stump leak in 1 patient, mild post-ERCP pancreatitis in 1 patient and mild mucosal tearing at gastro-esophageal junction during extraction of a plastic stent in 1 patient. The average cost of all procedures was $4550. This compares to a projected cost of $7766 and $6175 for OCBDE and LCBDE, respectively. The average cost saving per patient using SpyGlassÔ cholangioscopy instead of OCBDE or LCBDE was $3216 and $1625, respectively. The published rate of complications (bile leak, hemorrhage, and abscess) for CBDE is 3.2%. Treatment of these complications added $4977, $5216, and $3701 to the cost of CBDE. Conclusion: Single-operator SpyGlassÔ cholangioscopy with EHL is highly effective for the treatment of difficult CBD stones. By adopting this modality as primary treatment for these difficult stones, significant cost savings may be realised by avoiding surgical intervention.
Tu1537 Clinical risk factors for complications in patients undergoing percutaneous transhepatic cholangioscopy Dong Hoon Baek*, Dong Uk Kim, Geun Am Song, Tae Wook Kim, Seong Jun Lee Internal Medicine, Gastroenterology, Pusan National University Hospital, Busan, Korea (the Republic of) Background: Percutaneous transhepatic cholangioscopy (PTCS) has been widely used for the diagnosis and treatment of intrahepatic duct stones, strictures, and
Volume 83, No. 5S : 2016 GASTROINTESTINAL ENDOSCOPY AB599