Endoscopic ultrasound gastroenterostomy vs duodenal stenting for malignant gastric outlet obstruction: Cost-effectiveness study

Abstract

Background and study aims

Enteral stenting has been traditionally employed for managing malignant gastric outlet obstruction (GOO). However, concerns regarding high reintervention rates have brought into question its cost-effectiveness. Endoscopic ultrasound–guided gastroenterostomy (EUS-GE) with a lumen-apposing metal stent (LAMS) provides an alternative to luminal stenting. The goal of this study was to assess the cost-effectiveness of EUS-GE relative to duodenal stenting.

Patients and methods

A decision analysis was performed to analyze costs and survival in patients with unresectable or metastatic GOO. The model was designed with two treatment arms: self-expanding metal stent (SEMS) placement and EUS-GE with LAMS. Costs were derived from Medicare reimbursement rates (US$) while effectiveness was measured by quality-adjusted life years (QALYs). The primary outcome measure was the incremental cost-effectiveness ratio (ICER). Probabilistic sensitivity analyses were performed.

Results

Endoscopic stenting resulted in an average cost of $22,748 and 0.31 QALYs whereas EUS-GE cost $32,254 and yielded 0.53 QALYs, which yielded a difference of $9,507 in cost and 0.23 in QALY. EUS-GE was found to be a cost-effective strategy over duodenal stenting (ICER, $41994/QALY) at a willingness-to-pay of $100,000/QALY. In 10,000 Monte-Carlo simulations, EUS-GE was favored 62% of the time. Using a tornado diagram, the model was most sensitive to the probability of mortality in patients with duodenal stents compared with EUS-GE.

Conclusions

In patients with malignant GOO, EUS-GE is a cost-effective palliative intervention compared with duodenal stenting.

Keywords

Endoscopy Lower GI Tract - Stenting - Endoscopic ultrasonography - Endoscopy Upper GI Tract

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