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CC BY-NC-ND 4.0 · Endosc Int Open 2025; 13: a25097671
DOI: 10.1055/a-2509-7671
Original article

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

Authors

  • Daryl Ramai

    1   Gastroenterology, Hepatology, and Endoscopy, Brigham and Women's Hospital, Boston, United States (Ringgold ID: RIN1861)

  • Richard Nelson

    2   Division of Epidemiology, University of Utah Health, Salt Lake City, United States (Ringgold ID: RIN14434)
    3   VA Salt Lake City Medical Center, IDEAS Center, Salt Lake City, United States

  • Nathorn Chaiyakunapruk

    3   VA Salt Lake City Medical Center, IDEAS Center, Salt Lake City, United States
    4   Department of pharmacotherapy, College of Pharmacy, University of Utah, Salt Lake City, United States (Ringgold ID: RIN14434)

  • Andrew Ofosu

    5   Gastroenterology and Hepatology, University of Cincinnati, Cincinnati, United States (Ringgold ID: RIN2514)

  • John C Fang

    6   Gastroenterology, University of Utah Health, Salt Lake City, United States (Ringgold ID: RIN14434)
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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


Publication History

Received: 06 November 2024

Accepted after revision: 17 December 2024

Accepted Manuscript online:
02 January 2025

Article published online:
12 March 2025

© 2025. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial-License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/).

Georg Thieme Verlag KG
Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany

Bibliographical Record
Daryl Ramai, Richard Nelson, Nathorn Chaiyakunapruk, Andrew Ofosu, John C Fang. Endoscopic ultrasound gastroenterostomy vs duodenal stenting for malignant gastric outlet obstruction: Cost-effectiveness study. Endosc Int Open 2025; 13: a25097671.
DOI: 10.1055/a-2509-7671
 

  • References

  • 1 Sánchez-Aldehuelo R, Iñigo JC, Moreno BM. et al. EUS-guided gastroenterostomy versus duodenal self-expandable metal stent for malignant gastric outlet obstruction: results from a nationwide multicenter retrospective study (with video). Gastrointest Endosc 2022; 96: 1012-1020
    Search in Google Scholar
  • 2 Miller C, Benchaya JA, Martel M. et al. EUS-guided gastroenterostomy vs. surgical gastrojejunostomy and enteral stenting for malignant gastric outlet obstruction: a meta-analysis. Endosc Inter Open 2023; 1: E660-E6672
    Search in Google Scholar
  • 3 Vanella G, Dell’Anna G, Capurso G. et al. EUS-guided gastroenterostomy for management of malignant gastric outlet obstruction: a prospective cohort study with matched comparison with enteral stenting. Gastrointest Endosc 2023; 98: 337-347
    Search in Google Scholar
  • 4 Teoh AYB, Lakhtakia S, Tarantino I. et al. Endoscopic ultrasonography-guided gastroenterostomy versus uncovered duodenal metal stenting for unresectable malignant gastric outlet obstruction (DRA-GOO): a multicentre randomised controlled trial. Lancet Gastroenterol Hepatol 2024; 9: 124-132
    Search in Google Scholar
  • 5 Ramai D, Facciorusso A, Crinò SF. et al. EUS-guided gastroenteric anastomosis: A first-line approach for gastric outlet obstruction?. Endosc Ultrasound 2021; 10: 404-405
    Search in Google Scholar
  • 6 Sanders GD, Neumann PJ, Basu A. et al. Recommendations for conduct, methodological practices, and reporting of cost-effectiveness analyses: Second Panel on Cost-effectiveness in Health and Medicine. JAMA 2016; 316: 1093-1103
    Search in Google Scholar
  • 7 Husereau D, Drummond M, Augustovski F. et al. Consolidated Health Economic Evaluation Reporting Standards 2022 (CHEERS 2022) Statement: Updated Reporting Guidance for Health Economic Evaluations. Value Health 2022; 25: 3-9
    Search in Google Scholar
  • 8 Forbes N, Coelho-Prabhu N, Al-Haddad MA. et al. Adverse events associated with EUS and EUS-guided procedures. Gastrointest Endosc 2022; 95: 16-26
    Search in Google Scholar
  • 9 Krishnamoorthi R, Bomman S, Benias P. et al. Efficacy and safety of endoscopic duodenal stent versus endoscopic or surgcal gastrojejunostomy to treat malignant gastric outlet obstruction: systematic review and meta-analysis. Endosc Int Open 2022; 10: E874-E897
    Search in Google Scholar
  • 10 Garcia-Alonso FJ, Chavarria C, Subtil JC. et al. Prospective multicenter assessment of the impact of EUS-guided gastroenterostomy on patient quality of life in unresectable malignant gastric outlet obstruction. Gastrointest Endosc 2023; 98: 28-35
    Search in Google Scholar
  • 11 Schmidt C, Gerdes H, Hawkins W. et al. prospective observational study examining quality of life in patients with malignant gastric outlet obstruction. Am J Surg 2009; 198: 92-99
    Search in Google Scholar
  • 12 Tarantino I, Sinagra E, Binda C. et al. Perceived feasibility of endoscopic ultrasound-guided gastroenteric anastomosis: An Italian survey. Medicina 2022; 58: 532
    Search in Google Scholar
  • 13 Mangiavillano B, Repici A. EUS-guided gastro-enteral anastomosis for the treatment of gastric outlet obstruction: is the end of the enteral stent?. Expert Rev Gastroenterol Hepatol 2022; 16: 587-589
    Search in Google Scholar
  • 14 Conti Bellocchi MC, Gasparini E, Stigliano S. et al. Endoscopic ultrasound-guided gastroenterostomy versus enteral stenting for malignant gastric outlet obstruction: A retrospective propensity score-matched study. Cancers (Basel) 2024; 16: 724
    Search in Google Scholar
  • 15 Gibson JB, Behrman SW, Fabian TC. et al. Gastric outlet obstruction resulting from peptic ulcer disease requiring surgical intervention is infrequently associated with Helicobacter pylori infection. J Am Coll Surg 2000; 191: 32-37
    Search in Google Scholar