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

Abstract

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.

Cost-effective analysis of preliminary single-operator cholangioscopy for management of difficult biliary stones

“…The single session clearance rate of 88 % by Korrapati et al is in keeping with other reviews of aggregated literature in a similar context. A systematic review conducted by Alrajhi et al found a POC-EHL clearance rate of 88 %, derived from screening 1870 articles and analyzing 24 full-text studies 15 . As these were both peer reviewed studies, we assumed them to be validated estimates.…”

“…Success of ERCP mechanical lithotripsy was set as 63 % at first attempt, and 68 % at second intervention to reflect overall clearance rates 15 20 26 27 . These success rates are derived from literature based on biliary stones that have been defined “difficult” after at least one failed procedure.…”

“…Success of ERCP mechanical lithotripsy was set as 63% at first attempt, and 68% at second intervention to reflect overall clearance rates. [15,20,26,27] These success rates are derived from literature based on biliary stones that have been defined "difficult" after at least one failed procedure. As such, they are not indicative of the true ERCP success rate for undifferentiated CBD stones, rather they reflect outcomes for patient's who can be pre-determined to have "difficult" CBD stones based on clinical and imaging correlates.…”

“…One study out of a tertiary center in Belgium found an 27 % relative reduction in total procedures and an 11 % cost reduction when SOC was added as an adjunct during the index ERCP vs. when SOC was a separate procedure after ERCP failure 14 . Most recently, Alrahji et al demonstrated how early utilization of SOC for difficult choledocholithiasis is less costly compared to postponing SOC, without significantly compromising effectiveness 15 .…”

Difficult Biliary Stones: A Comprehensive Review of New and Old Lithotripsy Techniques

“…Similarly, Alrajhi et al performed a cost-effectiveness analysis investigating three possible strategies with a progressively delayed introduction of SOC in managing difficult stones after one failed ERCP. Again, the authors showed that the least expensive strategy was to perform SOC early after the first failed ERCP, while postponing SOC resulted in increased cost and marginal or no increase in efficacy [111]. Overall, these models suggest that early adoption of SOC could be costeffective, reducing the number of procedures, costs and, not less important, minimizing patient's stress subsequent to repeated procedures with incomplete treatment and/or AE.…”