Background and Aims

EUS-guided transmural drainage is effective in the management of pancreatic walled-off necrosis (WON). A lumen-apposing metal stent (LAMS) has recently been developed specifically for the drainage of pancreatic fluid collections that shows promising results. However, no cost-effectiveness data have been published in comparison with endoscopic drainage with traditional plastic stents (PSs). Our aim here was to compare the cost-effectiveness of LAMSs to PSs in the management of WON.

Methods

A decision tree was developed to assess both LAMSs and PSs over a 6-month time horizon. For each strategy, after the insertion of the respective stents, patients were followed for subsequent need for direct endoscopic necrosectomy, adverse events requiring unplanned endoscopy, percutaneous drainage (PCD), or surgery using probabilities obtained from the literature. The unit of effectiveness was defined as successful endoscopic drainage without the need for PCD or surgery. Costs in 2016 U.S.$ were based on inpatient institutional costs. Sensitivity analyses were performed. An a priori willingness-to-pay threshold of U.S.$50,000 was established.

Results

LAMSs were found to be more efficacious than PSs, with 92% and 84%, respectively, of the patients achieving successful endoscopic drainage of WON. LAMSs, however, were more costly: the average cost per patient of U.S.$20,029 compared with U.S.$15,941 for PSs. The incremental cost-effectiveness ratio favored LAMSs at U.S.$49,214 per additional patient successfully treated. Sensitivity analyses confirmed the robustness of the results.

Conclusion

LAMSs are more effective but also more costly than PSs in managing WON. Data from high-quality, adequately controlled, prospective, randomized trials are needed to confirm our findings.

中文翻译：

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比较腔内金属支架与塑料支架治疗胰腺壁坏死的成本效益分析

背景和目标

EUS引导的经壁引流可有效治疗胰腺壁坏死（WON）。最近开发了一种腔内金属支架（LAMS），专门用于胰腺液收集的引流，显示出令人鼓舞的结果。但是，与传统塑料支架（PSs）的内窥镜引流相比，尚无成本效益数据公布。我们的目的是比较WMS管理中LAMS与PS的成本效益。

方法

开发了一个决策树来评估6个月时间范围内的LAMS和PS。对于每种策略，在插入各自的支架后，患者均需要随后的直接内镜坏死切除术，不良事件需要计划内镜检查，经皮引流（PCD）或使用从文献中获得的概率进行手术。有效性的单位定义为无需PCD或手术即可成功进行内窥镜引流。2016年的美元成本基于住院机构成本。进行敏感性分析。事先设定了50,000美元的支付意愿门槛。

结果

发现LAMS比PS更有效，分别有92％和84％的患者成功完成了内镜引流WON。然而，LAMS的成本更高：每位患者的平均成本为20,029美元，而PS的平均成本为15,941美元。成本效益比的增加使LAMS的获益多于每位成功治疗的患者49,214美元。敏感性分析证实了结果的可靠性。

结论

在管理WON方面，LAMS比PS更为有效，但成本也更高。需要高质量，充分控制的，前瞻性，随机试验的数据来证实我们的发现。