Arguedas M R, Linder J D, Wilcox C M
Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA.
Endoscopy. 2004 Feb;36(2):174-8. doi: 10.1055/s-2004-814186.
Sphincter of Oddi manometry is considered to be the gold standard for diagnosing sphincter of Oddi dysfunction (SOD). Elevated basal sphincter pressures are found in about half of the patients with findings consistent with biliary type II SOD, and most of these patients will symptomatically improve after endoscopic sphincterotomy. Since manometric sphincter evaluation is not widely available, a decision analysis was used to compare the overall costs and outcomes of manometry-directed therapy with "empirical" sphincterotomy in patients with suspected biliary type II SOD.
A decision analysis model was constructed using a software program. In a hypothetical cohort of 100 patients with suspected type II SOD, the following strategies were evaluated: a). endoscopic retrograde cholangiopancreatography (ERCP) with manometry followed by biliary sphincterotomy only if an elevated sphincter of Oddi basal pressure was found; and b). "empirical" biliary sphincterotomy without manometry. Data on the probability of an elevated sphincter of Oddi basal pressure at the time of ERCP in patients with suspected biliary SOD type II, the proportion of patients who improved after biliary sphincterotomy (with and without elevated basal pressures), the proportion of patients who improved without biliary sphincterotomy, complications, and death were obtained from the literature and from our center. The procedural and hospitalization costs represented the average Medicare reimbursement at our institution. The expected overall costs and numbers of patients improving with each strategy were compared.[nl]
The strategy of ERCP with manometry resulted in total costs of US dollars 2790 per patient, whereas a strategy of "empirical" biliary sphincterotomy resulted in total costs of US dollars 2244. In a cohort of 100 patients with suspected SOD, 55 % of patients would be expected to improve if manometry were performed, compared to 60 % of patients improving with "empirical" biliary sphincterotomy. Univariate sensitivity analyses demonstrated that "empirical" biliary sphincterotomy continued to be a cost-saving strategy in comparison with ERCP with manometry as long as the probability of spontaneous improvement in patients with "normal" manometry was less than 41 %, the probability of complications associated with manometry was greater than 6 %, and the probability of complications due to biliary sphincterotomy was less than 19 %.
For patients with suspected biliary SOD type II, empirical biliary sphincterotomy performed by experienced endoscopists appears to be cost-saving in comparison with a strategy based on the results of manometry.
Oddi括约肌测压被认为是诊断Oddi括约肌功能障碍（SOD）的金标准。在约一半符合胆汁淤积型II型SOD表现的患者中发现基础括约肌压力升高，并且这些患者中的大多数在内镜下括约肌切开术后症状会改善。由于测压括约肌评估并未广泛应用，因此采用决策分析来比较针对疑似胆汁淤积型II型SOD患者进行测压指导治疗与“经验性”括约肌切开术的总体成本和结果。
使用软件程序构建决策分析模型。在一个假设的100例疑似II型SOD患者队列中，评估了以下策略：a）内镜逆行胰胆管造影（ERCP）并测压，仅在发现Oddi括约肌基础压力升高时进行胆管括约肌切开术；b）不进行测压的“经验性”胆管括约肌切开术。从文献和我们中心获取了关于疑似胆汁淤积型II型SOD患者在ERCP时Oddi括约肌基础压力升高的概率、胆管括约肌切开术后（基础压力升高和未升高）改善的患者比例、未进行胆管括约肌切开术而改善的患者比例、并发症和死亡的数据。手术和住院费用代表了我们机构的平均医疗保险报销费用。比较了每种策略的预期总体成本和改善患者数量。
测压指导的ERCP策略导致每位患者的总成本为2790美元，而“经验性”胆管括约肌切开术策略导致的总成本为2244美元。在100例疑似SOD患者队列中，如果进行测压，预计55%的患者会改善，相比之下，“经验性”胆管括约肌切开术后改善的患者为60%。单因素敏感性分析表明，只要“正常”测压患者自发改善的概率小于41%、与测压相关的并发症概率大于6%以及胆管括约肌切开术引起的并发症概率小于19%，“经验性”胆管括约肌切开术与测压指导的ERCP相比仍是一种节省成本的策略。
对于疑似胆汁淤积型II型SOD患者，由经验丰富的内镜医师进行的经验性胆管括约肌切开术与基于测压结果的策略相比似乎更节省成本。
