Prasath Vishnu, Quinn Patrick L, Oliver Joseph B, Arjani Simran, Ahlawat Sushil K, Chokshi Ravi J
Division of Surgical Oncology, Department of Surgery, Rutgers New Jersey Medical School, Newark, NJ, USA.
Division of Minimally Invasive Surgery, Department of Surgery, Rutgers New Jersey Medical School, Newark, NJ, USA.
Pancreatology. 2022 Mar;22(2):185-193. doi: 10.1016/j.pan.2021.11.011. Epub 2021 Dec 2.
Traditional management for infected necrotizing pancreatitis (INP) often utilizes open necrosectomy, which carries high morbidity and complication rates. Thus, minimally invasive strategies have gained favor, specifically step-up approaches utilizing endoscopic or minimally-invasive surgery (MIS); however, the ideal management modality for INP has not been identified.
A decision tree model was designed to analyze costs and survival associated with open necrosectomy, endoscopic step-up, and MIS step-up protocols for management of INP after 4 weeks of necrosis development with adequate retroperitoneal access. Costs were based on a third-party payer perspective using Medicare reimbursement rates. The model's effectiveness was represented by quality-adjusted life-years (QALYs). Sensitivity analyses were performed to validate results.
Endoscopic step-up was the dominant economic strategy with 7.92 QALYs for $90,864.09. Surgical step-up resulted in a decrease of 0.09 QALYs and a cost increase of $10,067.89 while open necrosectomy resulted in a decrease of 0.4 QALYs and an increased cost of $18,407.52 over endoscopic step-up. In 100,000 random-sampling simulations, 65.5% of simulations favored endoscopic step-up. MIS step-up was favored when MIS acute mortality rates fell and when MIS drainage success rates rose.
In our simulated patients with INP, the most cost-effective management strategy is endoscopic step-up. Cost-effectiveness varies with changes in acute mortality and drainage success, which will depend on local expertise.
感染性坏死性胰腺炎（INP）的传统治疗方法通常采用开放性坏死组织清除术，该方法具有较高的发病率和并发症发生率。因此，微创策略受到青睐，特别是采用内镜或微创手术（MIS）的逐步升级方法；然而，INP的理想治疗方式尚未确定。
设计了一个决策树模型，以分析在坏死发生4周后，采用开放性坏死组织清除术、内镜逐步升级和MIS逐步升级方案治疗INP且腹膜后通路充分时的成本和生存率。成本基于第三方支付方的视角，采用医疗保险报销率。该模型的有效性以质量调整生命年（QALYs）表示。进行敏感性分析以验证结果。
内镜逐步升级是主要的经济策略，90,864.09美元可获得7.92个QALYs。手术逐步升级导致QALYs减少0.09个，成本增加10,067.89美元，而开放性坏死组织清除术与内镜逐步升级相比，QALYs减少0.4个，成本增加18,407.52美元。在100,000次随机抽样模拟中，65.5%的模拟结果支持内镜逐步升级。当MIS急性死亡率下降且MIS引流成功率上升时，MIS逐步升级更受青睐。
在我们模拟的INP患者中，最具成本效益的管理策略是内镜逐步升级。成本效益随急性死亡率和引流成功率的变化而变化，这将取决于当地的专业知识。
