Ramai Daryl, Nelson Richard, Chaiyakunapruk Nathorn, Ofosu Andrew, Fang John C
Gastroenterology, Hepatology, and Endoscopy, Brigham and Women's Hospital, Boston, United States.
Division of Epidemiology, University of Utah Health, Salt Lake City, United States.
Endosc Int Open. 2025 Mar 12;13:a25097671. doi: 10.1055/a-2509-7671. eCollection 2025.
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.
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.
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.
In patients with malignant GOO, EUS-GE is a cost-effective palliative intervention compared with duodenal stenting.
传统上，肠道支架置入术用于治疗恶性胃出口梗阻（GOO）。然而，对高再次干预率的担忧使其成本效益受到质疑。内镜超声引导下胃造瘘术（EUS-GE）联合管腔对接金属支架（LAMS）为管腔支架置入术提供了一种替代方案。本研究的目的是评估EUS-GE相对于十二指肠支架置入术的成本效益。
进行决策分析，以分析不可切除或转移性GOO患者的成本和生存率。该模型设计了两个治疗组：自膨式金属支架（SEMS）置入和EUS-GE联合LAMS。成本来自医疗保险报销率（美元），而有效性通过质量调整生命年（QALY）来衡量。主要结局指标是增量成本效益比（ICER）。进行了概率敏感性分析。
内镜支架置入术的平均成本为22,748美元，QALY为0.31；而EUS-GE的成本为32,254美元，QALY为0.53，成本相差9,507美元，QALY相差0.23。在支付意愿为100,000美元/QALY的情况下，EUS-GE被发现是一种比十二指肠支架置入术更具成本效益的策略（ICER，41,994美元/QALY）。在10,000次蒙特卡洛模拟中，EUS-GE在62%的时间内更受青睐。使用龙卷风图，该模型对十二指肠支架置入术患者与EUS-GE相比的死亡概率最为敏感。
在恶性GOO患者中，与十二指肠支架置入术相比，EUS-GE是一种具有成本效益的姑息性干预措施。
