Suitable closure for post-duodenal endoscopic resection taking medical costs into consideration.

AIM: To compare closure methods, closure times and medical costs between two groups of patients who had post-endoscopic resection (ER) artificial ulcer floor closures. METHODS: Nineteen patients with duodenal adenoma, early duodenal cancer, and subepithelial tumors that received ER between September 2009 and September 2014 at Kagawa University Hospital and Ehime Rosai Hospital, an affiliated hospital of Kagawa University, were included in the study. We retrospectively compared two groups of patients who received post-ER artificial ulcer floor closure: the conventional clip group vs the over-the-scope clip (OTSC) group. Delayed bleeding, procedure time of closure, delayed perforation, total number of conventional clips and OTSCs and medical costs were analyzed. RESULTS: Although we observed delayed bleeding in three patients in the conventional clip group, we observed no delayed bleeding in the OTSC group (P = 0.049). We did not observe perforation in either group. The mean procedure times for ulcer closure were 33.26 ± 12.57 min and 9.71 ± 2.92 min, respectively (P = 0.0001). The resection diameters were 18.8 ± 1.30 mm and 22.9 ± 1.21 mm for the conventional clip group and the OTSC group, respectively, with significant difference (P = 0.039). As for medical costs, the costs of all conventional clips were USD $1257 and the costs of OTSCs were $7850 (P = 0.005). If the post-ER ulcer is under 20 mm in diameter, a conventional clip closure may be more suitable with regard to the prevention of delayed perforation and to medical costs. CONCLUSION: If the post-ER ulcer is over 20 mm, the OTSC closure should be selected with regard to safety and reliable closure even if there are high medical costs.

Cost comparison of gastrojejunostomy versus duodenal stent placement for malignant gastric outlet obstruction.

BACKGROUND: Gastrojejunostomy (GJJ) and stent placement are the most commonly used palliative treatments for malignant gastric outlet obstruction (GOO). In a recent randomized trial, stent placement was preferred in patients with a relatively short survival and GJJ in patients with a longer survival. As health economic aspects have only been studied in general terms, we estimated the cost of GJJ and that of stent placement in such patients. METHODS: In the SUSTENT study, patients were randomized to GJJ (n = 18) or stent placement (n = 21). Pancreatic cancer was the most common cause of GOO. We compared initial costs and costs during follow-up. For cost-effectiveness, the incremental cost-effectiveness ratio was calculated. RESULTS: Food intake improved more rapidly after stent placement than after GJJ, but long-term relief of obstructive symptoms was better after GJJ. More major complications (P = 0.02) occurred and more reinterventions were performed (P < 0.01) after stent placement than after GJJ. Initial costs were higher for GJJ compared to stent placement (euro8315 vs. euro4820, P < 0.001). We found no difference in follow-up costs. Total costs per patient were higher for GJJ compared to stent placement (euro12433 vs. euro8819, P = 0.049). The incremental cost-effectiveness ratio of GJJ compared to stent placement was euro164 per extra day with a gastric outlet obstruction scoring system (GOOSS) >or=2 adjusted for survival. CONCLUSIONS: Medical effects were better after GJJ, although GJJ had higher total costs. Since the cost difference between the two treatments was only small, cost should not play a predominant role when deciding on the type of treatment assigned to patients with malignant GOO (ISRCTN 06702358).

Palliation of malignant gastroduodenal obstruction with open surgical bypass or endoscopic stenting: clinical outcome and health economic evaluation.

Gastroduodenal outlet obstruction is a complication of advanced gastrointestinal malignant disease. In the past it was usually treated by an open surgical bypass procedure. During the last decade, endoscopic self-expandable stents (SEMS) have been used. The aim of this study was to compare these two palliative strategies concerning clinical outcome and health economy. A series of 36 patients with incurable malignant disease and gastroduodenal outlet obstruction syndrome were treated in a prospective study. According to the attending hospital and endoscopist on duty, 21 of the 36 patients were endoscopically treated with SEMS and 15 underwent an open surgical gastroenteroanastomosis. Health economic evaluation was based on the monetary charges for each patient associated with the procedure, postoperative care, and hospital stay. The hospital stay was 7.3 days for the stented group compared with 14.7 days for the open surgery group ( p > 0.05). The survivals were 76 and 99 days, respectively (NS). In the stented group all 15 patients (100%) alive after 1 month were able to eat or drink, and 11 (73%) of them tolerated solid food. In the surgical bypass group,9 out of 11 (81%) patients alive after 1 month could eat or drink, and 5 of them (45%) could eat solid food. The mean charges (U.S. dollars) during the hospital stay were $7215 for the stented group and $10,190 for the open surgery group ( p < 0.05). Palliation of the gastroduodenal obstruction in patients with malignant disease were at least as good, and the charges were lower for the endoscopic stenting procedure than for an open surgical bypass.

Duodenoscopy in treatment of acute gallstone pancreatitis.

OBJECTIVE: To probe the potential use of duodenoscopy in the diagnosis and treatment of acute gallstone pancreatitis (GP). METHODS: Fourty-five patients with acute GP were randomly divided into endoscopic retrograde cholangiopancreatography (ERCP) group (n=20) and non-ERCP group (n=25). Each group was subdivided into mild and severe groups according to APACHE II scores. They were given supportive treatment combined with traditional Chinese medicine. The patients in the ERCP group received ERCP within 24 hours after admission. If there were stones in the common bile duct with stenosis of the inferior extremity or ampulla, endoscopic sphincterotomy (ES) was performed to extract the stones by basket. If no calculi were identified or multiple stones were large, endoscopic naso-biliary drainage (ENBD) was carried out. RESULTS: The incidence of complication, length of hospitalization and cost were markedly lower in patients with severe acute GP in the ERCP group than those in the non-ERCP group (P<0.05), in contrast to the 2 mild subgroups of the ERCP and non-ERCP groups (P>0.05). CONCLUSION: It is feasible, effective and safe to apply duodenoscopy in the treatment of severe acute GP.

A comparative study of unsedated transnasal esophagogastroduodenoscopy and conventional EGD.

BACKGROUND: A significant portion of the cost and complications associated with conventional esophagogastroduodenoscopy (EGD) is attributed to conscious intravenous sedation, which usually results in loss of work on the day of the endoscopy. Earlier studies have described the feasibility and safety of unsedated transnasal EGD in normal volunteers. METHODS: We compared the diagnostic yield and patient acceptability of this new technique performed first, with conventional EGD performed second in 24 outpatients. RESULTS: The sensitivity of transnasal EGD was 89% and its specificity was 97%. Transnasal EGD was more acceptable and less stressful to the patients than conventional EGD (p < 0.05). Oxygen saturation and blood pressure did not change during transnasal EGD. CONCLUSION: Transnasal EGD is feasible, safe, and well tolerated by patients. Specificity of transnasal EGD is similar to, but its sensitivity is lower than, conventional EGD. By eliminating the need for sedation-related work loss and postprocedural monitoring, transnasal EGD potentially is more cost-effective than conventional EGD.

[More successful and cost effective--the non-transendoscopic method of TPCD]. / Erfolgreicher und kostensparender--die nicht-transendoskopische Methode der TPCD.

With TPCD best results are gained with large diameter endoprostheses. In this instance special duodenoscopes with a working channel of 3.2 or 4.2 mm are needed for the implantation of 10 or 12 French endoprostheses. Alternatively, using the non-transendoscopic technique large diameter endoprostheses of 14 or more French can be implanted independently from the diameter of the working channel with conventional endoscopes. We have used this method developed at our institution in 1204 patients since 1982 and compared its results with 192 patients in whom the transendoscopic technique with 7-10 French endoprostheses was administered. The success-rate (non-transendoscopic technique 94 vs transendoscopic technique 79%), early complications (5 vs 11%), method-specific mortality (0.3 vs 1%), in-hospital mortality (3.6 vs 21%) and late complications (19 vs 33%) are clearly in favour of the non-transendoscopic approach. The higher rate of early complications and consecutively higher in-hospital mortality of the transendoscopic method with 7-10 French endoprostheses was mainly due to frequent episodes of early cholangitis due to insufficient biliary drainage. The higher success-rate of the non-transendoscopic approach is method specific ("Prothesenleger" guidable). A change of the endoscope is not necessary in contradiction to the transendoscopic method. Additional costs of special duodenoscopes that can be used neither for ERCP nor sphincterotomy are superfluous.(ABSTRACT TRUNCATED AT 250 WORDS)

Primary panendoscopy.

Primary panendoscopy is defined as a limited-consultative, diagnostic, UGI endoscopic examination that provides, in non-critically ill patients with dyspeptic symptoms, an accurate and cost-effective alternative to the standard UGI x-ray examination. The procedure was instituted at St. Mary's Medical Center's hospital in February 1985. During the first 12 months, a total of 321 patients were examined: 212 inpatients and 109 outpatients. In those patients with complete information, primary panendoscopy changed the diagnosis in 67% and the treatment in 52%. As expected, the number of esophagogastroduodenoscopies decreased during this time, but the combined numbers of primary panendoscopies and esophagogastroduodenoscopies exceeded the projected increase of esophagogastroduodenoscopies. Similarly, the number of UGI x-ray examinations fell sharply. With a physician fee of $150.00 and a facility fee of $50.00, theoretical savings of some $117,000.00 to the patients were estimated. The authors conclude that primary panendoscopy provides a cost-effective and beneficial patient service that warrants broad consideration by gastroenterologists as they face the cost constraints being imposed within the health care system of the 1980s.

Current status of argon laser hemostasis of bleeding ulcers.

Endoscopic argon laser photocoagulation has been extensively studied in animals. Clinical pilot studies and randomized controlled trials have demonstrated that argon laser endoscopic hemostasis is both safe and efficient. Specific guidelines for successful endoscopic hemostasis have been determined. The limitations of the argon laser for emergency hemostasis are a strong absorption by blood, its expense and lack of portability, the inability to tamponade or to treat tangentially, and the vaporization potential. The Nd:YAG laser shares all these limitations except that it is less absorbed by blood. Because of these limitations, GI lasers are at present being used less for emergency hemostasis than for elective tumor ablation. Some new, non-laser, thermal devices which do not have these limitations have been developed. They are currently being evaluated in randomized trials. Perhaps because of these factors, the good results obtained with lasers for emergency hemostasis of bleeding ulcers have not been translated into clinical practice at most hospitals.