Specialist shortage in developing countries: comprehending delays in care.

We describe a case of a middle-aged woman who presented with progressive jaundice and was suspected to have rebound choledocholithiasis, which was initially managed with balloon extraction through endoscopic retrograde cholangiopancreatography at her first presentation. Healthcare in Pakistan, like many other developing countries, is divided into public and private sectors. The public sector is not always completely free of cost. Patients seeking specialised care in the public sector may find lengthy waiting times for an urgent procedure due to a struggling system and a lack of specialists and technical expertise. Families of many patients find themselves facing 'catastrophic healthcare expenditure', an economic global health quandary much ignored.

Role of Endoscopic Ultrasonography and Endoscopic Retrograde Cholangiopancreatography in the Clinical Assessment of Pancreatic Neoplasms.

Accurate diagnosis and staging of pancreatic neoplasms is essential for surgical planning and identification of locally advanced and metastatic disease that is incurable by surgery. The ability to position the endoscopic ultrasonography (EUS) transducer close to the pancreas combined with the use of fine-needle aspiration enables the accurate diagnosis of pancreatic cysts and solid masses. EUS is also increasingly being used to procure core tissue for molecular analysis that facilitates personalized treatment of pancreatic cancer. Various therapeutic interventions can be undertaken under EUS guidance. This article focuses on the applications of EUS and endoscopic retrograde cholangiopancreatography in pancreatic neoplasms.

Cost-effectiveness of preoperative biliary drainage for obstructive jaundice in pancreatic and periampullary cancer.

BACKGROUND: A recent Cochrane Review found that preoperative biliary drainage (PBD) in patients with resectable pancreatic and periampullary cancer undergoing surgery for obstructive jaundice is associated with similar mortality but increased serious morbidity compared with no PBD. Despite this clinical evidence of its lack of effectiveness, PBD is still in use. We considered the economic implications of PBD versus direct surgery for obstructive jaundice in patients with pancreatic and periampullary cancer. MATERIALS AND METHODS: Model-based cost-utility analysis estimating mean costs and quality-adjusted life years (QALYs) per patient from the perspective of the UK National Health Service over a 6-month time horizon. A decision tree model was constructed and populated with probabilities, outcomes, and cost data from published sources. One-way and probabilistic sensitivity analyses were undertaken. RESULTS: PBD was more costly than direct surgery (mean cost per patient £10,775 [$15,616] versus £8221 [$11,914]) and produced fewer QALYs (mean QALYs per patient 0.337 versus 0.343). Not performing PBD would result in cost savings of approximately £2500 ($3623) per patient to the National Health Service. PBD had <10% probability of being cost-effective at a maximum willingness to pay for a QALY of £20,000 ($28,986) to £30,000 ($43,478). CONCLUSIONS: There are significant cost savings to be gained by avoiding routine PBD in patients with resectable pancreatic and periampullary cancer where PBD is still routinely used in this context; this economic evidence should be used to support the clinical argument for a change in practice.

A comparative evaluation of EUS-guided biliary drainage and percutaneous drainage in patients with distal malignant biliary obstruction and failed ERCP.

BACKGROUND AND AIM: Endoscopic ultrasound-guided biliary drainage (EGBD) may be a safe, alternative technique to percutaneous transhepatic biliary drainage (PTBD) in patients who fail ERCP. However, it is currently unknown how both techniques compare in terms of efficacy, safety, and cost. The aims of this study were to compare efficacy, safety, and cost of EGBD to that of PTBD. METHODS: Jaundiced patients with distal malignant biliary obstruction who underwent EGBD or PTBD after failed ERCP were included. Technical success, clinical success, and adverse events between the two groups were compared. RESULTS: A total of 73 patients with failed ERCP subsequently underwent EGBD (n = 22) or PTBD (n = 51). Although technical success was higher in the PTBD group (100 vs. 86.4 %, p = 0.007), clinical success was equivalent (92.2 vs. 86.4 %, p = 0.40). PTBD was associated with higher adverse event rate (index procedure: 39.2 vs. 18.2 %; all procedures including reinterventions: 80.4 vs. 15.7 %). Stent patency and survival were equivalent between both groups. Total charges were more than two times higher in the PTBD group (p = 0.004) mainly due to significantly higher rate of reinterventions (80.4 vs. 15.7 %, p < 0.001). CONCLUSION: EGBD and PTBD are comparably effective techniques for treatment of distal malignant biliary obstruction after failed ERCP. However, EGBD is associated with decreased adverse events rate and is significantly less costly due to the need for fewer reinterventions. Our results suggest that EGBD should be the technique of choice for treatment of these patients at institutions with experienced interventional endosonographers.

Therapeutic approach to the malignant tumors of the biliary tract.

Cholangiocarcinomas (CCA) are malignant tumors that originate in the cholangiocytes, occur at any level of the biliary tract, are very aggressive and have a 5-year survival rate of 7-8%. Their diagnosis is late and difficult, and the prognosis is very poor. The only curative treatment of these tumors is the complete surgical resection. Signs of unresectability can be detected in most patients with CCA when establishing the diagnosis. Thus, only certain palliative measures can be employed in most cases. The ideal palliative method should be minimally invasive, accompanied by few complications, should offer an increased quality of life, require reduced hospitalization and the lowest costs. The palliative treatment of the obstructive jaundice may be achieved by means of surgical bypass, endoscopic insertion of biliary stents, percutaneous stents, transhepatic stents, photodynamic therapy and/or radio-chemotherapy.

Percutaneous treatment of malignant jaundice due to extrahepatic cholangiocarcinoma: covered Viabil stent versus uncovered Wallstents.

To compare clinical effectiveness of Viabil-covered stents versus uncovered metallic Wallstents, for palliation of malignant jaundice due to extrahepatic cholangiocarcinoma, 60 patients were enrolled in a prospective and randomized study. In half of the patients a bare Wallstent was used, and in the other half a Viabil biliary stent. Patients were followed up until death. Primary patency, survival, complication rates, and mean cost were calculated in both groups. Stent dysfunction occurred in 9 (30%) patients in the bare stent group after a mean period of 133.1 days and in 4 (13.3%) patients in the covered stent group after a mean of 179.5 days. The incidence of stent dysfunction was significantly lower in the covered stent group (P = 0.046). Tumor ingrowth occurred exclusively in the bare stent group (P = 0.007). Median survival was 180.5 days for the Wallstent and 243.5 days for the Viabil group (P = 0.039). Complications and mean cost were similar in the two groups. Viabil stent-grafts proved to be significantly superior to Wallstents for the palliation of malignant jaundice due to extrahepatic cholangiocarcinoma, with comparable cost and complication rates. Appropriate patient selection should be performed prior to stent placement.

Is metallic stenting worthwhile for biliary obstruction due to lymph node metastases?

BACKGROUND: The indications for metallic stents have widened from primary hepatobiliary cancers to the other diseases such as lymph node metastases from distant organs. The present study aimed to evaluate the results and establish the efficacy of metallic stenting in patients with obstructive jaundice due to metastatic lymph nodes. METHODS: Stent patency, survival and cost per patient until death were retrospectively compared between patients with primary carcinoma of the biliary tract (PC group; n = 71) and lymph node metastases from the gastric and colorectal carcinomas. (LN group; n = 26). RESULTS: Stent occlusion occurred in 17 patients in the PC group (24%). In contrast, stent occlusion was significantly more frequent in the LN group (P = 0.0293), occurring in 13 patients (50%). Cumulative stent patency was also significantly shorter in the LN group than that in the PC group (P = 0.0016). However, survival was almost the same between the two groups. The mean medical fee was 27% higher for the LN group than for the PC group, which was attributable to additional treatment for stent occlusion. DISCUSSION: The indications for metallic stent placement for biliary obstruction caused by lymph node metastases from the gastrointestinal tract seem limited. Further investigation of the treatments alternative to metallic stents would be required.