Endoscopic ultrasound versus endoscopic retrograde cholangiopancreatography for primary palliation of malignant distal biliary obstruction: a cost-effectiveness modeling analysis.
[BACKGROUND] Endoscopic retrograde cholangiopancreatography-guided transpapillary biliary drainage (ERCP-BD) is the standard for primary palliation of malignant distal biliary obstruction (MDBO), but
APA
Magahis PT, Mahadev S, et al. (2026). Endoscopic ultrasound versus endoscopic retrograde cholangiopancreatography for primary palliation of malignant distal biliary obstruction: a cost-effectiveness modeling analysis.. Endoscopy. https://doi.org/10.1055/a-2837-1405
MLA
Magahis PT, et al.. "Endoscopic ultrasound versus endoscopic retrograde cholangiopancreatography for primary palliation of malignant distal biliary obstruction: a cost-effectiveness modeling analysis.." Endoscopy, 2026.
PMID
41887604
Abstract
[BACKGROUND] Endoscopic retrograde cholangiopancreatography-guided transpapillary biliary drainage (ERCP-BD) is the standard for primary palliation of malignant distal biliary obstruction (MDBO), but endoscopic ultrasound-guided choledochoduodenostomy (EUS-CDS) has demonstrated improved technical success, efficiency, and safety in randomized trials. However, cost-effectiveness data are lacking. In this modeling study, we analyzed the cost-effectiveness of EUS-CDS with lumen-apposing metal stent (LAMS) and ERCP-BD with self-expandable metal stent (SEMS) for primary MDBO palliation.
[METHODS] A state-transition Markov model compared EUS-CDS and ERCP-BD over a 1-year time horizon from a US healthcare perspective. The base case was a 70-year-old with locally advanced, unresectable pancreatic cancer, common bile duct dilation >15 mm, and MDBO. Probabilities were derived from meta-analyses of randomized trials. Outcomes were incremental cost-effectiveness ratios (ICERs), with a willingness-to-pay (WTP) threshold of $100 000/quality-adjusted life year (QALY). Extensive sensitivity analyses were performed.
[RESULTS] EUS-CDS with LAMS was cost effective versus ERCP-BD with SEMS for primary treatment of MDBO at an ICER of $47 711/QALY. In one-way sensitivity analyses, EUS-CDS remained cost effective if it cost <$15 502 or if ERCP-BD cost >$11 174. ERCP-BD would become cost effective if technical success was >91%, reintervention <11%, or postprocedural pancreatitis <4%. Probabilistic sensitivity analysis showed EUS-CDS remained cost effective in 74.1% of iterations at a $100 000/QALY WTP threshold.
[CONCLUSIONS] In patients with MDBO and biliary dilation >15 mm, EUS-CDS with LAMS may be not only a clinically preferred option but also an economically viable primary approach. Continued efforts to minimize LAMS costs, decrease stent dysfunction, and identify optimal anatomic indications are warranted to facilitate wider adoption.
[METHODS] A state-transition Markov model compared EUS-CDS and ERCP-BD over a 1-year time horizon from a US healthcare perspective. The base case was a 70-year-old with locally advanced, unresectable pancreatic cancer, common bile duct dilation >15 mm, and MDBO. Probabilities were derived from meta-analyses of randomized trials. Outcomes were incremental cost-effectiveness ratios (ICERs), with a willingness-to-pay (WTP) threshold of $100 000/quality-adjusted life year (QALY). Extensive sensitivity analyses were performed.
[RESULTS] EUS-CDS with LAMS was cost effective versus ERCP-BD with SEMS for primary treatment of MDBO at an ICER of $47 711/QALY. In one-way sensitivity analyses, EUS-CDS remained cost effective if it cost <$15 502 or if ERCP-BD cost >$11 174. ERCP-BD would become cost effective if technical success was >91%, reintervention <11%, or postprocedural pancreatitis <4%. Probabilistic sensitivity analysis showed EUS-CDS remained cost effective in 74.1% of iterations at a $100 000/QALY WTP threshold.
[CONCLUSIONS] In patients with MDBO and biliary dilation >15 mm, EUS-CDS with LAMS may be not only a clinically preferred option but also an economically viable primary approach. Continued efforts to minimize LAMS costs, decrease stent dysfunction, and identify optimal anatomic indications are warranted to facilitate wider adoption.