Cost-effectiveness of treating esophageal varices

Quantitative measurements of esophageal varices using computed tomography for prediction of severe varices and the risk of bleeding: a preliminary study

BACKGROUND

We aimed to assess whether the quantitative parameters of esophageal varices (EV) based on computed tomography (CT) can noninvasively predict severe EV and the risk of esophageal variceal bleeding (EVB).

METHODS

A total of 136 endoscopically confirmed EV patients were included in this retrospective study and were divided into a non-conspicuous (mild-to-moderate EV, n = 30) and a conspicuous EV group (severe EV, n = 106), a bleeding (n = 89) and a non-bleeding group (n = 47). EV grade (EVG), EV diameter (EVD), cross-sectional surface area (CSA), EV volume (EVV), spleen volume (SV), splenic vein (SNV), portal vein (PV), diameter of left gastric vein (DLGV), and the opening type of LGV were measured independently using 3D-slicer. Univariate and multivariate logistic analysis were used to determine the independent factors and the receiver operating characteristic (ROC) curves were performed to evaluate the diagnostic performance.

RESULTS

The difference of EVG, EVD, CSA, EVV, DLGV, SNV between the conspicuous and non-conspicuous EV group were statistically significant (p < 0.05), area under the curves (AUCs) of them for predicting severe EV were 0.72, 0.772, 0.704, 0.768, 0.707, 0.65, with corresponding sensitivities of 70.3%, 63.5%, 50%, 74.3%, 52.7%, 48.6%, specificities of 71.4%, 85.7%, 100%, 71.4%, 81%, 81%, respectively. EVG, CSA (odds ratio 3.258, 95% CI 1.597-6.647; 1.029, 95% CI 1.008-1.050) were found to be independent predictive factors. However, there was no significant difference of the included indices between the bleeding and non-bleeding group (p > 0.05).

CONCLUSIONS

CT can be used as a noninvasive method to predict the severity of EV, which may reduce the invasive screening of endoscopy.

Endoscopic Treatment of Gastric and Ectopic Varices

Gastric variceal bleeding has a high mortality. Endoscopic cyanoacrylate injection is the standard therapy; however, rebleeding and unexpected adverse events, such as injection sites ulcers and distal glue embolisms, are pitfalls of this therapy. Endoscopic ultrasound (EUS)-guided endovascular therapies offer a safer and more practical alternative for the treatment of gastric varices. EUS-guided combined therapy with coiling and cyanoacrylate injection is the most promising alternative with high obliteration rates and fewer adverse events reported. The authors reviewed the latest available data for all endoscopic therapies proposed for the management of gastric varices in patients with chronic liver disease.

Computed Tomographic Portography with Esophageal Variceal Measurements in the Evaluation of Esophageal Variceal Severity and Assessment of Esophageal Variceal Volume Efficacy

RATIONALE AND OBJECTIVES

The aim of our study is to evaluate the severity of esophageal varices (EV), based on the computed tomographic portography (CTP) measurement of EV in the distal esophagus and to assess the prediction value of EV volume.

PATIENTS AND METHODS

A total of 53 EV patients examined by CTP within 4 weeks of upper endoscopy were evaluated, the patients were divided into a nonconspicuous EV group (mild-to-moderate EV, n = 28) and a conspicuous EV group (severe EV, n = 25) according to endoscopy results. The diameter, cross-sectional surface area (CSA), and volume of EV were measured independently using 3D-slicer (Boston) by two experienced abdominal radiologists blinded to endoscopy findings. The averaged values measured by the two observers were used in the final dataset, these indicators' predictive performances were studied by using receiver operating characteristic curve analysis, and the area under the curve (A_z) and the cutoff values were calculated to distinguish mild-to-moderate from severe EV.

RESULTS

The A_z values of volume, diameter and CSA in differentiating severe EV were 0.817, 0.794, and 0.784 for observer-1, corresponding values for observer-2 were 0.796, 0.774, and 0.707, there was almost perfect interobserver agreement for all measurements. All indices were larger in the conspicuous group than the nonconspicuous group in both observers (p ≤ 0.01). In the final dataset, application of a 654.0-mm³-volume criterion yielded sensitivity, specificity of 96%, 50%, application of a 5.2-mm-diameter criterion yielded sensitivity, specificity of 80%, 75%, and application of a 68.6-mm²-CSA criterion yielded sensitivity, specificity of 52%, 93%.

CONCLUSION

The volume of EV could be used as a new effective indictor for evaluating EV, and use of volume, diameter, and CSA of EV based on CTP allows discrimination between mild-to-moderate and severe EV in cirrhotic patients.

Direct costs of care in a randomized controlled trial of endoscopic sclerotherapy versus emergency portacaval shunt for bleeding esophageal varices in cirrhosis--Part 4

BACKGROUND

Emergency treatment of bleeding esophageal varices (BEV) in cirrhotic patients is of prime importance because of the high mortality rate surrounding the episode of acute bleeding. Nevertheless, there is a paucity of randomized controlled trials of emergency surgical therapy and no reports of the costs of any of the widely used forms of emergency treatment. The important issue of direct costs of care was examined in a randomized controlled trial that compared endoscopic sclerotherapy (EST) to emergency portacaval shunt (EPCS).

METHODS

Two hundred eleven unselected consecutive patients with ultimately biopsy-proven cirrhosis and endoscopically proven acute BEV were randomized to EST (n = 106) or EPCS (n = 105). Diagnostic workup was completed, and EST or EPCS was initiated within 8 h. Criteria for failure of EST or EPCS were clearly defined, and crossover rescue treatment was applied, when primary therapy failed. Ninety-six percent of patients underwent more than 10 years follow-up, or until death. Complete charges for all aspects of care were obtained continuously for more than 10 years.

RESULTS

Direct charges for all aspects of care were significantly lower in patients treated by EPCS than in patients treated by emergency EST followed by long-term repetitive sclerotherapy. Charges per patient, per year of treatment, and per year in each child's risk class were significantly lower in patients randomized to EPCS. Charges in patients who failed endoscopic sclerotherapy and underwent a rescue portacaval shunt were significantly higher than the charges in both the unshunted sclerotherapy patients and the patients randomized to EPCS. This result was particularly noteworthy given the widespread practice of using surgical portacaval shunt as rescue treatment only when all other forms of therapy have failed.

CONCLUSIONS

In this randomized controlled trial of emergency treatment of acute BEV, EPCS was significantly superior to EST with regard to direct costs of care as reflected in charges for care as well as in survival rate, control of bleeding, and incidence of portal-systemic encephalopathy. These results provide support for the use of EPCS as a first line of emergency treatment of BEV in cirrhosis.

A prospective evaluation of computerized tomographic (CT) scanning as a screening modality for esophageal varices

Patients with cirrhosis require endoscopic screening for large esophageal varices. The aims of this study were to determine the cost-effectiveness and patient preferences of a strategy employing abdominal computerized tomography (CT) as the initial screening test for identifying large esophageal varices. In a prospective evaluation,102 patients underwent both CT and endoscopic screening for gastroesophageal varices. Two radiologists read each CT independently; standard upper gastrointestinal endoscopy was the reference standard. Agreement between radiologists, and between endoscopists regarding size of varices was determined using kappa statistic. Cost-effectiveness analysis was performed to determine the optimal screening strategy for varices. Patient preference was assessed by questionnaire. CT was found to have approximately 90% sensitivity in the identification of esophageal varices determined to be large on endoscopy, but only about 50% specificity. The sensitivity of CT in detecting gastric varices was 87%. In addition, a significant number of gastric varices, peri-esophageal varices, and extraluminal pathology were identified by CT that were not identified by endoscopy. Patients overwhelmingly preferred CT over endoscopy. Agreement between radiologists was good regarding the size of varices (Kappa = 0.56), and exceeded agreement between endoscopists (Kappa = 0.36). Use of CT as the initial screening modality for the detection of varices was significantly more cost-effective compared to endoscopy irrespective of the prevalence of large varices.

CONCLUSION

Abdominal CT as the initial screening test for varices could be cost-effective. CT also permits evaluation of extra-luminal pathology that impacts management.