Das, Ananya

Objective The aim of the study was to perform an economic analysis to identify the clinical and cost determinants of pancreatic cancer (PC) surveillance in high-risk individuals (HRIs). Methods A Markov model was created to compare the following 3 strategies: no screening, endoscopic ultrasound (EUS), and magnetic resonance imaging (MRI) screening. Patients were considered HRIs according to the Cancer of the Pancreas Screening consortium recommendations. Risk for developing PC, survival, and costs data were obtained from the Surveillance, Epidemiology, and End Results and Medicare databases. Surveillance effectiveness was obtained from a recent meta-analysis. Results Analysis of a cohort with fivefold relative risk of PC higher than the US population showed that MRI is the most cost-effective strategy. For those with the highest risk (>×20 relative risk), EUS became the dominant strategy. Our model was impacted by cost and imaging performance, but still cost-effective within the range reported in literature. Threshold analysis showed that if MRI increases greater than US $1600, EUS becomes more cost-effective. Once patients reached the age of 76 years, “no screening” was favored. Both surveillance strategies were cost-effective over a wide range of willingness to pay. Conclusions Abdominal imaging followed by pancreatectomy is cost-effective to prevent PC in HRIs, favoring MRI in moderate risk cases but EUS in those with highest risk.

Background. ERCP is customarily performed with the patient in prone position. For patients intolerant of prone positioning, ERCP in left lateral decubitus (LLD) position offers a potential alternative. Aims. To compare efficacy and safety of ERCP in the LLD position versus prone position. Methods. Consecutive ERCP reports from August 2009 to October 2010 at Mayo Clinic Arizona were reviewed. Inclusion criteria. Age > 18 years, native papilla, and biliary indication. Primary outcome measure. Bile duct cannulation rate. Secondary outcomes. Times to ampullary localization and bile duct cannulation and complication rate. Results. ERCPs reviewed from 59 patients in two positions: 39 prone and 20 LLD. Cannulation Rate. 100% prone versus 90% in LLD (P=0.11). Median (IRQ) times. (1) Ampullary localization: 90 sec (70–110) prone versus 100 sec (80–118) (P=0.16); (2) bile duct cannulation: 140 sec (45–350) prone versus 165 sec (55–418) LLD (P=0.54). Complications. No periprocedure; postprocedure 4 (10%) prone versus 3 (15%) LLD (P=0.65). Conclusion. ERCP performed in LLD position allowed deep bile duct cannulation in 90% of patients without significantly increased procedural times or rate of complications as compared to prone position.