Miguel R. Arguedas

Prognostic factors for the survival of patients with esophageal carcinoma in the U.S.: the importance of tumor length and lymph node status.

The current TNM classification system does not consider tumor length or the number of lymph nodes in the staging and classification scheme for patients with esophageal carcinoma. Using data from the National Cancer Institute SEER Program, the authors explored the effect of tumor length and number of positive lymph nodes on survival in patients with esophageal carcinoma.

Influence of Hepatic Encephalopathy on Health-Related Quality of Life in Patients with Cirrhosis

Cirrhosis is associated with decrements in health-related quality of life (HRQOL), but the specific effects of encephalopathy, especially subclinical, on quality of life are incompletely understood. Therefore, the aim of our study was to define the effects of encephalopathy on specific domains of HRQOL in a sample of patients with advanced liver disease. The sample consisted of 160 patients with cirrhosis presenting for liver transplantation evaluation. Health-related quality of life was measured with the Short Form-36 questionnaire. Clinical, demographic, and laboratory data were collected. The presence and degree of encephalopathy was ascertained clinically and by the use of the Reitan trail test. HRQOL scores were compared according to liver disease severity and to the presence and degree of encephalopathy. In addition, scores were compared to US population norms. Data were obtained from 148 patients. Compared to the US general population, the physical and mental component summary scores were lower in patients with cirrhosis. Among patients with cirrhosis, there were no significant differences in the physical and mental component summary scores according to age, gender, ethnicity, and etiology (hepatocellular versus/ cholestatic and HCV versus non-HCV). Increasing severity of liver disease (based on the Child-Pugh score), a history of hospitalizations, and a history of ascites were associated with decreased physical component summary scores but not mental component summary scores. Patients with encephalopathy (overt and subclinical) had decreased physical and mental component summary scores compared to patients without encephalopathy. Compared to patients without encephalopathy, those with subclinical encephalopathy had a lower mental component summary score. In conclusion, cirrhosis is associated with a decreased HRQOL, especially at advanced stages. Increased severity of liver disease is associated with decreased physical aspects of quality of life. Overt hepatic encephalopathy negatively affects both physical and mental aspects of quality of life, whereas subclinical encephalopathy affects mainly the mental aspects, independently of liver disease severity.

Biliary stents in malignant Obstructive jaundice due to pancreatic carcinoma: A cost-effectiveness analysis

OBJECTIVES:Obstructive jaundice frequently complicates pancreatic carcinoma and is associated with complications such as malabsorption, coagulopathy, progressive hepatocellular dysfunction, and cholangitis in addition to disabling pruritus, which greatly interferes with terminal patients’ quality of life. Endoscopic placement of biliary stents decreases the risk of these complications and is considered the procedure of choice for palliation for patients with unresectable tumors. We used decision analysis with Markov modeling to compare the cost-effectivenesses of plastic stents and metal stents in patients with unresectable pancreatic carcinoma.METHODS:A model of the natural history of unresectable pancreatic carcinoma was constructed using probabilities derived from the literature. Cost estimates were obtained from Medicare reimbursement rates and supplemented by the literature. Two strategies were evaluated: 1) initial endoscopic plastic stent placement and 2) initial endoscopic metal stent placement. We compared total costs and performed cost-effectiveness analysis in these strategies. The outcome measures were quality-adjusted life months. Sensitivity analyses were performed on selected variables.RESULTS:Our baseline analysis showed that initial plastic stent placement was associated with a total cost of

Cost-effectiveness of screening, surveillance, and primary prophylaxis strategies for esophageal varices.

13,879/patient and 1.799 quality-adjusted life months. Initial placement of a metal stent cost

Where do ERCP, endoscopic ultrasound, magnetic resonance cholangiopancreatography, and intraoperative cholangiography fit in the management of acute biliary pancreatitis? A decision analysis model

13,466/patient and conferred 1.832 quality-adjusted life months. Among the variables examined, expected patient survival was demonstrated by sensitivity analyses to have the most influence on the results of the model.CONCLUSION:Initial endoscopic placement of a metal stent is a cost-saving strategy compared to initial plastic stent placement, particularly in patients expected to survive longer than 6 months.

Expandable Metal Biliary Stents Before Pancreaticoduodenectomy for Pancreatic Cancer: A Monte-Carlo Decision Analysis

OBJECTIVE:Screening for varices is recommended in patients with cirrhosis to institute primary prophylaxis to prevent variceal bleeding. Our aim was to compare the cost-effectiveness of four strategies, including no screening/no prophylaxis, universal screening and primary prophylaxis with β-blockers, universal screening and primary prophylaxis with variceal ligation, and universal institution of primary prophylaxis with β-blockers without screening.METHODS:We constructed a Markov simulation model in two hypothetical cohorts of 50-yr-old patients with cirrhosis (one compensated and one decompensated), who were followed for 5 yr. Transition probabilities were derived from the medical literature, and costs reflected Medicare reimbursement rates at our institution.RESULTS:In patients with compensated cirrhosis, screening and primary prophylaxis with β-blockers is associated with an incremental cost-effectiveness ratio of

A Cost-Minimization Analysis of Alternative Strategies in Diagnosing Pancreatic Cancer

3605 per year of life saved. The results were most sensitive to the prevalence of varices and risk of variceal bleeding. In patients with decompensated liver disease, primary prophylaxis without screening was associated with an incremental cost-effectiveness ratio of

Video-assisted thoracoscopic surgery with talc pleurodesis in the management of symptomatic hepatic hydrothorax.

1154 per year of life saved. The results were most sensitive to the cost of β-blockers and endoscopy.CONCLUSIONS:Screening for varices is an affordable strategy in compensated liver disease, whereas universal primary prophylaxis with β-blockers is cost-effective in decompensated patients.

Hepatic venous pressure gradient measurements to assess response to primary prophylaxis in patients with cirrhosis: a decision analytical study

OBJECTIVES:The role of ERCP in acute biliary pancreatitis (ABP) is controversial. Magnetic resonance cholangiopancreatography (MRCP) and endoscopic ultrasonography (EUS) are modalities for bile duct visualization that could lower costs and prevent ERCP-related complications. We analyzed costs and examined the cost-effectiveness of these modalities to define their role in ABP.METHODS:A decision analysis model of ABP was constructed. The strategies evaluated were 1) ERCP, 2) MRCP followed by ERCP if positive for common bile duct stones (CBDS) or if biliary sepsis ensued, 3) EUS followed by ERCP if positive or if biliary sepsis ensued, and 4) observation with intraoperative cholangiography at the time of cholecystectomy with ERCP only if biliary sepsis ensued. We compared costs and performed cost-effectiveness analysis between strategies at probabilities of CBDS ranging from 0% to 100%. The outcome measures were total costs and costs per ABP death prevented.RESULTS:At probabilities of CBDS < 15%, observation with intraoperative cholangiography is the least expensive strategy, whereas EUS and ERCP are the least expensive strategies at probabilities of 15–58% and >58%, respectively. In terms of cost-effectiveness, at probabilities of CBDS of 7–45%, EUS is the most cost-effective alternative, and at a probability of >45% ERCP is the most cost-effective option.CONCLUSIONS:Total costs and cost-effectiveness ratios of these strategies in patients with ABP are highly dependent on the probability of CBDS.

Risk of Aspiration Pneumonia in Suspected Variceal Hemorrhage: The Value of Prophylactic Endotracheal Intubation Prior to Endoscopy

BACKGROUND & AIMS Endoscopic placement of plastic or self-expandable metal biliary stents (SEMS) relieves obstructive jaundice from pancreatic cancer. Short-length, distally placed SEMS do not preclude subsequent pancreaticoduodenectomy. We sought to determine whether SEMS placement in patients whose surgical status is uncertain is cost-effective for management of obstructive jaundice. METHODS A Markov model was constructed to evaluate costs and outcomes associated with endoscopic biliary stenting for obstructive jaundice. Strategies evaluated were: (1) initial plastic stent with plastic stents for subsequent occlusions in nonsurgical candidates after staging (plastic followed-up by [f/u] plastic), (2) initial plastic with subsequent SEMS (plastic f/u metal), (3) initial short-length SEMS with subsequent plastic (metal f/u plastic), and (4) initial short-length SEMS with subsequent expandable metal stent (metal f/u metal). Published stent occlusion rates, ERCP complication rates and outcomes, cholangitis rates and outcomes, pancreatic cancer mortality rates, and Whipple complication rates were used. Costs were based on 2004 Medicare standard allowable charges and were accrued until all patients reached an absorbing health state (death or pancreaticoduodenectomy) or 24 cycles (24 mo) ended. RESULTS Average costs per patient from Monte Carlo simulation were: (1) metal f/u metal,