Suspected sphincter of Oddi dysfunction type II: empirical biliary sphincterotomy or manometry-guided therapy?

Area of Science:

• Gastroenterology
• Surgical Innovation
• Health Economics

Background:

• Sphincter of Oddi manometry is the gold standard for diagnosing Sphincter of Oddi Dysfunction (SOD).
• Elevated basal sphincter pressures are observed in approximately half of patients with biliary type II SOD.
• Many patients with elevated pressures improve after endoscopic sphincterotomy.

Purpose of the Study:

• To compare the costs and outcomes of manometry-directed therapy versus empirical sphincterotomy for suspected biliary type II SOD.
• To evaluate the cost-effectiveness of diagnostic manometry versus immediate therapeutic sphincterotomy.
• To inform clinical decision-making in the management of SOD.

Main Methods:

• A decision analysis model was used to compare two strategies in a hypothetical cohort of 100 patients with suspected type II SOD.
• Strategy A: ERCP with manometry, followed by sphincterotomy only if manometry showed elevated pressure.
• Strategy B: Empirical biliary sphincterotomy without manometry. Costs and outcomes were derived from literature and institutional data.

Main Results:

• Empirical biliary sphincterotomy cost $2244 per patient, compared to $2790 for manometry-directed ERCP.
• Sixty percent of patients improved with empirical sphincterotomy, versus 55% with manometry-directed therapy.
• Empirical sphincterotomy remained cost-saving under various sensitivity analyses, including probabilities of spontaneous improvement and complication rates.

Conclusions:

• Empirical biliary sphincterotomy by experienced endoscopists is a cost-saving strategy for suspected biliary type II SOD.
• This approach offers a favorable balance of cost and patient outcomes compared to manometry-based strategies.
• The findings support the use of empirical sphincterotomy in select patient populations with suspected SOD.