Importance and Cost Analysis of Endoscopic Ultrasonography in Whipple Operations

Öz

Objective: Evidence-based medical practice reveals that endoscopic ultrasonography (EUS) has a great impact on the clinical evaluation of pancreatic masses. EUS can provide high-resolution images of the pancreas of accepted quality far beyond those obtained by transabdominal ultrasound (US), computed tomography (CT), or magnetic resonance imaging (MR). In this way, the distinction of benign pancreatic lesions can be revealed more clearly, and medical treatment of approximately 10% patients without surgery can benefit many aspects (patient size, hospital management, financial resource management, etc.). While this situation causes a waste of resources for reimbursement institutions, it causes a decrease in the quality of life for the patient as it becomes susceptible to complications. Other factors that can increase transaction costs; Additional radiological procedures, advanced examinations and increased examinations due to complications that may occur in the patient are among the factors that increase the cost of the procedure. Materials and Methods: After the literature review, the number of Whipple operations between 2015 and 2019 was obtained from the Social Security Institution Medula database and analyzed on a sectoral basis. The cost of Whipple and EUS procedures to hospitals in 2019 was calculated with the simple distribution method based on the data of two sampled hospitals. Results: According to the literature, Whipple operation is performed in 10% of patients considering that it is malignant although it is benign. It has been determined that benign lesions can be defined more clearly with EUS, and medical follow-up and treatment can be performed without an operation. According to the data of 2015-2019, if there is a 10% reduction in the number of Whipple operations, it is thought that 848 patients underwent Whipple surgery for benign reasons within 5 years. Conclusion: Whipple operations performed for benign reasons cause a waste of resources for reimbursement institutions, increase the rate of re-application, loss of workforce for patients and healthcare professionals, complications for the patient and decrease in the patient's quality of life. According to data from 2019 based on the number of operations performed by Whipple in Turkey, it is anticipated that benign pancreatic masses can be defined more clearly by EUS diagnosis method and an annual saving of 3,248,355.22 ₺ can be achieved with non-operative treatments.

Anahtar Kelimeler

• Whipple operation
• Endoscopic ultrasonography (EUS)
• pancreatic masses
• cost-benefit analysis

Whipple Operasyonlarında Endoskopik Ultrasonagrafinin Önemi ve Fayda-Maliyet Analizi

Öz

Giriş ve Amaç: Kanıta dayalı tıp uygulamaları, endoskopik ultrasonografinin (EUS) pankreas kitlelerinin klinik değerlendirmesinde büyük bir etkisi olduğunu ortaya koymaktadır. EUS, transabdominal ultrason (US), bilgisayarlı tomografi (BT) veya manyetik rezonans görüntüleme (MR) ile elde edilenin çok ötesinde kabul edilen kalitede pankreasın yüksek çözünürlüklü görüntülerini sağlayabilmektedir. Bu sayede benign pankreas lezyonlarının ayrımı daha net biçimde ortaya konabilir, yaklaşık %10 hastanın operasyonsuz medikal tedavisi ile birçok yönden (hasta boyutu, hastane yönetimi, mali kaynak yönetimi vb.) fayda sağlanabilir. Gereç ve Yöntemler: Literatür taraması sonrası Sosyal Güvenlik Kurumu Medula veri tabanından 2015-2019 yılları arasındaki Whipple ameliyat sayıları sektörel bazda elde edilerek incelenmiştir. Örneklem en çok EUS işlemi yapılan iki hastane verisi üzerinden basit dağıtım yöntemi ile 2019 yılı Whipple ve EUS işlemlerinin hastanelere maliyeti hesaplanmıştır. Bulgular: Literatüre göre, %10 hastaya benign olmasına rağmen malign olduğu düşünülerek Whipple operasyonu uygulanmaktadır. EUS ile benign karakterde lezyonların daha net olarak tanımlanabileceği, bu sayede operasyon olmaksızın medikal takip ve tedavi yapılabileceği saptanmıştır. 2015-2019 yılı verilerine göre, Whipple operasyon sayılarında %10 azalma olması halinde, 5 yıl içinde 848 hastaya benign nedenlerle Whipple operasyonu yapıldığı düşünülmektedir. Sonuç: Benign nedenlerle yapılan Whipple operasyonları geri ödeme kuruluşları açısından kaynak israfına neden olurken, tekrar başvuru oranlarının artmasına, hasta ve sağlık çalışanları açısından iş gücü kaybına ve hasta açısından komplikasyonlara ve hastanın yaşam kalitesinde düşmeye neden olmaktadır. 2019 yılı verilerine göre Türkiye’de yapılan Whipple operasyon sayılarından yola çıkarak EUS tanı yöntemi sayesinde benign pankreas kitlelerinin daha net tanımı yapılarak operasyon olmaksızın yapılan tedavileri ile yıllık 3.248.355,22 ₺ bir tasarruf sağlanabileceği öngörülmektedir.

Anahtar Kelimeler

• Whipple operasyonu
• Endoskopik Ultrasonografi (EUS)
• Pankreas kitleleri
• Fayda-maliyet analizi

Kaynakça

1. McGuigan, A, Kelly, P, Turkington, R.C, et al., World Journal Of Gastroenterology, 2018, 24, 4846-61.
2. Ilic, M, Ilic, I, Epidemiology of pancreatic cancer, World Journal of Gastroenterology, 2016, 22, 9694-705.
3. Yadav, D, Notahara, K, Smyrk, T.C, et al., Idiopathic chronic focal pancreatitis: clinical profile, histology, and natural history after resection, Clinical Gastroenterology and Hepatology, 2003, 1(2), 129-35.
4. Ryan, D.P, Hong, T.S, Bardeesy, N, Pancreatic adenocarcinoma, The New England Journal of Medicine, 2014, 371, 1039-49.
5. Çamlıdağ, İ, Danacı, M, Nadir Pankreatik Tümörler, Türk Radyoloji Seminerleri, 2019, 7, 181-196.
6. Kato, T, Tsukamoto, Y, Naitoh, Y, et al., Ultrasonographic and endoscopic ultrasonographic angiography in pancreatic mass lesions, Acta Radiologica, (Stockholm, Sweden: 1987). 1995, 36(4), 381-387.
7. Modi, B, Shires, G.T, Pancreatic cancer, cystic pancreatic neoplasms, and other nonendocrine pancreatic tumor. In: Feldman M, Friedman L, Brandt L; eds, Sleisenger and Fordtran’s Gastrointestinal and Liver Disease, 11th ed., Chapter 60, Elsevier, Philadelphia, 2020, 947-65.
8. Daniel, D, Von Hoff, Pancreatic Cancer: Harrison’s Principles of Internal Medicine 20th ed., Chapter 79, Mc Graw Hill Education, 2018, 591-96.

9. Manzia, T.M, Toti, L, Lenci, I, et al., Benign Disease and unexpected histological findings after pancreaticoduodenectomy: the role of endoscopic ultrasound fine needle aspiration, Annals of Royal Collage of Surgeons of England, 2010, 92(4), 295-301.
10. Yarandi S, Runge T, Wang L, et al., Increased incidance of benign pancreatic pathology following pancreaticoduodenectomy for presumed malignancy over 10 years despite use of endoscopic ultrasound, Diagnostic and Therapeutic Endoscopy, 2014, 2014, 1-6.
11. Osborne, N.H, Colleti, L.M, Pancreaticoduodenectomy, in Minter, R, Doherty, G.M, Current Procedures Surgery, McGraw-Hill Education, New York, 2010, pp 121-30.
12. Villines, Z, Whipple Procedure: what you need to know, Medical News Today, https://www.medicalnewstoday.com/articles/3184511.php. (accessed 13.03.2019).
13. McMillan, M.T, Vollmer, C.M, Predictive factors for pancreatic fistula following pancreatectomy, Langenbeck’s Archives of Surgery, 2014, 399, 811-24.
14. Harnoss, J.C, Ulrich, A.B, Harnoss, J.M, et al., Use and results of consensus definitions in pancreatic surgery: a systematic review, Surgery, 2014, 155, 47–57.
15. Küçük, H.F, Kaptanoğlu, H, Akyol, L, et al., Whipple uygulanan 25 ardışık hastanın değerlendirilmesi, Kartal Eğitim ve Araştırma Tıp Dergisi, 2005, 16(3), 147-152.
16. Syed, A, Edwards, M, Sutton, J, Factors Influencing Readmission After Pancreaticoduodenectomy: A Multi-Institutional Study of 1302 Patients, Annals of Surgery, 2012, 256(3), 529-37.
17. Castillo, C.F, Oyarvide, V.M, McGrath, D, et al., Evaluation of Whipple Procedure at Massachusetts General Hospital, Journal of Surgery, 2012, 152(3), 56-63.
18. American Cancer Society, Surgery of pancreatic Cancer, https://www.cancer.org/cancer/pancreatic-cancer/treating /surgery.html (accessed 08.08.2020).
19. Kamisawa, T, Egawa, N, Nakajima, H, et al., Clinical difficulties in the differentiation of autoimmune pancreatitis and pancreatic carcinoma, The American Journal of Gastroenterology, 2003, 98(12), 2694-9.
20. Puli, S.R, Bechtold, M.I, Buxbaum, J.l, et al., How good is endoscopic ultrasound-guided fine-needle aspiration in diagnosing the correct etiology for a solid pancreatic mass, A meta-analysis and systemic review, Pancreas, 2013, 42, 20-26.
21. Hewitt, M.J, McPhail, M.J, Possamai, L, et al., EUS-guided FNA for diagnosis of solid pancreatic neoplasms: a meta-analysis, Gastrointestinal Endoscopy, 2012, 75, 319-31.
22. Jin-Ping, L, Yong, Y, Wei, Z, et al., Comparison of endoscopic ultrasound guided fine needle aspiration and Pet/CT in preoperative diagnosis of pancreatic adenocarcinoma, Pancreatology, 2017, (17), 617-622.
23. Şahin, M, Cindoruk, M, Endosonografi yapılan pankreatik kitle lezyonlarının cerrahi ve ince iğne Aspirasyon biyopsi verilerinin patolojik sonuçlar ile analizi: 6 yıllık deneyim, Pamukkale Tıp Dergisi, 2019, 12(1), 1-6.