The Cost-Effectiveness of Colonic Stenting as a Bridge to Curative Surgery in Patients with Acute Left-Sided Malignant Colonic Obstruction: A Canadian Perspective

Abstract

The cost-effectiveness of colonic stenting as a bridge to curative surgery in patients with acute left-sided malignant colonic obstruction: A Canadian perspective. Can J Gastroenterol 2006;20(12):779-785.BACKGROUND: Over the past several years, colonic stenting has been advocated as an alternative to the traditional surgical approach for relieving acute malignant left-sided colonic obstruction. The aim of the present study was to determine the most cost-effective strategy in a Canadian setting. PATIENTS AND METHODS: A decision analytical model was developed to compare three competing strategies: CS -emergent colonic stenting followed by elective resective surgery and reanastomosis; RS -emergent resective surgery followed by creation of either a diverting colostomy or primary reanastomosis; and DC -emergent diverting colostomy followed by elective resective surgery and reanastomosis. The costs were estimated from the perspective of the Manitoba provincial health plan. RESULTS: The use of CS resulted in fewer total operative procedures per patient (mean CS 1.03, RS 1.32, DC 1.9), lower mortality rate (CS 5%, RS 11%, DC 13%) and lower likelihood of requiring a permanent stoma (CS 7%, RS 14%, DC 14%). CS is slightly more expensive than DC, but less costly than RS (DC $11,851, CS $13,164, RS $13,820). The incremental cost-effectiveness ratio associated with the use of CS versus DC is $1,415 to prevent a temporary stoma, $1,516 to prevent an additional operation and $15,734 to prevent an additional death. CONCLUSIONS: Colonic stenting for patients with acute colonic obstruction secondary to a resectable colonic tumour is comparable in cost with surgical options, and reduces the likelihood of requiring both temporary and permanent stomas. Colonic stenting should be offered as the initial therapeutic modality for Canadian colorectal cancer patients presenting with acute obstruction as a bridge to definitive RS.

A meta-analysis of the use of a transanal drainage tube to prevent anastomotic leakage after anterior resection by double-stapling technique for rectal cancer

“…However, hospital stay was longer in patients with diverting stoma than in patients with no stoma, because they needed some time to learn how to handle the stoma appliance [14]. Moreover, diverting stoma also increases patient discomfort, overall cost, and the duration of hospitalization since the patient will need a second operation for closure of the stoma [17,18]. Phatak et al [19] reported that diverting ileostomies are associated with a significant risk for ileostomy-related morbidity including dehydration and perioperative complications of stoma closure.…”

Colonic acute malignant obstructions: effectiveness of self-expanding metallic stent as bridge to surgery

“…In our study, the recanalization rate, although with a small sample size and with no statistical significance, was higher in BG compared to SG, probably due to resolution of occlusions and an improvement in global clinical and nutritional assessment. SEMS insertion and a delay in surgical intervention appears to reduce the mean time of hospital stay, to 13.5±3 days, compared to 16.1±7.7 days in SG, as described in the literature (17)(18)(19)(20), and this leads to significant cost-saving. We explain the reduction in the length of hospital stay by a lower rate of early complications between the two procedures (stenting and surgery) ( Table 5) and by a lower rate of early complication between urgent surgery and delayed surgery (Table 6), although this latter data was not statistically significant.…”

Primary colon resection or Hartmann's procedure in malignant left-sided large bowel obstruction? The use of stents as a bridge to surgery

“…A Canadian study based on a decision analytical model even suggested that the use of colonic stenting for patients with acute malignant colonic obstruction is less expensive than emergency resective surgery [20] . Whether this is so, in fact, cannot be confirmed and should be prospectively proven by true comparative studies.…”