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Case Reports
. 2006 Dec;20(12):779-85.
doi: 10.1155/2006/307324.

The cost-effectiveness of colonic stenting as a bridge to curative surgery in patients with acute left-sided malignant colonic obstruction: a Canadian perspective

Harminder Singh  1 , Steven Latosinsky, Brennan M R Spiegel, Laura E Targownik
Affiliations
Case Reports

The cost-effectiveness of colonic stenting as a bridge to curative surgery in patients with acute left-sided malignant colonic obstruction: a Canadian perspective

Harminder Singh et al. Can J Gastroenterol. 2006 Dec.

Abstract
in English, French

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 dollars, CS 13,164 dollars, RS 13,820 dollars). The incremental cost-effectiveness ratio associated with the use of CS versus DC is 1,415 dollars to prevent a temporary stoma, 1,516 dollars to prevent an additional operation and 15,734 dollars 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.

HISTORIQUE :: Depuis quelques années, l’endoprothèse colique (EC) est préconisée au lieu de la démarche chirurgicale classique pour soulager une occlusion colique gauche maligne et aiguë. La présente étude vise à déterminer la stratégie la plus rentable au Canada.

PATIENTS ET MÉTHODOLOGIE :: Un modèle analytique décisionnel a été mis au point pour comparer trois stratégies concurrentes : une EC émergente suivie d’une résection chirurgicale (RC) non urgente et d’une réanastomose, une RC émergente suivie de la création d’une colostomie de dérivation (CD) ou d’une réanastomose primaire ou une CD émergente suivie d’une RC non urgente et d’une réanastomose. Les coûts ont été estimés d’après le régime d’assurance-maladie de la province du Manitoba.

RÉSULTATS :: Le recours à l’EC a favorisé un moins grand nombre d’opérations par patient (moyenne d’EC de 1,03, de RC de 1,32 et de CD de 1,9), un taux de mortalité plus faible (EC de 5 %, RC de 11 %, CD de 13 %) et une diminution de la probabilité de stomie permanente (EC de 7 %, RC de 14 %, CD de 14 %). L’EC est légèrement plus coûteuse que la CD, mais moins coûteuse que la RC (CD : 11 851 $, EC : 13 164 $, CD : 13 820 $). Le ratio coût-efficacité incrémentiel associé à l’usage de l’EC plutôt que de la CD est de 1 415 $ pour prévenir une stomie temporaire, de 1 516 $ pour prévenir une opération supplémentaire et de 15 734 $ pour prévenir un décès supplémentaire.

CONCLUSIONS :: Le coût de l’EC pour les patients atteints d’une occlusion colique aiguë secondaire à une tumeur colique pouvant être réséquée est comparable aux options chirurgicales en matière de coût, et cette intervention réduit la probabilité de recourir à une stomie temporaire ou permanente. L’EC devrait être offerte à titre de modalité thérapeutique initiale aux patients canadiens atteints d’un cancer colorectal ayant une occlusion aiguë, en attendant la RC définitive.

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Figures

Figure 1)
Figure 1)
Effect of cost ($CDN) of stent placement on the differential costs among the three strategies: colonic stenting (CS); diverting colostomy (DC) and resective surgery (RS). K One thousand; vs Versus
Figure 2)
Figure 2)
Two-way sensitivity analysis of both hospital length of stay (HLOS) and the cost ($CDN) of stent placement on the total cost of the competing strategies. CS Colonic stenting; DC Diverting colostomy; RS Resective surgery
Figure 3)
Figure 3)
A Effect of rate of successful stent deployment on the variance in the requirement of temporary colostomy with colonic stenting (CS) versus resective surgery (RS). More patients with CS required temporary stomas, when rate of stent deployment fell below 26%. B Effect of rate of successful stent deployment on the variance in the requirement of permanent colostomy. More patients with CS compared with RS or diverting colostomy (DC) required permanent stomas when the rate of stent deployment fell below 26%
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