Skip to main content

Advertisement

SpringerLink
Log in

Cost-effectiveness of palliative emergent surgery versus endoscopic stenting for acute malignant colonic obstruction

  • Published:
Surgical Endoscopy Aims and scope Submit manuscript

Abstract

Background

Endoscopic stenting has demonstrated value over emergent surgery as a palliative intervention for patients with acute large bowel obstruction due to advanced colorectal cancer. However, concerns regarding high reintervention rates and the risk of perforation have brought into question its cost-effectiveness.

Methods

A decision tree analysis was performed to analyze costs and survival in patients with unresectable or metastatic colorectal cancer who present with acute large bowel obstruction. The model was designed with two treatment arms: self-expanding metallic stent (SEMS) placement and emergent surgery. Costs were derived from medicare reimbursement rates (US$), while effectiveness was represented by quality-adjusted life years (QALYs). The primary outcome measure was the incremental cost-effectiveness ratio (ICER). The model was tested for validation using one-way, two-way, and probabilistic sensitivity analyses.

Results

Endoscopic stenting resulted in an average cost of $43,798.06 and 0.68 QALYs. Emergent surgery cost $5865.30 more, while only yielding 0.58 QALYs. This resulted in an ICER of − $58,653.00, indicating that SEMS placement is the dominant strategy. One-way and two-way sensitivity analyses demonstrated that emergent surgery would require an improved survival rate in comparison to endoscopic stenting to become the favored treatment modality. In 100,000 probabilistic simulations, endoscopic stenting was favored 96.3% of the time.

Conclusions

In patients with acute colonic obstruction in the presence of unresectable or metastatic disease, endoscopic stenting is a more cost-effective palliative intervention than emergent surgery. This recommendation would favor surgery over SEMS placement with improved surgical survival, or if the majority of patients undergoing stenting required reintervention.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3

Similar content being viewed by others

References

  1. American Cancer Society (2019) Cancer facts & figures 2019. American Cancer Society, Atlanta

    Google Scholar 

  2. Siegel RL, Miller KD, Jemal A (2019) Cancer statistics, 2019. CA Cancer J Clin 69(1):7–34

    Article  Google Scholar 

  3. Takahashi H, Okabayashi K, Tsuruta M, Hasegawa H, Yahagi M et al (2015) Self-expanding metallic stents versus surgical intervention as palliative therapy for obstructive colorectal cancer: a meta-analysis. World J Surg 39(8):2037–2044

    Article  Google Scholar 

  4. Frago R, Ramirez E, Millan M, Kreisler E, del Valle E et al (2014) Current Management of Acute Malignant Large Bowel Obstruction: A Systematic Review. Am J Surg 207(1):127–138

    Article  Google Scholar 

  5. Biondo S, Pares D, Frago R, Marti-Rague J, Kreisler E et al (2004) Large bowel obstruction: predictive factors for postoperative mortality. Dis Colon Rectum 47(11):1889–1897

    Article  Google Scholar 

  6. Tuca A, Guell E, Martinez-Losada E, Codorniu N (2012) Malignant bowel obstruction in advanced cancer patients: epidemiology, management, and factors influencing spontaneous resolution. Cancer Manag Res 4:159–169

    Article  Google Scholar 

  7. Baer C, Menon R, Bastawrous S, Bastawrous A (2017) Emergency presentations of colorectal cancer. Surg Clin North Am 97(3):529–545

    Article  Google Scholar 

  8. Kim EJ, Kim YJ (2016) Stents for colorectal obstruction: past, present, and future. World J Gastroenterol 22(2):842–852

    Article  CAS  Google Scholar 

  9. Van Hooft JE, van Halsema EE, Vanbiervliet G, Beets-Tan RG, DeWitt JM et al (2014) Self-expandable metal stents for obstructing colonic and extracolonic cancer: European Society of Gastrointestinal Endoscopy (ESGE) clinical guideline. Endoscopy 46(11):990–1053

    Article  Google Scholar 

  10. Huang X, Lv V, Zhang S, Meng L (2014) Preoperative colonic stents versus emergency surgery for acute left-sided malignant colonic obstruction: a meta-analysis. J Gastrointest Surg 18(3):584–591

    Article  Google Scholar 

  11. Sagar J (2011) Colorectal stents for the management of malignant colonic obstructions. Cochrane Database Syst Rev 11:CD007378

    Google Scholar 

  12. Thornton JG, Lilford RJ, Johnson N (1992) Decision analysis in medicine. BMJ 304(7023):1099–1103

    Article  CAS  Google Scholar 

  13. Young CJ, De-Loyde KJ, Young JM, Solomon MJ, Chew EH et al (2015) Improving quality of life for people with incurable large-bowel obstruction: randomized control trial of colonic stent insertion. Dis Colon Rectum 58(9):838–849

    Article  Google Scholar 

  14. Kobborg M, Broholm M, Frostberg E, Jeppesen M, Gogenur I (2017) Short-term results of self-expanding metal stents for acute malignant large bowel obstruction. Colorectal Dis 19(10):O365–O371

    Article  CAS  Google Scholar 

  15. Ahn HJ, Kim SW, Lee SW, Lee SW, Lim CH et al (2016) Long-term outcomes of palliation for unresectable colorectal cancer obstruction in patients with good performance status: endoscopic stent versus surgery. Surg Endosc 30(11):4765–4775

    Article  Google Scholar 

  16. Siddiqui A, Cosgrove N, Yan LH, Brandt D, Janowski R et al (2017) Long-term outcomes of palliative colonic stenting versus emergency surgery for acute proximal malignant colonic obstruction: a multicenter trial. Endosc Int Open 5(4):E232–E238

    Article  Google Scholar 

  17. Ceze N, Charachon A, Locher C, Aparicio T, Mitry E et al (2016) Safety and efficacy in advanced colorectal cancer: a of palliative systemic chemotherapy combined with colorectal self-expandable metallic stents multicenter study. Clin Res Hepatol Gastroenterol 40(2):230–238

    Article  CAS  Google Scholar 

  18. Beck JR, Pauker SG, Gottlieb JE, Klein K, Kassirer JP (1982) A convenient approximation of life expectancy (The “DEALE”). II. Use in medical decision making. Am J Med 73(6):889–897

    Article  CAS  Google Scholar 

  19. Lee JY, Ock M, Jo MW, Son WS, Lee HJ et al (2017) Estimating utility weights and quality-adjusted life year loss for colorectal cancer-related health states in Korea. Sci Rep 7(1):5571

    Article  Google Scholar 

  20. Riberio IB, Bernardo WM, Martins BDC, de Moura DTH, Baba ER et al (2018) Colonic stent versus emergency surgery as treatment of malignant colonic obstruction in the palliative setting: a systematic review and meta-analysis. Endosc Int Open 6(5):E558–E567

    Article  Google Scholar 

  21. Neumann PJ, Cohen JT, Weinstein MC (2014) Updating cost-effectiveness: the curious resilience of the $50,000-per-QALY threshold. N Engl J Med 371(9):796–797

    Article  CAS  Google Scholar 

  22. Fiori E, Lamazza A, Schillaci A, Femia S, Demasi E et al (2012) Palliative management for patients with subacute obstruction and stage IV unresectable rectosigmoid cancer: colostomy versus endoscopic stenting: final results of a prospective randomized trial. Am J Surg 204(3):321–326

    Article  Google Scholar 

  23. Riberio IB, de Moura DTH, Thompson CC, de Moura EGH (2019) Acute abdominal obstruction: colon stent or emergency surgery? An evidence-based review. World J Gastrointest Endosc 11(3):193–208

    Article  Google Scholar 

  24. Van Hooft JE, Fockens P, Marinelli AW, Timmer R, van Berkel AM et al (2008) Early closure of a multicenter randomized clinical trial of endoscopic stenting versus surgery for stage IV left-sided colorectal cancer. Endoscopy 40(3):184–191

    Article  Google Scholar 

  25. Targownik LE, Spiegel BM, Sack J, Hines OJ, Dulai GS et al (2014) Colonic stent vs emergency surgery for management of acute left-sided malignant colonic obstruction: a decision analysis. Gastrointest Endosc 60(6):865–874

    Article  Google Scholar 

  26. Singh H, Latosinsky S, Spiegel BM, Targownik LE (2006) 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 20(12):779–785

    Article  CAS  Google Scholar 

  27. Xinopoulos D, Dimitroulopoulos D, Theodosopoulos T, Tsamakidis K, Bitsakou G et al (2004) Stenting or stoma creation for patients with inoperable malignant colonic obstructions? Results of a study and cost-effectiveness analysis. Surg Endosc 18(3):421–426

    Article  CAS  Google Scholar 

  28. Young CJ, Zahid A (2018) Randomized controlled trial of colonic stent insertion in non-curable large bowel obstruction: a post hoc cost analysis. Colorectal Dis 20(4):288–295

    Article  CAS  Google Scholar 

  29. Yoon JY, Jung YS, Hong SP, Kim TI, Kim WH et al (2011) Outcomes of secondary stent-in-stent self-expandable metal stent insertion for malignant colorectal obstruction. Gastrointest Endosc 74(3):625–633

    Article  Google Scholar 

  30. Yoon JY, Park SJ, Hong SP, Kim TI, Kim WH et al (2013) Outcomes of Secondary Self-Expandable Metal Stents Versus Surgery After Delayed Initial Palliative Stent Failure in Malignant Colorectal Obstruction. Digestion 88(1):46–55

    Article  Google Scholar 

  31. Clarke L, Abbott H, Sharma P, Eglinton TW, Frizelle FA (2018) Impact of restenting for recurrent colonic obstruction due to tumour ingrowth. BJS Open 1(6):202–206

    Article  Google Scholar 

  32. Moroi R, Endo K, Ichikawa R, Nagai H, Shinkai H et al (2014) The effectiveness of self-expandable metallic stent insertion in treating right-sided colonic obstruction: a comparison between SEMS and decompression tube placement and an investigation of the safety and difficulties of sems insertion in right colons. Gastroenterol Res Pract 2014:372918

    Article  Google Scholar 

  33. Ji WB, Kwak JM, Kang HD, Um JW, Lee SI et al (2017) Clinical benefits and oncologic equivalence of self-expandable metallic stent insertion for right-sided malignant colonic obstruction. Surg Endosc 31(1):153–158

    Article  Google Scholar 

  34. Van Halsema EE, van Hooft JE, Small AJ, Baron TH, Garcia-Cano J et al (2014) Perforation in colorectal stenting: A meta-analysis and a search for risk factors. Gastrointest Endosc 79(6):970–982

    Article  Google Scholar 

  35. Small AJ, Coelho-Prabhu N, Baron TH (2010) Endoscopic placement of self-expandable metal stents for malignant colonic obstruction: long-term outcomes and complication factors. Gastrointest Endosc 71(3):560–572

    Article  Google Scholar 

  36. Lee JH, Emelogu I, Kukreja K, Ali FS, Nogueras-Gonzalez G et al (2019) Safety and efficacy of metal stents for malignant colonic obstruction in patients treated with bevacizumab. Gastrointest Endosc 90(1):116–124

    Article  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Division of Surgical Oncology, Department of Surgery, Rutgers New Jersey Medical School, Newark, NJ, USA

    Patrick L. Quinn, Simran Arjani & Ravi J. Chokshi

  2. Division of Gastroenterology and Hepatology, Department of Medicine, Rutgers New Jersey Medical School, Newark, NJ, USA

    Sushil K. Ahlawat

  3. Division of Surgical Oncology, Department of Surgery, Rutgers New Jersey Medical School, 205 South Orange Ave, F1222, Newark, NJ, 07103, USA

    Ravi J. Chokshi

Authors
  1. Patrick L. Quinn
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Simran Arjani
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Sushil K. Ahlawat
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Ravi J. Chokshi
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

All authors contributed to the conception and design, acquisition of data, analysis, and interpretation of data, editing, and final approval. PLQ and SA contributed to the drafting of the article. The revision of the article was performed by SKA and RJC.

Corresponding author

Correspondence to Ravi J. Chokshi.

Ethics declarations

Disclosures

Patrick L. Quinn, Simran Arjani, Dr. Sushil K Ahlawat, and Dr. Ravi J. Chokshi have no conflicts of interest or financial ties to disclose.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Quinn, P.L., Arjani, S., Ahlawat, S.K. et al. Cost-effectiveness of palliative emergent surgery versus endoscopic stenting for acute malignant colonic obstruction. Surg Endosc 35, 2240–2247 (2021). https://doi.org/10.1007/s00464-020-07637-x

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00464-020-07637-x

Keywords

Search

Navigation