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

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.

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Authors and Affiliations

Authors

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.

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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.

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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

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

Keywords

  • Cost-effectiveness
  • Colon cancer
  • Colonic obstruction
  • Palliative surgery
  • Stents