Abstract
Purpose
This decision analysis examines the cost-effectiveness of colonic stenting as a bridge to surgery vs. surgery alone in the management of emergent, malignant left colonic obstruction.
Methods
We used a Markov chain Monte Carlo decision analysis model to determine the effect on health-related quality of life of two strategies: emergency surgery vs. emergency colonic stenting as a bridge to definitive surgery. All relevant health states were modeled during a patient’s expected lifespan. Outcome measures were mortality, the proportion of patients requiring a colostomy, quality-adjusted life expectancy, and costs. Deterministic and probabilistic sensitivity analyses were performed.
Results
In our model, colonic stenting was more effective (9.2 quality-adjusted life months benefit) and less costly (CAD $3,763; U.S. $3,135) than emergency surgery. Its benefits were secondary to reductions in acute mortality and in the likelihood of requiring a permanent colostomy. The results were only dependent on the rate of stenting complications (perforation, technical placement failure, and migration) and the patient’s risk of surgical mortality, with the benefits being greatest among patients at high risk of operative mortality.
Conclusions
Colonic stenting as a bridge to surgery is more effective and less costly than surgery in the treatment of emergent, malignant left colonic obstruction. The benefits are most pronounced in high-risk patients and are diminished by increases in stent placement failure rates and perforation rates. In low-risk patients, the benefits are more modest and may not outweigh the risks.
Similar content being viewed by others
References
Jemal A, Siegel R, Ward E, et al. Cancer statistics 2006. CA Cancer J Clin 2006;56:106-30.
Dauphine CE, Tan P, Beart RW, Vukasin P, Cohen H, Corman ML. Placement of self-expanding metal stents for acute malignant large-bowel obstruction: a collective review. Ann Surg Oncol 2002;9:574-.
Ness RM, Holmes AM, Klein R, Dittus R. Utility valuations for outcome states of colorectal cancer. Am J Gastroenterol 1999;94:1650-.
Ramsey SD, Andersen MR, Etzioni R, et al. Quality of life in survivors of colorectal carcinoma. Cancer 2000;88:1294-03.
Renner K, Rosen HR, Novi G, Holbling N, Schiessel R. Quality of life after surgery for rectal cancer: do we still need a permanent colostomy? Dis Colon Rectum 1999;42:1160-.
Nugent KP, Daniels P, Stewart B, Patankar R, Johnson CD. Quality of life in stoma patients. Dis Colon Rectum 1999;42:1569-4.
Park JJ, Del Pino A, Orsay CP, et al. Stoma complications: the Cook County Hospital experience. Dis Colon Rectum 1999;42:1575-0.
Gooszen AW, Geelkerken RH, Hermans J, Lagaay MB, Gooszen HG. Quality of life with a temporary stoma: ileostomy vs. colostomy. Dis Colon Rectum 2000;43:650-.
Sprangers MA, Taal BG, Aaronson NK, te Velde A. Quality of life in colorectal cancer: stoma vs. nonstoma patients. Dis Colon Rectum 1995;38:361-.
Dominitz JA, Provenzale D. Patient preferences and quality of life associated with colorectal cancer screening. Am J Gastroenterol 1997;97:2171-.
Tekkis PP, Kinsman R, Thompson MR, Stamatakis JD. The Association of Coloproctology of Great Britain and Ireland study of large bowel obstruction caused by colorectal cancer. Ann Surg 2004;240:76–81.
Martinez-Santos C, Lobato RF, Fradejas JM, Pinto I, Ortega Deballon P, Moreno Azcoita M. Self-expandable stent before elective surgery vs. emergency surgery for the treatment of malignant colorectal obstructions: comparison of primary anastomosis and morbidity rates. Dis Colon Rectum 2002;45:401-.
Chen H-S, Sheen-Chen S-M. Obstruction and perforation in colorectal adenocarcinoma: an analysis of prognosis and current trends. Surgery 2000;127:370-.
Kelley WE Jr, Brown PW, Lawrence W Jr, Terz JJ. Penetrating, obstructing and perforating carcinomas of the colon and rectum. Arch Surg 1981;116:381-.
Leitman IM, Sullivan JD, Brams D, DeCosse JJ. Multivariate analysis of morbidity and mortality from the initial surgical management of obstructing carcinoma of the colon. Surg Gynecol Obstet 1992;174:513-.
Mulcahy HE, Skelly MM, Husain A, O’Donoghue DP. Long-term outcome following curative surgery for malignant large bowel obstruction. Br J Surg 1996;83:46–50.
Smothers L, Hynan L, Fleming J, Turnage R, Simmang C, Anthony T. Emergency surgery for colon carcinoma. Dis Colon Rectum 2003;46:24–30.
Al-Homoud S, Purkayastha S, Aziz O, et al. Evaluating operative risk in colorectal cancer surgery: ASA and POSSUM-based predictive models. Surg Oncol 2004;13:83–92.
Poon JT, Chan B, Law WL. Evaluation of P-POSSUM in surgery for obstructing colorectal cancer and correlation of the predicted mortality with different surgical options. Dis Colon Rectum 2005;48:493-.
Biondo S, Pares D, Frago R, et al. Large bowel obstruction: predictive factors for postoperative mortality. Dis Colon Rectum 2004;47:1889-7.
Sebastian S, Johnston S, Geoghegan T, Torreggiani W, Buckley M. Pooled analysis of the efficacy and safety of self-expanding metal stenting in malignant colorectal obstruction. Am J Gastroenterol 2004;99:2051-.
Law WL, Choi HK, Lee YM, Chu KW. Palliation for advanced malignant colorectal obstruction by self-expanding metallic stents: prospective evaluation of outcomes. Dis Colon Rectum 2004;47:39–43.
Meisner S, Hensler M, Knop FK, West F, Wille-Jorgensen P. Self-expanding metal stents for colonic obstruction: experiences from 104 procedures in a single center. Dis Colon Rectum 2004;47:444-0.
Xinopoulos D, Dimitroulopoulos D, Theodosopoulos T, et al. Stenting or stoma creation for patients with inoperable malignant colonic obstructions? Results of a study and cost-effectiveness analysis. Surg Endosc 2004;18:421-.
Gatto NM, Frucht H, Sundararajan V, Jacobson JS, Grann VR, Neugut AI. Risk of perforation after colonoscopy and sigmoidoscopy: a population-based study. J Natl Cancer Inst 2003;95:230-.
McArdle CS, McMillan DC, Hole DJ. The impact of blood loss, obstruction and perforation on survival in patients undergoing curative resection for colon cancer. Br J Surg 2006;93:483-.
Porter GA, O’Keefe GE, Yakimets WW. Inadvertent perforation of the rectum during abdominoperineal resection. Am J Surg 1996;172:324-.
Slanetz CA Jr. The effect of inadvertent intraoperative perforation on survival and recurrence in colorectal cancer. Dis Colon Rectum 1984;27:792-.
Birkmeyer JD, Birkmeyer NO. Decision analysis in surgery. Surgery 1996;120:7–15.
Rabeneck L, Paszat LF, Rothwell DM, He J. Temporal trends in new diagnoses of colorectal cancer with obstruction, perforation, or emergency admission in Ontario: 1993-001. Am J Gastroenterol 2005;100:672-.
Ng KC, Law WL, Lee YM, Choi HK, Seto CL, Ho JW. Self-expanding metallic stent as a bridge to surgery versus emergency resection for obstructing left-sided colorectal cancer: a case-matched study. J Gastrointest Surg 2006;10:798–803.
Saida Y, Sumiyama Y, Nagao J, Uramatsu M. Long-term prognosis of preoperative “bridge to surgery-expandable metallic stent insertion for obstructive colorectal cancer: comparison with emergency operation. Dis Colon Rectum 2003;46(Suppl):S44-.
Rudinskaite G, Tamelis A, Saladzinskas Z, Pavalkis D. Risk factors for clinical anastomotic leakage following the resection of sigmoid and rectal cancer. Medicina (Kaunas) 2005;41:741-.
Bowne WB, Lee B, Wong WD, et al. Operative salvage for locoregional recurrent colon cancer after curative resection: an analysis of 100 cases. Dis Colon Rectum 2005;48:897–909.
Koruth NM, Krukowski ZH, Youngson GG, et al. Intra-operative colonic irrigation in the management of left-sided large bowel emergencies. Br J Surg 1985;72:708-1.
Tan SG, Nambiar R, Rauff A, Ngoi SS, Goh HS. Primary resection and anastomosis in obstructed descending colon due to cancer. Arch Surg 1991;126:748-1.
Biondo S, Pares D, Kreisler E, et al. Anastomotic dehiscence after resection and primary anastomosis in left-sided colonic emergencies. Dis Colon Rectum 2005;48:2272-0.
Branagan G, Finnis D. Prognosis after anastomotic leakage in colorectal surgery. Dis Colon Rectum 2005;48:1021-.
Walker KG, Bell SW, Rickard MJ, et al. Anastomotic leakage is predictive of diminished survival after potentially curative resection for colorectal cancer. Ann Surg 2004;240:255-.
Patriti A, Contine A, Carbone E, Gulla N, Donini A. One-stage resection without colonic lavage in emergency surgery of the left colon. Colorectal Dis 2005;7:332-.
Konishi T, Watanabe T, Kishimoto J, Nagawa H. Risk factors for anastomotic leakage after surgery for colorectal cancer: results of prospective surveillance. J Am Coll Surg 2006;202:439-4.
Tang R, Chen HH, Wang YL, et al. Risk factors for surgical site infection after elective resection of the colon and rectum: a single-centre prospective study of 2809 consecutive patients. Ann Surg 2001;234:181-.
Pokorny H, Herkner H, Jakesz R, Herbst F. Mortality and complications after stoma closure. Arch Surg 2005;140:956-0.
Sutton CD, Marshall LJ, Williams N, Berry DP, Thomas WM, Kelly MJ. Colorectal anastomotic leakage often masquerades as a cardiac complication. Colorectal Dis 2003;6:21-.
Maggard MA, Zingmond D, O’Connell JB, Ko CY. What proportion of patients with an ostomy (for diverticulitis) get reversed? Am Surg 2004;70:928-1.
Dixon AR, Holmes JT. Hartmann’s procedure for carcinoma of rectum and distal sigmoid colon: 5-year audit. J R Coll Surg Edinb 1990;35:166-.
Desai DC, Brennan EJ, Reilly JF, Smink RD. The utility of the Hartmann procedure. Am J Surg 1998;175:152-.
Keck JO, Collopy BT, Ryan PJ, Fink R, Mackay JR, Woods RJ. Reversal of Hartmann’s procedure: effect of timing and technique on ease and safety. Dis Colon Rectum 1994;37:243-.
Banerjee S, Leather AJ, Rennie JA, Samano N, Gonzalez JG, Papagrigoriadis S. Feasibility and morbidity of reversal of Hartmann’s. Colorectal Dis 2005;7:454-.
Tepper JE, O’Connell M, Hollis D, Niedzwiecki D, Cooke E, Mayer RJ. Analysis of surgical salvage after failure of primary therapy in rectal cancer: results from Intergroup Study 0114. J Clin Oncol 2003;21:3623-.
Goldberg RM, Fleming TR, Tangen CM, et al. Surgery for recurrent colon cancer: strategies for identifying resectable recurrence and success rates after resection. Ann Intern Med 1998;129:27–35.
Freund HR, Raniel J, Sulam MM. Factors affecting the morbidity of colostomy closure: a retrospective study. Dis Colon Rectum 1982;25:712-.
Gamjobst W, Leaverton GH, Sullivan ES. Safety of colostomy closure. Am J Surg 1978;136:85-.
Knox AJ, Birkett FD, Collins CD. Closure of colostomy. Br J Surg 1971;58:669-2.
Parks SE, Hastings PR. Complications of colostomy closure. Am J Surg 1985;149:672-.
Pittman DM, Smith LE. Complications of colostomy closure. Dis Colon Rectum 1985;28:836-3.
Riesener KP, Lehnen W, Hofer M, Kasperk R, Braun JC, Schumpelick V. Morbidity of ileostomy and colostomy closure: impact of surgical technique and perioperative treatment. World J Surg 1997;21:103-.
Rosen L, Friedman IH. Morbidity and mortality following intra–peritoneal closure of transverse loop colostomy. Dis Colon Rectum 1980;23:508-2.
Salley RK, Bucher RM, Rodning CB. Colostomy closure: morbidity reduction employing a semi–standardized protocol. Dis Colon Rectum 1983;26:319-2.
Read TE, Mutch MG, Chang BW, et al. Locoregional recurrence and survival after curative resection of adenocarcinoma of the colon. J Am Coll Surg 2002;195:33–40.
Sonnenberg FA, Beck JR. Markov models in medical decision making: a practical guide. Med Decis Making 1993;13:322-8.
Verdecchia A, De Angelis R, Capocaccia R, et al. The cure for colon cancer: results from the EUROCARE study. Int J Cancer 1998;77:322-.
Lee ET, Go OT. Survival analysis in public health research. Annu Rev Public Health 1997;18:105-4.
Surveillance, Epidemiology and End Results (SEER) program Public-Use Data (1973-002). National Cancer Institute, DCCPS, Surveillance Research Program, Cancer Statistics Branch, released April 2005, based on the November 2004 submission. Available at: http://www.seer.cancer.gov. Accessed May 2006.
Miller AR, Cantor SB, Peoples GE, Pearlstone DB, Skibber JM. Quality of life and cost-effectiveness analysis of therapy for locally recurrent rectal cancer. Dis Colon Rectum 2000;43:1695-01.
Taylor WE, Donohue JH, Gunderson LL, et al. The Mayo Clinic experience with multimodality treatment of locally advanced or recurrent colon cancer. Ann Surg Oncol 2002;9:177-5.
Schedule of benefits: Physician Services. Available at: http://www.health.gov.on.ca/english/providers/program/ohip/sob/physserv/physserv_mn.html. Accessed June 26, 2006.
Maroun J, Ng E, Berthelot J-M, et al. Lifetime costs of colon and rectal cancer management in Canada. Chronic Dis Can 2003;24:91–101.
Ontario Case Costing Project. Available at: http://www.occp.ocm. Accessed November 2005.
Guidelines for the economic evaluation of health technologies: Canada (3rd edition): Ottawa:Canadian Agency for Drugs and Technologies in Health; 2006 (Available at: http://www.cadth.ca/media/pdf/186_EconomicGuidelines_e.pdf).
Gold MR, Siegel JE, Russell LB, Weinstein MC. Cost-effectiveness in health and medicine. New York: Oxford University Press, 1996.
Claxton K, Sculpher M, McCabe C, et al. Probabilistic sensitivity analysis for NICE technology assessment: not an optional extra. Health Econ 2005;14:339-7.
Ades AE, Claxton K, Sculpher M. Evidence synthesis, parameter correlation and probabilistic sensitivity analysis. Health Econ 2006;15:373-1.
Laupacis A, Feeny D, Detsky AS, Tugwell PX. How attractive does a new technology have to be to warrant adoption and utilization? Tentative guidelines for using clinical and economic evaluations. CMAJ 1992;146:473-1.
Richardson WS, Detsky AS. Users-Guides to the Medical Literature: VII. How to use a clinical decision analysis: B. What are the results and will they help me in caring for my patients? JAMA 1995;273:1610-.
Wright JC, Weinstein MC. Gains in life expectancy from medical interventions - standardizing data on outcomes. N Engl J Med 1998;339:380-.
Targownik LE, Spiegel BM, Sack J, et al. Colonic stent vs. emergency surgery for management of acute left-sided malignant colonic obstruction: a decision analysis. Gastrointest Endosc 2004;60:865-4.
Osman HS, Rashid HI, Sathananthan N, Parker MC. The cost-effectiveness of self expanding metal stents in the management of malignant left-sided large bowel obstruction. Colorectal Dis 2000;2:233-.
Author information
Authors and Affiliations
Corresponding author
Additional information
Dr. Govindarajan receives salary support from the National Cancer Institute of Canada Clinical Research Fellowship. Dr. Law receives salary support as a Career Scientist from the Ontario Ministry of Health and Long-term Care. Neither of these organizations was involved in any aspect of this study.
Read at the meeting of The American Society of Colon and Rectal Surgeons, Seattle, Washington, June 3 to 7, 2006.
About this article
Cite this article
Govindarajan, A., Naimark, D., Coburn, N.G. et al. Use of Colonic Stents in Emergent Malignant Left Colonic Obstruction: A Markov Chain Monte Carlo Decision Analysis. Dis Colon Rectum 50, 1811–1824 (2007). https://doi.org/10.1007/s10350-007-9047-9
Received:
Revised:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s10350-007-9047-9