Colonic stent vs. emergency surgery for management of acute left-sided malignant colonic obstruction: a decision analysis

Gastrointest Endosc. 2004 Dec;60(6):865-74. doi: 10.1016/s0016-5107(04)02225-4.

Abstract

Background: Acute colonic obstruction because of malignancy is often a surgical emergency. Surgical decompression with colostomy with or without resection and eventual re-anastomosis is the traditional treatment of choice. Endoscopic colonic stent insertion effectively decompresses the obstructed colon, allowing for surgery to be performed electively. This study sought to determine the cost-effectiveness of colonic stent vs. surgery for emergent management of acute malignant colonic obstruction.

Methods: Decision analysis was used to calculate the cost-effectiveness of two competing strategies in a hypothetical patient presenting with acute, complete, malignant colonic obstruction: (1) emergent colonic stent followed by elective surgical resection and re-anastomosis; (2) emergent surgical resection followed by diversion (Hartmann's procedure) or primary anastomosis. Cost estimates were obtained from a third-party payer perspective. Primary outcome measures were mortality, stoma requirement, and total number of operative procedures.

Results: Colonic stent resulted in 23% fewer operative procedures per patient (1.01 vs. 1.32 operations per patient), an 83% reduction in stoma requirement (7% vs. 43%), and lower procedure-related mortality (5% vs. 11%). Colonic stent was associated with a lower mean cost per patient ($45,709 vs. $49,941).

Conclusions: Colonic stent insertion followed by elective surgery appears more effective and less costly than emergency surgery under base-case conditions. This finding remains robust over a wide range of assumptions for clinical inputs in sensitivity analysis. Our findings suggest that colonic stent insertion should be offered, whenever feasible, as a bridge to elective surgery in patients presenting with malignant colonic obstruction.

Publication types

  • Comparative Study
  • Research Support, Non-U.S. Gov't
  • Research Support, U.S. Gov't, Non-P.H.S.
  • Research Support, U.S. Gov't, P.H.S.

MeSH terms

  • Acute Disease
  • Aged
  • Colectomy / economics*
  • Colonic Diseases / economics
  • Colonic Diseases / mortality
  • Colonic Diseases / therapy*
  • Colonic Neoplasms / complications*
  • Colonic Neoplasms / economics
  • Colonic Neoplasms / mortality
  • Colonic Neoplasms / therapy
  • Colostomy / economics*
  • Combined Modality Therapy
  • Cost-Benefit Analysis / statistics & numerical data
  • Decision Support Techniques*
  • Elective Surgical Procedures / economics
  • Emergencies / economics*
  • Humans
  • Intestinal Obstruction / economics
  • Intestinal Obstruction / mortality
  • Intestinal Obstruction / therapy*
  • Male
  • Mathematical Computing
  • Reoperation / economics
  • Software
  • Stents / economics*
  • Survival Rate