The Cost Effectiveness of Colonic Stenting As a Bridge to Curative Surgery in Patients with Acute Left-Sided Malignant Colonic Obstruction: A Canadian Perspective

Abstract

Acute colonic obstruction will develop in up to one-third of patients with colon cancer. Traditionally, patients with acute colonic obstruction require emergency surgery for creation of a diverting colostomy, followed by surgical resection of the tumour if there is no evidence of metastatic disease. Over the last several years, colonic stents has also been proven to be efficacious for relieving malignant obstruction in both the palliative setting and as a bridge to surgical resection. The aim of this study was to determine the most cost-effective strategy for patients with acute malignant left-sided colonic obstruction in a Canadian setting. Methods: We developed a decision analytical model to calculate the cost-effectiveness of three competing strategies: 1) emergent colonic stenting (CS) followed by elective surgical resection and reanastomosis, 2) emergent resective surgery (RS) followed by creation of either a diverting colostomy or primary reanastomosis, 3) emergent diverting colostomy (DC) followed by elective surgical resection and reanastomosis. The costs were estimated from the perspective of Manitoba's provincial health plan. Clinical outcomes evaluated included the proportion of patients requiring a permanent or temporary stoma, the total number of operations required by a patient, and overall mortality. Results: The use of CS results in fewer total operative procedures per patient (mean operations 1.03 vs. 1.32 with RS and 1.9 with DC), a lower mortality rate (5% vs. 11% with RS and 13% with DC) and a lower likelihood of requiring a permanent stoma (7% vs. 14% with RS as well as DC). CS is slightly more expensive than DC, but less costly than RS (11,851 with DC vs. $13,164 for CS vs. $13,820 with RS). The incremental cost effectiveness ratio (ICER) associated with the use of CS vs. DC is $1,415 to prevent a temporary stoma, $1,516 to prevent an additional operation, and $15,734 to prevent an additional death. Conclusions: Colonic stenting for patients with acute colonic obstruction secondary to a resectable colonic tumor is comparable in cost to surgical options and reduces the likelihood of requiring both temporary and permanent stomas, and may also be associted with lower procedure related mortality. Colonic stenting should be offered as the initial therapeutic modality for Canadian colorectal cancer patients presenting with acute obstruction as a bridge to definitive surgical resection. Tabled 1 Cost per patient (\$CDN) Mean Operations per patient % requiring temp. stoma % requiring permanent stoma % mortality Emergency Colonic Stenting (CS) 13,164 1.03 7 2 5 Emergency Resective Surgery (RS) 13,820 1.32 44 14 11 Emergency Diverting Colostomy (DC) 11,851 1.90 100 14 13 Open table in a new tab