Use of Colonic Stents in Emergent Malignant Left Colonic Obstruction: A Markov Chain Monte Carlo Decision Analysis

Abstract

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. 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. In our model, colonic stenting was more effective (9.2 quality-adjusted life months benefit) and less costly (CAD dollars 3,763; US dollars 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. 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.