Expected Patient Survival Research Articles

Short-term outcomes of posterior surgery for thoracolumbar spinal metastasis

Purpose The purpose of the work is to evaluate the postoperative quality of life, neurological condition, and ambulatory status of patients with spinal metastases treated surgically during the first year after surgery in countries with limited resources. Methods This was a prospective case series study. All patients with spinal metastasis and indicated for surgery, presented to our facility from 2020 to 2021 were included in the study. Clinical evaluation includes visual analog score (VAS) for back pain, the Frankel grading system for neurological assessment, the Tokuhashi severity and survival score for predicting the expected patient survival period, and the 5Q-ED score for assessment of quality of life. Results This study included 30 patients with thoracolumbar spine metastasis who underwent surgery, 21 males and 9 females in the age range of between 18 and 72 years with a median value of 49.17 ± 13.272 years. Five patients died within 6 months postoperatively due to advanced malignancy, while the remaining 25 patients were followed-up for at least 1 year. Conclusion Surgical treatment for metastatic spinal tumor can improve quality of life in a substantially high percentage of patients with acceptable complication rates in a limited resource setting. Spinal surgery for metastatic cancer significantly reduces pain and is effective in preserving neurological function over short-term follow-up with acceptably low morbidity. The Tokuhashi score (especially primary site of malignancy) had a significant effect on overall survival.

Defining the ethical considerations surrounding kidney transplantation for frail and cognitively impaired patients: a Delphi study of geriatric transplant experts

BackgroundAmong adult kidney transplant (KT) candidates, 21% are frail and 55% have cognitive impairment, increasing the risk of pre- and post-KT mortality. Centers often assess frailty status and cognitive function during transplant evaluation to help identify appropriate candidate. Yet, there are no ethical guidelines regarding the use of frailty and cognitive function during this evaluation. We seek to develop a clinical consensus on balancing utility and justice in access to KT for frail and cognitively impaired patients.MethodsTwenty-seven experts caring for ESRD patients completed a two-round Delphi panel designed to facilitate consensus (> 80% agreement).ResultsExperts believed that denying patients transplantation based solely on expected patient survival was inequitable to frail or cognitively impaired candidates; 100% agreed that frailty and cognitive impairment are important factors to consider during KT evaluation. There was consensus that health related quality of life and social support are important to consider before waitlisting frail or cognitively impaired patients. Experts identified important factors to consider before waitlisting frail (likely to benefit from KT, frailty reversibility, age, and medical contraindications) and cognitively impaired (degree of impairment and medication adherence) patients.ConclusionsClinical experts believed it was ethically unacceptable to allocate organs solely based on patients’ expected survival; frailty and cognitive impairment should be measured at evaluation when weighed against other clinical factors. Ethical guidelines regarding the use of frailty and cognitive function during KT evaluation ought to be developed.

Cemented long versus standard femoral stem in proximal femoral metastasis: a noninferiority single-blinded quasi-randomized clinical trial

Background and purposeProximal femur is a common site for metastasis, it has a significant impact on patient’s quality of life, and traditional treatment aims at protecting as much as possible from the femur. However, recent studies have demonstrated increased rate of complications and questioned the need for long stem in this high-risk group. Our purpose is to determine whether standard-length femoral stem is noninferior to long femoral stem in the treatment of proximal femoral metastasis.Patients and methodsBetween 2019 and 2021, we prospectively included 24 patients with proximal femoral metastasis leading either to impending or pathological fractures (5 and 19 cases, respectively). We included patients with lesions due to metastasis, lymphoma, or multiple myeloma. Patients were quasi-randomized based on their order of presentation into two groups based on the femoral stem length, cemented standard (group 1) and long (group 2) femoral stem. Oncological complications, survival, stem complications, and functional outcomes were recorded and analyzed using SPSS 25.Results24 patients were included in the final analysis, 13 case in group 1 and 11 in group 2, and mean age 57.6 years. Mean follow-up duration was 10 months, and 11 patients died of the whole-study population with mean survival of (10.85 ± 2.23, 8.82 ± 3.6) months in group 1, 2, respectively. The complication rate was higher in the standard group; however, this difference did not reach statistical significance. No difference was found between study groups regarding functional outcomes, except for VAS at 6 months which was higher in standard group.ConclusionWe believe that the ubiquitous use of long stem in the management of proximal femoral metastasis should be questioned considering the expected patient survival and low rate of complications associated with the use of standard stem.Clinicaltrials.gov registration numberNCT04660591.

Distal femoral replacement – Cemented or cementless? Current concepts and review of the literature

Distal femoral endoprosthetic replacement has been successfully used to reconstruct distal femoral defects after tumor resection for over four decades. Despite continued advances, aseptic loosening continues to be the most common failure mode after infection. Debate still exists about a variety of design features and the optimal fixation method remains controversial. To date, no large-scale study or meta-analysis has demonstrated the superiority of one fixation technique over another. While the classic dichotomy of cemented versus cementless stems is well-known, the contemporary surgeon needs to fully understand the optimal clinical setting for each type of fixation technique and additional strategies to maximize implant stability. In clinical practice, the choice of fixation must be tailored to the individual patient. The surgeon must consider whether the operation is being performed for primary sarcoma or metastatic carcinoma, the presence of distant metastases, age, comorbidities, and whether radiotherapy has been previously given or will be required at the site of fixation. The best strategy for each patient optimizes tumor control and appropriately weighs risks of fixation failure versus the expected patient survival. This review will explore cemented and uncemented distal femoral replacement and highlight modern concepts to optimize each technique.

Economic Implications of Longer Battery Longevity of Cardiac Resynchronization Therapy Defibrillator Devices in the United States

Introduction The economic impact of generator longevity differs by indicated patient population, as the magnitude of Cardiac Resynchronization Therapy Defibrillator devices (CRT-Ds) survival benefit varies by indication and so does the expected survival of the patient. The objective of this study is to understand cost savings associated with incremental years of battery life from a U.S. payer perspective. Methods Patient data from 7 prospective trials were used to project expected patient survival. Weibull/Gompertz statistical models were fitted to data from: (a) InSync III Marquis, MIRACLE, MIRACLE ICD, PROSPECT and Adaptive CRT for Class III/IV patients, (b) REVERSE for Class II patients, and (c) BLOCK-HF for AV Block patients. Mean battery longevity scenarios used half-yearly increments. A payer perspective based on the 2018 U.S. Centers for Medicare and Medicaid Services (CMS) Medicare program was used. Results Testing mean battery scenarios from 5.5 to 8.5 years, 6 additional months of device longevity result in average Medicare savings of $2,692 for Class III/IV patients, $5,429 for Class II patients and $3,754 for AV Block patients. Additional economic benefits associated with avoiding changeout-related complications were not included in these device cost projections. Conclusions Increasing CRT-D battery life can result in reductions in device-related cost across all indicated patient groups, with economic benefits being maximized among NYHA Class II subjects. But the relative impact lessens as additional battery years are added.

Visceral Fat Volume From Standard Preoperative CT is an Independent Predictor of Short-term Survival in Patients Undergoing Surgery for Metastatic Spine Disease.

This is a retrospective cohort. Determine the relationship of body morphometry to postoperative survival in patients with vertebral metastases. Most operations for vertebral metastases aim for palliation not cure, yet expected patient survival heavily influences treatment plans. We seek to demonstrate that preoperative fat and muscle volumes on standard-of-care computed tomography (CT) are independent predictors of survival after surgery for vertebral metastases. Included data were preoperative neurological status, adjuvant treatments, CT-assessed body composition, health comorbidities, details of oncologic disease, and Tomita and Tokuhashi scores. Body composition-visceral fat area, subcutaneous fat area, and total muscle area-were assessed on preoperative L3/4 CT slice with Image J software. Multivariable logistic regressions were used to determine independent predictors of 3-, 6-, and 12-month survival. We included 75 patients (median age, 57, 57.3% male, 66.7% white) with the most common primary lesions being lung (17.3%), prostate (14.7%), colorectal (12.0%), breast (10.7%), and kidney (9.3%). The only independent predictor of 3-month survival was visceral fat area [95% confidence interval (CI): 1.02-1.23 per 1000 mm; P=0.02]. Independent predictors of survival at 6 months were body mass index (95% CI: 1.04-1.35 per kg/m; P=0.009), Karnofsky performance status (95% CI: 1.00-1.15; P<0.05), modified Charlson Comorbidity Index (95% CI: 1.11-7.91; P=0.03), and postoperative chemotherapy use (95% CI: 1.13-4.71; P=0.02). Independent predictors of 12-month survival were kidney primary pathology (95% CI: 0.00-0.00; P<0.01), body mass index (95% CI: 1.03-1.39 per kg/m; P=0.02), and being ambulatory preoperatively (95% CI: 1.28-17.06; P=0.02). Visceral fat mass was an independent, positive predictor of short-term postoperative survival in patients treated for vertebral metastases. As a result, we believe that the prognostic accuracy of current predictors may be improved by the addition of visceral fat volume as a risk factor.

151. Hyperthermia, generated by focused ultrasound, in combination with radiations for a more effective glioblastoma therapy

Purpose The existing transcranial focused ultrasound device (Insightec Exablate 4000 Neuro) can induce hyperthermia in a brain region ten times larger than was recently covered with ablation [1] . The purpose of this work was to theoretically derive how a relatively small volume of glioblastoma multiforme (GBM) can be effectively treated by combining focused ultrasound based hyperthermia with an external beam radiotherapy. Methods We applied a mathematical descriptions of GBM proliferation and diffusion, in the frame of the reaction diffusion theory. We formulated equations capturing of the impact of radiotherapy and heat on GBM in the reaction diffusion equation, including the regrowth induced by stem cells [2] . Results Our calculated results show that the expected patient survival could be significantly improved by this treatment [3] . For the future, due to the lower power required for a single heating point, a somewhat lower frequency could be hypothesized, without risks of cavitation. This modification would allow the heating of larger tumors in less central regions. Conclusions The proposed methodology, now limited to a small tumors in a quite central location, can be easily improved in several different respects. These results advocate thorough experiments to validate this very promising theoretical therapeutic benefit.

PC08.08 Debate #3: Brain Metastases with a Driver Mutation Should Be Treated with Systemic Therapy First (CON)

PC08.08 Debate #3: Brain Metastases with a Driver Mutation Should Be Treated with Systemic Therapy First (CON)

Factors associated with local recurrence after surgery for bone metastasis to the extremities.

With increasing life expectancy of patients with bone metastasis, durable surgical stabilization of bone metastasis is necessary. Local recurrence (LR) can compromise surgical stabilization and necessitate retreatment. We analyzed LR rate and factors associated with LR in patients undergoing surgery for bone metastasis. Patients (n = 301) who underwent surgery for bone metastasis to the extremities were reviewed. Possible factors that might be associated with LR were investigated. LR rate was 16% (49/301). Surgical margin was associated with LR, as patients with en-bloc resection had significantly less LR than patients who underwent curettage (5/66 vs 44/235, P = 0.03). Prostate cancer had lowest rate (0%) of LR and colon cancer had highest rate (31%). Interval from surgery to LR differed among primary cancer types (4.5 ± 3.9 months [lung cancer], vs 12.3 ± 12.9 months [other cancers], P = 0.041). In multivariate analysis, en-bloc surgical margins (HR = 0.372, P = 0.036) and primary cancers of breast or prostate (HR = 0.391, P = 0.049) were independent factors associated with longer LR-free survival. LR after surgery for bone metastasis to extremities is affected by surgical margin and primary cancer type. These factors, along with expected patient survival, need to be considered when planning surgery for bone metastasis to extremities.

Prognostic factors in patients with spinal metastasis: a systematic review and meta-analysis

Background ContextIncidence of symptomatic spinal metastasis has increased owing to improvement in treatment of the disease. One of the key factors that influences decision-making is expected patient survival. To our knowledge, no systematic reviews or meta-analysis have been conducted that review independent prognostic factors in spinal metastases. PurposeThis study aimed to determine independent prognostic factors that affect outcome in patients with metastatic spine disease. Study DesignThis is a systematic literature review and meta-analysis of publications for prognostic factors in spinal metastatic disease. Patient SamplePooled patient results from cohort and observational studies. Outcome MeasurementMeta-analysis for poor prognostic factors as determined by hazard ratio (HR) and 95% confidential interval (95% CI). MethodsWe systematically searched relevant publications in PubMed and Embase. The following search terms were used: (“‘spinal metastases’” OR “‘vertebral metastases’” OR ““spinal metastasis” OR ‘vertebral metastases’) AND (‘“prognostic factors”' OR “‘survival’”). Inclusion criteria were prospective and retrospective cohort series that report HR and 95% CI of independent prognostic factors from multivariate analysis. Two reviewers independently assessed all papers. The quality of included papers was assessed by using Newcastle-Ottawa Scale for cohort studies and publication bias was assessed by using funnel plot, Begg test, and Egger test. The prognostic factors that were mentioned in at least three publications were pooled. Meta-analysis was performed using HR and 95% CI as the primary outcomes of interest. Heterogeneity was assessed using the I2 method. ResultsA total of 3,959 abstracts (1,382 from PubMed and 2,577 from Embase) were identified through database search and 40 publications were identified through review of cited publications. The reviewers selected a total of 51 studies for qualitative synthesis and 43 studies for meta-analysis. Seventeen poor prognostic factors were identified. These included presence of a neurologic deficit before surgery, non-ambulatory status before radiotherapy (RT), non-ambulatory status before surgery, presence of bone metastases, presence of multiple bone metastases (>2 sites), presence of multiple spinal metastases (>3 sites), development of motor deficit in <7 days before initiating RT, development of motor deficit in <14 days before initiating RT, time interval from cancer diagnosis to RT <15 months, Karnofsky Performance Score (KPS) 10–40, KPS 50–70, KPS<70, Eastern Cooperative Oncology Group (ECOG) grade 3–4, male gender, presence of visceral metastases, moderate growth tumor on Tomita score (TS) classification, and rapid growth tumor on TS classification. ConclusionsSeventeen independent poor prognostic factors were identified in this study. These can be categorized into cancer-specific and nonspecific prognostic factors. A tumor-based prognostic scoring system that combines all specific and general factors may enhance the accuracy of survival prediction in patients with metastatic spine disease.

Endoscopic management of malignant biliary stenosis. Update and highlights for standard clinical practice.

The present review describes the various indications of biliary stent placement in patients with biliary malignancies. It deals in depth with biliary accesses and their effectiveness, as well as with the use of different stents according to lesion type and expected patient survival. For liver hilum lesions, which are somewhat more complex, the usefulness of and need for unilateral or bilateral drainage is assessed, as it is the most appropriate method. All in all, this is an up-to-date literature review that may help clinicians in their daily decision-making, as well as to improve and optimize patient outcomes.

Characteristics and Performance of Minority‐Serving Dialysis Facilities

To examine the structure, processes, and outcomes of American dialysis facilities that predominantly treat racial-ethnic minority patients. Secondary analysis of data from all patients who initiated dialysis during 2005-2008 in the United States. In this retrospective cohort study, we examined the associations of the racial-ethnic composition of the dialysis facility with facility-level survival and achievement of performance targets for anemia and dialysis adequacy. We obtained dialysis facility- and patient-level data from the national data registry of patients with end-stage renal disease. We linked these data with clinical performance measures from the Centers for Medicare and Medicaid Services. Overall, minority-serving facilities were markedly larger, more often community based, and less likely to offer home dialysis than facilities serving predominantly white patients. A significantly higher proportion of minority-serving dialysis facilities exhibited worse than expected survival as compared with facilities serving predominantly white patients (p < .001 for each). However, clinical performance measures for anemia and dialysis adequacy were similar across minority-serving status. While minority-serving facilities generally met dialysis performance targets mandated by Medicare, they exhibited worse than expected patient survival.

Impact of extending device longevity on the long-term costs of implantable cardioverter-defibrillator therapy: a modelling study with a 15-year time horizon

To determine the long-term costs of extending device longevity in four patient populations requiring a single-chamber implantable cardioverter-defibrillator (ICD) or requiring cardiac resynchronization therapy with defibrillation (CRT-D) device over a 15-year time window. We considered patient populations with an accepted indication for a single-chamber ICD for prevention of sudden cardiac death in the context of preserved (Population A) or impaired (Population B) left ventricular function; or with indication for a CRT-D device in the context of heart failure in New York Heart Association class II (Population C) or III (Population D). Expected patient survival and a cost analysis, including the cost of complications, was undertaken from a hospital perspective. Extended device longevity of 5 vs. 9 years for ICDs (Populations A and B); 4 vs. 7 years for CRT-Ds (Populations C and D) were considered. Over a 15-year time horizon, total, yearly, and per diem savings, per patient, from extending ICD longevity to 9 years were €10 926.91, €728.46, and €1.99 for Population A, and €7661.32, €510.75, and €1.40 for Population B. Total, yearly, and per diem savings from extending CRT-D longevity to 7 years were €13 630.38, €908.69, and €2.49 for Population C, and €10 968.29, €731.22, and €2.00 for Population D. Avoidance of a generator replacement amounted up to 46.6-62.5% of the saving. Extending device longevity has an important effect on the long-term cost of device therapy, both for ICD and CRT-D. This has important implications for device choice.

Variation in Dialysis Quality Measures by Facility, Neighborhood, and Region

We examined whether dialysis facility characteristics, neighborhood demographics, and region are associated with Centers for Medicare and Medicaid Services (CMS) dialysis facility quality measures in order to determine the most important targets for intervention. We linked US census data to the CMS Dialysis Compare File which contains information for facility outcomes for all CMS-certified dialysis facilities in 2007 (n=5616). We then used linear and logistic regression to characterize the association between dialysis facility quality--worse than expected patient survival, and the proportion of individuals in a facility achieving dialysis adequacy (urea reduction rate >65) or target hemoglobin (10<Hgb<12 g/dL)--and dialysis facility characteristics, neighborhood demographics, and region. Only an increasing proportion of African Americans in the neighborhood is consistently associated with worse dialysis facility outcomes, even after controlling for neighborhood poverty. Facilities with the highest proportion of African Americans in the neighborhood had worse patient survival [odds ratio (OR) 4.6; 95% confidence interval (CI), 2.8-7.6], were less likely to have adequate dialysis (β -1.4; 95% CI, -2.3 to -0.6), and achieve targeted hemoglobin (β -3.1; 95% CI, -4.7 to -1.6) compared to those with the lowest proportion. No other predictor-facility, neighborhood, or region--was consistently associated with dialysis facility quality. The proportion of African Americans in the dialysis facility neighborhood is strongly and consistently associated with lower facility quality. Quality improvement efforts are particularly needed for dialysis facilities in minority communities.

Development and pilot testing of a decision aid for surrogates of patients with prolonged mechanical ventilation*

Shared decision making is inadequate in intensive care units. Decision aids can improve decision making quality, though their role in an intensive care units setting is unclear. We aimed to develop and pilot test a decision aid for shared decision makers of patients undergoing prolonged mechanical ventilation. Intensive care units at three medical centers. Fifty-three surrogate decision makers and 58 physicians. We developed the decision aid using defined methodological guidelines. After an iterative revision process, formative cognitive testing was performed among surrogate-physician dyads. Next, we compared the decision aid to usual care control in a prospective, before/after design study. Primary outcomes were physician-surrogate discordance for expected patient survival, comprehension of relevant medical information, and the quality of communication. Compared to control, the intervention group had lower surrogate-physician discordance (7 [10] vs. 43 [21]), greater comprehension (11.4 [0.7] vs. 6.1 [3.7]), and improved quality of communication (8.7 [1.3] vs. 8.4 [1.3]) (all p<.05) post-intervention. Hospital costs were lower in the intervention group ($110,609 vs. $178,618; p=.044); mortality did not differ by group (38% vs. 50%, p=.95). Ninety-four percent of the surrogates and 100% of the physicians reported that the decision aid was useful in decision making. We developed a prolonged mechanical ventilation decision aid that is feasible, acceptable, and associated with both improved decision-making quality and less resource utilization. Further evaluation using a randomized controlled trial design is required to evaluate the decision aid's effect on long-term patient and surrogate outcomes.

Indications for Vascular Grafts as Hemodialysis Access: Consensus from Experience in Italy

In Italy, the use of arteriovenous grafts (AVG) is limited (1-5 %) due to different approaches to vascular access (VA) management as compared to other countries, where guidelines (which may not apply to the Italian setting) have been produced. Therefore, the Study Group (GdS) on VA of the Italian Society of Nephrology produced this position paper, providing a list of 8 recommendations built upon current guidelines. The most controversial and innovative issues of existing guidelines have been summed up in 12 different statements. We selected 60 Italian dialysis graft experts, nephrologists and vascular surgeons (PP1SIN Study Investigators). They were asked to express their agreement/disagreement on each issue, thus creating a new method to share and exchange information. Most of them agreed (consensus > 90%) on specific criteria set to choose AVG over native AVF (nAVF) and tunnelled venous catheter (tVC) and on the necessary conditions to implant them. They did not fully agree on the use of AVG in obese patients, in patients at risk of developing ischemia, on the priority of AVG as an alternative to brachial-basilic fistula with vein transposition, and in case of a poorly organized setting regarding graft maintenance. Keeping in mind that the nAVF should be preferred whenever is feasible, AVGs are indicated when superficial veins are unavailable or to repair a nAVF (bridge graft). An AVG is an alternative to tVC if the expected patient survival is long enough to guarantee its clinical benefits.

Liver transplantation in adults: Choosing the appropriate timing

Liver transplantation is indicated in patients with acute liver failure, decompensated cirrhosis, hepatocellular carcinoma and rare liver-based genetic defects that trigger damage of other organs. Early referral to a transplant center is crucial in acute liver failure due to the high mortality with medical therapy and its unpredictable evolution. Referral to a transplant center should be considered when at least one complication of cirrhosis occurs during its natural history. However, because of the shortage of organ donors and the short-term mortality after liver transplantation on one hand and the possibility of managing the complications of cirrhosis with other treatments on the other, patients are carefully selected by the transplant center to ensure that transplantation is indicated and that there are no medical, surgical and psychological contraindications. Patients approved for transplantation are placed on the transplant waiting list and prioritized according to disease severity. Thus, the appropriate timing of transplantation depends on recipient disease severity and, although this is still a matter of debate, also on donor quality. These two variables are known to determine the "transplant benefit" (i.e., when the expected patient survival is better with, than without, transplantation) and should guide donor allocation.

Automatic glioma characterization from dynamic susceptibility contrast imaging: Brain tumor segmentation using knowledge‐based fuzzy clustering

To assess whether glioma volumes from knowledge-based fuzzy c-means (FCM) clustering of multiple MR image classes can provide similar diagnostic efficacy values as manually defined tumor volumes when characterizing gliomas from dynamic susceptibility contrast (DSC) imaging. Fifty patients with newly diagnosed gliomas were imaged using DSC MR imaging at 1.5 Tesla. To compare our results with manual tumor definitions, glioma volumes were also defined independently by four neuroradiologists. Using a histogram analysis method, diagnostic efficacy values for glioma grade and expected patient survival were assessed. The areas under the receiver operator characteristics curves were similar when using manual and automated tumor volumes to grade gliomas (P = 0.576-0.970). When identifying a high-risk patient group (expected survival <2 years) and a low-risk patient group (expected survival >2 years), a higher log-rank value from Kaplan-Meier survival analysis was observed when using automatic tumor volumes (14.403; P < 0.001) compared with the manual volumes (10.650-12.761; P = 0.001-0.002). Our results suggest that knowledge-based FCM clustering of multiple MR image classes provides a completely automatic, user-independent approach to selecting the target region for presurgical glioma characterization.

Results of liver transplantation: With or without milan criteria?

Results of liver transplantation: With or without milan criteria?

Biliary stents in malignant obstructive jaundice due to pancreatic carcinoma: a cost-effectiveness analysis

OBJECTIVES: Obstructive jaundice frequently complicates pancreatic carcinoma and is associated with complications such as malabsorption, coagulopathy, progressive hepatocellular dysfunction, and cholangitis in addition to disabling pruritus, which greatly interferes with terminal patients’ quality of life. Endoscopic placement of biliary stents decreases the risk of these complications and is considered the procedure of choice for palliation for patients with unresectable tumors. We used decision analysis with Markov modeling to compare the cost-effectivenesses of plastic stents and metal stents in patients with unresectable pancreatic carcinoma. METHODS: A model of the natural history of unresectable pancreatic carcinoma was constructed using probabilities derived from the literature. Cost estimates were obtained from Medicare reimbursement rates and supplemented by the literature. Two strategies were evaluated: 1) initial endoscopic plastic stent placement and 2) initial endoscopic metal stent placement. We compared total costs and performed cost-effectiveness analysis in these strategies. The outcome measures were quality-adjusted life months. Sensitivity analyses were performed on selected variables. RESULTS: Our baseline analysis showed that initial plastic stent placement was associated with a total cost of $13,879/patient and 1.799 quality-adjusted life months. Initial placement of a metal stent cost $13,466/patient and conferred 1.832 quality-adjusted life months. Among the variables examined, expected patient survival was demonstrated by sensitivity analyses to have the most influence on the results of the model. CONCLUSION: Initial endoscopic placement of a metal stent is a cost-saving strategy compared to initial plastic stent placement, particularly in patients expected to survive longer than 6 months.