title: Colonic stent vs. emergency surgery for management of acute left-sided malignant colonic obstruction: a decision analysis.
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.
authors.affiliation: Division of Digestive Diseases, School of Medicine, UCLA Center for the Health Sciences, University of California-Los Angeles, Los Angeles, CA 90095, USA.
authors.forename: Laura E
authors.initials: LE
authors.lastname: Targownik
authors.forename: Brennan M
authors.initials: BM
authors.lastname: Spiegel
authors.forename: Jonathan
authors.initials: J
authors.lastname: Sack
authors.forename: Oscar J
authors.initials: OJ
authors.lastname: Hines
authors.forename: Gareth S
authors.initials: GS
authors.lastname: Dulai
authors.forename: Ian M
authors.initials: IM
authors.lastname: Gralnek
authors.forename: James J
authors.initials: JJ
authors.lastname: Farrell
mesh_terms: D000208:Acute Disease; D000368:Aged; D003082:Colectomy / Q000191:economics*; D003108:Colonic Diseases / Q000191:economics / Q000401:mortality / Q000628:therapy*; D003110:Colonic Neoplasms / Q000150:complications* / Q000191:economics / Q000401:mortality / Q000628:therapy; D003125:Colostomy / Q000191:economics*; D003131:Combined Modality Therapy; D003362:Cost-Benefit Analysis / Q000706:statistics & numerical data; D003661:Decision Support Techniques; D017558:Elective Surgical Procedures / Q000191:economics; D004630:Emergencies / Q000191:economics*; D006801:Humans; D007415:Intestinal Obstruction / Q000191:economics / Q000401:mortality / Q000628:therapy*; D008297:Male; D008432:Mathematical Computing; D012086:Reoperation / Q000191:economics; D012984:Software; D015607:Stents / Q000191:economics*; D015996:Survival Rate