title: Optimal treatment for severe neurogenic bowel dysfunction after chronic spinal cord injury: a decision analysis.
abstract: BACKGROUND
  When conservative management fails in patients with chronic spinal cord injury (SCI) and neurogenic bowel dysfunction, clinicians have to choose from a variety of treatment options which include colostomy, ileostomy, Malone anterograde continence enema (MACE) and sacral anterior root stimulator (SARS) implantation. This study employed a decision analysis to examine the optimal treatment for bowel management of young individuals with chronic refractory constipation in the setting of chronic SCI.
  
  
  METHODS
  A decision analysis was created to compare the four surgical strategies using baseline analysis, one-way and two-way sensitivity analyses, 'worst scenario' and 'best scenario' sensitivity analyses, and probabilistic sensitivity analyses. Quality-adjusted life expectancy (QALE) was the primary outcome.
  
  
  RESULTS
  The baseline analysis indicated that patients who underwent the MACE procedure had the highest QALE value compared with the other interventions. Sensitivity analyses showed that these results were robust.
  
  
  CONCLUSIONS
  The MACE procedure may provide the best long-term outcome in terms of the probability of improving bowel function, reducing complication rates and the incidence of autonomic dysreflexia, and being congruent with patients' preferences. The analysis was sensitive to changes in assumptions about quality of life/utility, and thus the results could change if more specific estimates of utility became available.
authors.affiliation: Spinal Program, Krembil Neuroscience Centre, Toronto Western Hospital, University of Toronto, 399 Bathurst Street, Toronto, Ontario, Canada. jfurlan@uhnres.utoronto.ca
authors.forename: J C
authors.initials: JC
authors.lastname: Furlan
authors.forename: D R
authors.initials: DR
authors.lastname: Urbach
authors.forename: M G
authors.initials: MG
authors.lastname: Fehlings
mesh_terms: D001341:Autonomic Nervous System / Q000503:physiopathology; D002908:Chronic Disease; D003248:Constipation / Q000503:physiopathology / Q000601:surgery*; D003661:Decision Support Techniques; D006801:Humans; D011788:Quality of Life; D012680:Sensitivity and Specificity; D012720:Severity of Illness Index; D013119:Spinal Cord Injuries / Q000150:complications* / Q000503:physiopathology; D016896:Treatment Outcome