Surgical strategies for faecal incontinence--a decision analysis between dynamic graciloplasty, artificial bowel sphincter and end stoma.
BACKGROUND
Artificial bowel sphincter (ABS) and dynamic graciloplasty (DG) are surgical treatments for faecal incontinence (FI). FI may affect quality of life (QOL) so severely that patients are often willing to consider a permanent end stoma (ES). It is unclear which is the more cost-effective strategy.


METHODS
Probability estimates for patients with FI were obtained from published data (ABS, n = 319; DG, n = 301), supplemented by expert opinion. The primary outcome was quality-adjusted life years (QALYs) gained from each strategy. Factors considered were the risk of failure of the primary and redo operation and the consequent risk of permanent stoma. Results were assessed as incremental cost-effectiveness ratio (ICER).


RESULTS
Over the 5-year time horizon, ES gave a QALY gain of 3.45 for 16,280 pounds sterling, giving an ICER of 4719 pounds sterling/QALY. ABS produced a gain of 4.38 QALYs for 23,569 pounds sterling, giving an ICER of 5387 pounds sterling/QALY. DG produced a gain of 4.00 QALYs for 25,035 pounds sterling, giving an ICER of 6257 pounds sterling/QALY. With the willingness-to-pay threshold set at 30,000 pounds sterling/QALY, ES was the most cost-effective intervention. The ABS was most cost-effective after 10 years.


CONCLUSIONS
All three procedures were found to be cost-effective. The ES was most cost-effective over 5 years, while the ABS was most cost-effective in excess of 10. DG maybe considered as an alternative in specialist centres.
Tan
E K
EK
Department of Biosurgery and Surgical Technology, Imperial College London, St Mary's Hospital, London, UK.
Vaizey
C
C
Cornish
J
J
Darzi
A
A
Tekkis
P P
PP
D001003:Anal Canal / Q000601:surgery*; D003362:Cost-Benefit Analysis; D003661:Decision Support Techniques; D005242:Fecal Incontinence / Q000601:surgery*; D006801:Humans; D008390:Markov Chains; D011336:Probability; D019651:Plastic Surgery Procedures / Q000191:economics / Q000379:methods; D012086:Reoperation; D054047:Surgical Stomas; D016896:Treatment Outcome