Govindarajan Anand, Naimark David, Coburn Natalie G, Smith Andrew J, Law Calvin H L
Division of General Surgery, University of Toronto, Toronto, Ontario, Canada.
Dis Colon Rectum. 2007 Nov;50(11):1811-24. doi: 10.1007/s10350-007-9047-9. Epub 2007 Sep 27.
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.
本决策分析探讨了在急诊恶性左半结肠梗阻的治疗中，结肠支架置入术作为手术桥梁与单纯手术相比的成本效益。
我们使用马尔可夫链蒙特卡罗决策分析模型来确定两种策略对健康相关生活质量的影响：急诊手术与急诊结肠支架置入术作为确定性手术的桥梁。在患者的预期寿命期间对所有相关健康状态进行建模。结果指标包括死亡率、需要结肠造口术的患者比例、质量调整生命预期以及成本。进行了确定性和概率性敏感性分析。
在我们的模型中，与急诊手术相比，结肠支架置入术更有效（质量调整生命月获益9.2个月）且成本更低（3763加元；3135美元）。其益处主要源于急性死亡率和需要永久性结肠造口术可能性的降低。结果仅取决于支架置入并发症（穿孔、技术置入失败和移位）的发生率以及患者的手术死亡风险，在手术死亡风险高的患者中益处最大。
在治疗急诊恶性左半结肠梗阻时，结肠支架置入术作为手术桥梁比手术更有效且成本更低。在高危患者中益处最为显著，而支架置入失败率和穿孔率的增加会使益处减少。在低危患者中，益处较为有限，可能无法超过风险。
