Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia.
Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia.
Gut. 2018 Nov;67(11):1965-1973. doi: 10.1136/gutjnl-2017-313823. Epub 2017 Oct 7.
To compare the cost-effectiveness of endoscopic submucosal dissection (ESD) and wide-field endoscopic mucosal resection (WF-EMR) for removing large sessile and laterally spreading colorectal lesions (LSLs) >20 mm.
An incremental cost-effectiveness analysis using a decision tree model was performed over an 18-month time horizon. The following strategies were compared: WF-EMR, universal ESD (U-ESD) and selective ESD (S-ESD) for lesions highly suspicious for containing submucosal invasive cancer (SMIC), with WF-EMR used for the remainder. Data from a large Western cohort and the literature were used to inform the model. Effectiveness was defined as the number of surgeries avoided per 1000 cases. Incremental costs per surgery avoided are presented. Sensitivity and scenario analyses were performed.
1723 lesions among 1765 patients were analysed. The prevalence of SMIC and low-risk-SMIC was 8.2% and 3.1%, respectively. Endoscopic lesion assessment for SMIC had a sensitivity and specificity of 34.9% and 98.4%, respectively. S-ESD was the least expensive strategy and was also more effective than WF-EMR by preventing 19 additional surgeries per 1000 cases. 43 ESD procedures would be required in an S-ESD strategy. U-ESD would prevent another 13 surgeries compared with S-ESD, at an incremental cost per surgery avoided of US$210 112. U-ESD was only cost-effective among higher risk rectal lesions.
S-ESD is the preferred treatment strategy. However, only 43 ESDs are required per 1000 LSLs. U-ESD cannot be justified beyond high-risk rectal lesions. WF-EMR remains an effective and safe treatment option for most LSLs.
NCT02000141.
比较内镜黏膜下剥离术（ESD）与大面积内镜黏膜切除术（WF-EMR）治疗>20mm 大型无蒂侧向扩展结直肠病变（LSL）的成本效果。
采用决策树模型进行了增量成本效果分析，时间范围为 18 个月。比较了以下策略：对高度怀疑含有黏膜下浸润性癌（SMIC）的病变行 WF-EMR、通用 ESD（U-ESD）和选择性 ESD（S-ESD）治疗，其余病变行 WF-EMR 治疗。该模型的数据来源于一个大型的西方队列和文献。有效性定义为每 1000 例手术中避免的手术次数。每避免一次手术的增量成本均有报道。进行了敏感性和情景分析。
1765 例患者的 1723 个病变进行了分析。SMIC 和低危-SMIC 的患病率分别为 8.2%和 3.1%。内镜下评估 SMIC 的敏感度和特异度分别为 34.9%和 98.4%。S-ESD 是最经济的策略，与 WF-EMR 相比，每 1000 例可预防 19 例额外手术。S-ESD 策略需要 43 例 ESD 治疗。与 S-ESD 相比，U-ESD 可预防另外 13 例手术，但避免一次手术的增量成本为 210112 美元。U-ESD 仅在高危直肠病变中具有成本效果。
S-ESD 是首选的治疗策略。然而，每 1000 例 LSL 仅需要 43 例 ESD 治疗。对于高危直肠病变，U-ESD 无法得到合理证明。对于大多数 LSL，WF-EMR 仍然是一种有效且安全的治疗选择。
NCT02000141。
