Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University, Stanford, California.
Department of Management Sciences and Engineering, Stanford University, Stanford, California.
Clin Gastroenterol Hepatol. 2019 Dec;17(13):2740-2748.e6. doi: 10.1016/j.cgh.2019.02.041. Epub 2019 Mar 5.
BACKGROUND & AIMS: Complex benign rectal polyps can be managed with transanal surgery or with endoscopic resection (ER). Though the complication rate after ER is lower than transanal surgery, recurrence is higher. Patients lost to follow up after ER might therefore be at increased risk for rectal cancer. We evaluated the costs, benefits, and cost effectiveness of ER compared to 2 surgical techniques for removing complex rectal polyps, using a 50-year time horizon-this allowed us to capture rates of cancer development among patients lost from follow-up surveillance.
We created a Markov model to simulate the lifetime outcomes and costs of ER, transanal endoscopic microsurgery (TEM), and transanal minimally invasive surgery (TAMIS) for the management of a complex benign rectal polyp. We assessed the effect of surveillance by allowing a portion of the patients to be lost to follow up. We calculated the cost, quality-adjusted life years (QALYs), and incremental cost-effectiveness ratio or each intervention over a 50-year time horizon.
We found that TEM was slightly more effective than TAMIS and ER (TEM, 19.54 QALYs; TAMIS, 19.53 QALYs; and ER, 19.53 QALYs), but ER had a lower lifetime discounted cost (ER cost $7161, TEM cost $10,459, and TAMIS cost $11,253). TEM was not cost effective compared to ER, with an incremental cost-effectiveness ratio of $485,333/QALY. TAMIS was dominated by TEM. TEM became cost effective when the mortality from ER exceeded 0.63%, or if the loss to follow up rate exceeded 25.5%.
Using a Markov model, we found that ER, TEM, and TAMIS have similar effectiveness, but ER is less expensive, in management of benign rectal polyps. As the rate of loss to follow up increases, transanal surgery becomes more effective relative to ER.
复杂的良性直肠息肉可以通过经肛门手术或内镜下切除（ER）来治疗。虽然 ER 的并发症发生率低于经肛门手术，但复发率更高。因此，ER 后失访的患者可能面临更高的直肠癌风险。我们使用 50 年的时间范围评估了 ER 与两种切除复杂直肠息肉的手术技术（经肛门内镜微创手术（TEM）和经肛门微创外科（TAMIS））相比的成本、效益和成本效益，这使我们能够捕捉到失访患者中癌症发展的比率。
我们创建了一个马尔可夫模型，以模拟 ER、TEM 和 TAMIS 治疗复杂良性直肠息肉的终生结果和成本。我们通过允许一部分患者失访来评估监测的效果。我们计算了每个干预措施在 50 年时间范围内的成本、质量调整生命年（QALY）和增量成本效益比。
我们发现 TEM 比 TAMIS 和 ER 略有效（TEM，19.54 QALY；TAMIS，19.53 QALY；和 ER，19.53 QALY），但 ER 的终身贴现成本较低（ER 成本为 7161 美元，TEM 成本为 10459 美元，TAMIS 成本为 11253 美元）。与 ER 相比，TEM 不具有成本效益，增量成本效益比为 485333 美元/QALY。TAMIS 优于 TEM。当 ER 的死亡率超过 0.63%或失访率超过 25.5%时，TEM 变得具有成本效益。
使用马尔可夫模型，我们发现 ER、TEM 和 TAMIS 在治疗良性直肠息肉方面具有相似的疗效，但 ER 更便宜。随着失访率的增加，经肛门手术相对于 ER 变得更有效。
