Use of colonic stents in emergent malignant left colonic obstruction: A markov chain monte carlo decision analysis
Use of colonic stents in emergent malignant left colonic obstruction: A markov chain monte carlo decision analysis
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DOI：
10.1007/s10350-007-9047-9
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发表时间：
2007-11-01
影响因子：
3.9
通讯作者：
Law, Calvin H. L.
中科院分区：
文献类型：
--
作者：
Govindarajan, Anand;Naimark, David;Law, Calvin H. L.
目的：本决策分析探讨了在紧急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独手术的成本效益。方法：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：紧急手术与紧急结肠支架置入术作为根治性手术的桥梁。所有相关的健康状态都是在患者的预期寿命期间建模的。结果指标包括死亡率、需要结肠造口术的患者比例、质量调整预期寿命和费用。进行了确定性和概率敏感性分析。结果：在我们的模型中，结肠支架置入术比急诊手术更有效（9.2 个质量调整生命月获益）且成本更低（3,763 加元；3,135 美元）。其好处其次是降低急性死亡率和需要永久性结肠造口术的可能性。结果仅取决于支架置入并发症（穿孔、技术置入失败和移位）的发生率和患者手术死亡的风险，手术死亡风险高的患者获益最大。结论：结肠支架置入作为手术的桥梁，在治疗紧急的恶性左半结肠梗阻方面比手术更有效且成本更低。其益处在高危患者中最为明显，但会因支架置入失败率和穿孔率的增加而减弱。对于低风险患者，其益处较为温和，可能不会超过风险。
Purpose: 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.Methods: 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.Results: In our model, colonic stenting was more effective (9.2 quality-adjusted life months benefit) and less costly (CAD $3,763; U.S. $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.Conclusions: 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.