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Original Article
Colonic stenting: is the bridge to surgery worth its cost? A cost-effectiveness analysis at a single Asian institution
Michelle Shi Qing Khooorcid, Frederick H. Kohorcid, Sharmini Su Sivarajahorcid, Leonard Ming-Li Hoorcid, Darius Kang-Lie Aworcid, Cheryl Xi-Zi Chongorcid, Fung Joon Fooorcid, Winson Jianhong Tanorcid

DOI: https://doi.org/10.3393/ac.2023.00738.0105
Published online: August 5, 2024

Colorectal Service, Department of General Surgery, Sengkang General Hospital, Singapore

Correspondence to: Frederick H. Koh, MBBS (S’pore), MRCS (Edin), MMed (Surg), FRCS (Edin), FAMS (Surg) Colorectal Service, Department of General Surgery, Sengkang General Hospital, 110 Sengkang East Way, Singapore 544886 Email: frederick.koh.h.x@singhealth.com.sg
• Received: October 28, 2023   • Revised: December 5, 2023   • Accepted: December 12, 2023

© 2024 The Korean Society of Coloproctology

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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  • Purpose
    In patients with acute left-sided colonic obstruction, stenting can convert an emergency operation into a semi-elective procedure. However, its use continues to be debated. We performed a cost-effective analysis using our institution’s experiences.
  • Methods
    Endoscopic, surgical, and financial details were prospectively collected for patients who presented with acute colonic obstruction and underwent stenting between 2019 and 2022. Outcomes were defined as technical/clinical success and successful surgical resection. The financial cost of stenting was compared with the expected cost without stenting.
  • Results
    Forty patients were included, with 29 undergoing definitive resection. The most common pathology was primary colon cancer (27 patients, 93%). Endoscopic stenting had high technical (90%) and clinical (83%) success rates, with low rates of complications such as perforation (2 patients, 7%) and migration (0 patients, 0%). As a bridge to surgery, the median procedure time was 226 minutes and the surgical outcomes also showed a low rate of complications (3 patients, 11%), such as anastomotic leakage (0 patients, 0%), intraabdominal abscesses (2 patients, 7%), and 30-day postoperative mortality (0 patients, 0%). The cumulative costs with colonic stenting were $32,900, while the expected costs with emergency surgery, including stoma reversal, were $40,700 (healthcare cost-savings of $7,800 per person). The difference was mainly due to the avoidance of upfront emergency surgery. The incremental cost-effectiveness ratio was 0.81, favoring colonic stenting over upfront emergency surgery.
  • Conclusion
    Colonic stenting as a bridge to surgery is safe and cost-effective for treating left-sided colonic obstruction with high success rates and low complication rates.
Mechanical large bowel obstruction is a common surgical condition encountered in the acute hospital setting, and the most common etiology is colorectal malignancy [1]. Colorectal cancer is the third most common cancer diagnosed annually, with an annual incidence ranging between 25 and 50 in 100,000 [2]. It is estimated that up to a third of patients newly diagnosed with colon cancer—especially left-sided colon cancers—present with symptoms of large bowel obstruction [3]. Furthermore, 8% to 13% of colon cancer patients develop large bowel obstruction, which can lead to bowel ischemia and perforation if left untreated [4].
For patients presenting with acute left-sided colonic obstruction, the European Society for Gastrointestinal Endoscopy (ESGE) in 2020 recommended stenting as a valid alternative to emergency surgery [5]. Endoscopic colonic stenting aims to convert an emergency operation to a semi-elective procedure to mitigate the surgical and anesthetic risks of emergency surgery, as well as to improve the rates of laparoscopic resection [6, 7]. Furthermore, stenting also seeks to avoid stoma creation during the definitive resection, thereby mitigating the psychosocial implications of having a stoma, as well as reducing the need and cost for subsequent stoma reversal, with its associated hospitalization [7, 8].
As a bridge to surgery, successful colonic stenting increases the rates of laparoscopic surgery increases and primary anastomosis, while reducing postoperative complications [3, 9, 10]. Despite these positive results for colonic stenting, there remains doubt regarding the safety and efficacy of colonic stenting as a bridge to surgery due to its high reintervention rates [11, 12]. A randomized controlled trial in 2008 had a disproportionately high number of perforations in the stenting group (6 out of 11 adverse events, vs. 1 adverse event in the surgical group), which led to the trial being stopped prematurely [13]. There have also been debates regarding oncological outcomes, as perforation may occur during stent placement, resulting in tumor spread and hence increasing the risk of local recurrence and reducing the overall survival rate [9, 1416]. In contrast, other long-term studies have reported that stenting as a bridge to surgery was associated with low recurrence rates, low complication rates, and overall acceptable oncological outcomes [7, 9, 1719].
Aside from its psychosocial and oncological effects, colorectal cancer also represents an economic burden to countries in terms of healthcare costs and productivity losses [20, 21]. Hospitalization costs represent a significant proportion of the economic burden due to prolonged hospitalization stays, with an average of 10 to 11 days estimated in an international retrospective analysis [22, 23].
By avoiding emergency upfront open resection and stoma creation, allowing time to optimize the patient for laparoscopic surgery with its associated reduced duration of hospitalization, endoscopic colonic stenting can decrease both patient and healthcare costs. However, limited data have been reported on the cost-effectiveness of colonic stenting compared to emergency surgery in Asia; instead, stenting has generally been evaluated in either a European or American setting [12, 24]. As data on healthcare costs are variable depending on the healthcare system, we aimed to evaluate the efficacy of colonic stenting as a viable bridge to elective surgery in Asia, as well as its cost benefits over emergency surgery to address malignant large bowel obstruction.
Ethics statement
The study was approved by the SingHealth Centralised Institutional Review Board (No. 2020/2525). Written consents were obtained from patients participating in the study.
Study design
We conducted a review of a prospectively collected colorectal cancer database of all endoscopically stented presumed-malignant large bowel obstructions at presentation at Sengkang General Hospital in Singapore between April 2019 and October 2022. We excluded patients who presented with metastatic unresectable disease or eventually declined surgery in favor of expectant management in the final analysis. Endoscopic, perioperative, and financial details for these patients were collected and analyzed.
Data collection
Outcomes were defined as technical and clinical success, as well as successful surgical resection. Technical success was defined as successful stent deployment across the colonic stricture with immediate establishment of luminal patency, evident by the endoscopic observation of the passage of proximal feculent material through the stent [2527]. Clinical success was defined as a successful scheduled surgical outcome of definitive resection and primary anastomosis [2527]. Clinical failure included technical failure, unplanned return to the emergency room, and failure of stenting in decompression requiring subtotal or total colectomy. Histopathological reporting of colon cancer was graded in accordance with the American Joint Committee on Cancer (AJCC) staging. Thirty-day morbidity from the stent and subsequent surgical procedure was graded according to the Clavien-Dindo classification, and mortality data were analyzed. Data on the surgical outcomes of patients who underwent emergency surgery for left-sided colonic obstruction were also collected.
We performed a cost-effectiveness analysis on colonic stenting for acute colonic obstruction based on hospital financial data modelling and compared this against the modelled financial data of those who had upfront emergency surgery for malignant large bowel obstruction, including stoma closure. The costs of adjuvant treatment and its associated stoma-related complications were not included in the cost analysis.
Endoscopic stenting technique
Colonic stenting procedures were either performed in the endoscopic suite with the patient under sedation or in the emergency operating theatre with the patient under monitored sedation with fluoroscopic guidance. All procedures were performed by 2 accredited endoscopists, with at least 1 specialist-accredited consultant colorectal surgeon.
Following flexible sigmoidoscopy with an EVIS EXERA III GIF-1TH190 endoscope (Olympus) to visualize the offending stricturing lesion, a 450 Jagwire Guidewire (Boston Scientific) supported with a tandem catheter (Boston Scientific) was advanced through the lumen of the stricture under direct vision and fluoroscopic guidance. Contrast was then injected to estimate the approximate length of the lesion to aid in selecting the length of the stent. A Wallflex Colonic Stent (22 mm diameter with varying length [60/90/120 mm] and pliability [regular/soft]; Boston Scientific) was passed through the narrowed lumen after exchanging the stent over the guidewire. Deployment took place under fluoroscopic and endoscopic guidance.
Technical success was evaluated at the time of endoscopy, and clinical success was achieved when the planned interval surgical resection was performed. In addition to clinical parameters, all patients had an abdominal x-ray performed within 24 hours after the procedure to ensure that the deployed stent remained in a satisfactory position with adequate expansion after the procedure. After successful stent insertion, elective surgery was planned for within 2 weeks as recommended by the ESGE guidelines [5].
Statistical analysis
Categorical data, such as patient demographics, were presented as proportions or percentages while continuous data were presented as median values with interquartile ranges (IQRs). Cost-effectiveness analysis was performed by obtaining the mean costs between a patient who would have undergone emergency surgery and those who would have undergone colonic stenting as provided by our finance office. The incremental cost-effectiveness ratio was calculated.
For those who underwent upfront emergency surgery, cost modelling considered surgical costs, including the index operation with its related hospitalization costs (including high-dependency stay), as well as stomal consumables, stoma nursing support, and the associated stoma closure with its related hospitalization costs. For those who underwent colonic stenting, cost modelling included the endoscopic procedural costs and the costs of the stent, definitive surgery, and all its associated hospitalization.
During the 42-month study period, 40 patients presented with presumed-malignant large bowel obstruction and underwent endoscopic stenting at our institution. Of these, 29 patients had colonic stenting performed as an eventual bridge to definitive surgery, as shown in Fig. 1. The other 11 patients did not undergo definitive resection due to metastatic disease and comorbidities. Additionally, 1 patient is still on neoadjuvant chemotherapy for systemic control of disease prior to definitive resection.
Table 1 demonstrates the demographics and disease factors of patients undergoing colonic stenting. The median age of patients presenting with acute left-sided colonic obstruction was 66 years (IQR, 57–71 years), and most of them were classified as American Society of Anesthesiologists (ASA) physical status class II at baseline. They were symptomatic from the obstruction for a median length of 2 days (IQR, 3–7 days). Based on computed tomography, the offending lesion was most frequently located in the sigmoid colon (19 patients, 66%), followed by the descending colon (8 patients, 28%).
Stenting outcomes
The median length of the stented lesion was 5.5 cm. Twenty-six (90%) out of the 29 patients who underwent colonic stenting achieved technical success, while 24 patients (83%) achieved clinical success and underwent elective resection.
Of the patients who did not achieve technical success, 2 patients (7%) had perforation and none had stent migration. Both patients who had immediate perforation on the table during colonic stent insertion presented with a relatively long duration of symptoms, 7 and 11 days, respectively. In the other patient who did not achieve technical success, stenting failed as the wire was unable to be passed through the obstructing lesion and the decision was made for emergency surgery. Two other patients did not achieve clinical success despite initial technical success, resulting in a total of 5 patients (17%) not achieving clinical success. One patient’s surgery was delayed due to COVID-19 infection, and he presented with delayed perforation 17 days after colonic stenting, while another experienced re-obstruction despite technical success, requiring emergency surgery.
The majority of patients with colonic stents had 6-cm-long stents inserted (23 patients, 79%), followed by 9-cm-long stents (5 patients, 17%). The last patient had two 6-cm stents deployed in an overlapping technique to traverse a long stricture.
Surgical outcomes
Table 2 summarizes the stenting and surgical outcomes of patients who underwent colonic stenting, while Table 3 summarizes the difference in surgical outcomes between colonic stenting and emergency surgery for left-sided colonic obstruction.
In patients who achieved technical and clinical success, the median time to surgery was 13 days (IQR, 9–17 days). Twenty-one patients (72%) underwent laparoscopic surgery. Eight patients (28%) required open surgery. Colonic stenting had failed in 5 of these patients, and the other 3 had undergone successful colonic stenting but required open surgery due to adhesions from prior operations (2 patients) or bleeding (1 patient).
Of the 29 patients, 2 presented with benign causes of intestinal obstruction—1 with endometriosis resulting in a left-sided colonic fibrotic stricture, and the other with benign fissuring ulcers secondary to segmental colitis associated with diverticular disease. All 27 patients who presented with a malignant cause of intestinal obstruction had primary colonic cancer. A majority (17 patients, 63%) presented with stage II disease; all had at least T3 disease and above, with invasion of the muscularis propria, according to the AJCC staging system [28].
Twenty-four patients (83%) had primary anastomosis without stomas, while the other 5 patients (17%) required stoma creation. Of these 5 patients with stomas, colonic stenting had failed in 3, while the other 2 required a stoma in view of low anterior resection. The 30-day morbidity rate from surgery was 14% (4 patients), while the 30-day mortality rate was 0% (0 patients). Of note, no anastomotic leakage was encountered. Hence out of the 24 patients who achieved clinical success, 21 successfully underwent laparoscopic surgery, and 22 did not require a stoma creation.
In comparison, all patients who underwent upfront emergency surgery required open surgery (63 patients, 100%), while for colonic stenting, only 8 patients (28%) required open surgery. Patients who underwent emergency surgery were also more likely to require a stoma (67%) than those who underwent colonic stenting (17%).
Healthcare savings
A large majority (24 patients, 83%) stayed for 1 day (IQR, 1–1 day) in the high-dependency unit after definitive resection of their colonic lesion, and a median of 7 days (IQR, 5–13.5 days) in the general ward. Table 4 shows the median postresection hospital stay.
Most patients who underwent colonic stenting (21 patients, 73%) underwent elective resection without stoma creation, while the patients who underwent emergency surgery were most likely to undergo resection with a stoma (42 patients, 67%), with a further 62% of these patients (26 patients) undergoing stoma reversal. An example of the cost breakdown of colonic stenting as compared to emergency surgery is demonstrated in Table 5, and the overall costs of colonic stenting as compared to emergent surgery based on surgical outcomes are summarized in Table 6.
Based on these projections, cost-effectiveness and estimated savings were calculated. The expected cumulative cost of management with colonic stenting from acute management to definitive treatment calculated was $32,900. This included the initial hospital stay after colonic stenting, as well as the subsequent elective admission for definitive surgery, with a median of a 1-day stay in the high-dependency unit and a total of 10 days of general ward stay based on our hospital’s financial records. The expected cost of emergency surgery, including eventual stoma reversal, was $40,700, which included the costs of stoma supplies, the 2 procedures, a 1-day stay in the high-dependency unit, and a median of 12 days in the general ward.
In total, this resulted in an estimated healthcare cost-savings of $7,800 per person, which were mainly due to the avoidance of upfront emergency surgery with stoma creation. The incremental cost-effectiveness ratio was 0.81, demonstrating that colonic stenting carries significant healthcare cost-savings for patients. The overall difference in the duration of hospitalization for management with colonic stenting over upfront emergency surgery was 2 days, favoring stenting. Fig. 2 demonstrates the outcomes and costs of patients who underwent colonic stenting as compared to emergency surgery.
Safety of colonic stenting
Our overall complication rate from colonic stenting was 10%. These patients presented with early perforation (2 patients, 7%) or delayed perforation (1 patient, 3%) during endoscopic colonic stenting, and none (0%) presented with stent migration. The overall technical success rate was 90% (26 patients), and the clinical success rate was 83% (24 patients). Reasons for failure included perforation (3 patients, 10%), re-obstruction (1 patient, 3%), and technical difficulty (1 patient, 3%). The predictors of outcomes for colonic stenting include preprocedural factors (e.g., the duration of symptoms), procedural factors (e.g., tumor location, tumor length, and stent diameter), and postprocedural factors (e.g., length of time to surgery) [2931]. Longer symptom duration is a known risk factor for technical failure, and the patients who presented with immediate perforation on table had symptoms for longer than the median duration (7 and 11 days, respectively) [26].
A meta-analysis in 2021 found overall rates of technical (92%) and clinical (82%) success that were comparable to our technical (90%) and clinical (83%) success rates [31]. The ESGE guidelines recommend that colonic stenting be performed by experienced endoscopists, noting that studies have shown an increase in technical success after performing 20 endoscopic stenting procedures [5]. At our institution, colonic stenting was carried out only by experienced endoscopists, with at least 1 other colorectal surgeon on standby. This is likely one of the factors accounting for our high technical and clinical success rates. Our institutional data demonstrate that colonic stenting is safe, with comparable technical and clinical success rates to those of other institutions. With proper patient selection and available specialists, colonic stenting is a safe and effective bridge to surgery.
Outcomes
Patients with unsuccessful stent procedures had a higher rate of open procedures, which could be attributed to the failure to successfully decompress the bowel, making laparoscopic work unfeasible. When patients present with obstruction and are not optimized for emergency surgery, they often have longer postoperative recovery, with poor surgical outcomes (e.g., respiratory complications and readmissions) and an elevated risk of surgical complications [32, 33]. By stenting an obstructed lesion, we convert these patients to elective surgery and hence enable preoperative optimization [6, 33]. This can be demonstrated by the short stay in the high-dependency unit, as well as the shorter hospitalization stay (about 3 days overall). Our overall complication rate was also acceptable, at approximately 14%, with 10% of patients having Clavien-Dindo III to IV complications. Emergency surgery with resection has been reported to show a high rate of anastomotic leak, at approximately 15% [34]; notably, however, our study did not have any patients who presented with anastomotic leak.
Fast recovery from surgery is also essential, as patients present with obstruction, which is a poor prognostic factor; hence, adjuvant chemotherapy would be recommended [35]. Aside from preoperative optimization, an elective laparoscopic resection also avoids wound complications from an open midline incision, shortens the hospital stay, and hence allows the earlier initiation of postoperative adjuvant chemotherapy [36]. A large proportion of our patients who underwent colonic stenting as a bridge to surgery achieved clinical success and were able to proceed for definitive resection and subsequent chemotherapy.
Cost analysis
Our analysis found that patients who presented with acute left-sided obstruction and proceeded for emergency resection could expect an initial hospital bill ranging from US $39,100 to $46,100. This corresponds with findings in the literature, where a systematic review [37] reported the initial management costs for colorectal cancer could vary US $7,893 to $60,289, while another systematic review [38] described a similar range of USD $19,929 to $67,195. As our patients presented with obstructed colorectal cancer with a need for longer postoperative high-dependency monitoring, it may be expected that their healthcare bill would be on the higher end of the spectrum.
Our study found that, as a bridge to surgery, colonic stenting offered a cheaper alternative, with an initial hospital bill of US $6,500. Overall, the hospital bill after colonic stenting and definitive resection is expected to range from US $28,400 to $52,900. The cumulative costs are US $32,900 owing to our low complication rate. This translates to a difference of approximately US $7,800 per patient. Furthermore, colonic stenting also reduces both the temporary and permanent stoma rates and mitigates the psychosocial effect of stoma creation [25, 39]. Furthermore, the incremental cost-effectiveness ratio was found to be 0.81, favoring colonic stenting as compared to emergency surgery and suggesting that healthcare resources should be directed towards stenting where possible.
These findings are concordant with various studies in Italy and Canada, which reported that colonic stenting is a cost-effective and safe alternative to emergency surgery [39, 40]. To the best of our knowledge, no cost analysis on colonic stenting has been performed in Asia prior to our study, and our paper is the first to demonstrate that colonic stenting in an Asian institution is a safe and cost-effective procedure that reduces healthcare costs and burden.
The healthcare costs of intestinal obstruction and emergency surgery translate into a heavy strain on patients, their families, and the healthcare system. With these savings, physicians should consider colonic stenting where appropriate in the management of an obstructed large bowel with left-sided pathology.
Limitations
There are some limitations to this study, including selection bias as patients who were suitable for colonic stenting generally had better prognostic factors, such as no bowel ischemia or perforation. Furthermore, our single institution has a relatively small number of patients who underwent colonic stenting. More data from a larger, multicenter multinational cohort study would be required prior to making definitive conclusions with regards to the cost-efficacy of colonic stenting. Due to the acute presentation of our patients with large bowel obstruction, a randomized controlled trial may not be feasible due to the inherent risks associated with both procedures and ethical considerations. Hence, we were unable to make a comparison between stenting and 1-stage surgery where stoma formation can be avoided through colonic washout intraprocedurally.
Conclusions
In patients with left-sided colonic obstruction, stenting as a bridge to surgery is a safe, clinically effective, and cost-effective means to treat acute colonic obstruction with high success rates and low complication rates, while avoiding open emergency operation. In the future, more data will be needed to determine the optimal timing from stenting to resection, as well as the utility of colonic stenting prior to neoadjuvant chemotherapy.

Conflict of interest

Frederick H. Koh is an Editorial Board member of Annals of Coloproctology, but was not involved in the reviewing or decision process of this manuscript. No other potential conflict of interest relevant to this article was reported.

Funding

None.

Author contributions

Conceptualization: all authors; Data curation: MSQK; Investigation: MSQK; Methodology: MSQK; Visualization: all authors; Writing–original draft: MSQK, FHK; Writing–review & editing: all authors. All authors read and approved the final manuscript.

Additional information

This study was presented as a poster presentation at the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) 2023 Annual Meeting on March 29–April 1, 2023, in Montreal, Canada; and at the 19th Congress of the Asia Pacific Federation of Coloproctology (APFCP) on October 19–21, 2023, in Singapore.

Fig. 1.
Number of patients who underwent stent insertion.
ac-2023-00738-0105f1.jpg
Fig. 2.
Outcomes and costs of patients (USD) who underwent colonic stenting as compared to emergency surgery.
ac-2023-00738-0105f2.jpg
Table 1.
Demographics and pathological causes of patients undergoing colonic stenting
Variable Value (n=29)
Demographic
 Age (yr) 66 (57–71)
 ASA physical status
  I 2 (7)
  II 21 (69)
  III 5 (17)
  IV 1 (3)
Pathological cause
 Malignant cause of obstruction 27 (93)
 Length of symptoms (day) 2 (3–7)
 TNM stagea
  II 17 (63)
  III 6 (22)
  IV 4 (15)
Lymphovascular invasiona 13 (48)
Perineural invasiona 10 (37)
Tumor location
 Transverse colon 1 (3)
 Splenic flexure 1 (3)
 Descending colon 8 (28)
 Sigmoid  19 (66)

Values are presented as median (interquartile range) or number (%).

ASA, American Society of Anesthesiologists.

aAmong 27 malignant cases.

Table 2.
Post-stenting outcomes of patients who underwent colonic stenting as a bridge to surgery
Outcome Value (n=29)
Technical success 26 (90)
Clinical success 24 (83)
Stent complication
 Perforation 3 (10)
 Migration 0 (0)
Time to surgery (day) 13 (9–17)
Type of definitive surgery
 Open surgery 8 (28)
 Laparoscopic surgery 21 (72)
Primary anastomosis
 Without stoma 24 (83)
 With stoma 3 (10)
Time to first bowel motion (day) 3 (2–4)
Procedure time (min) 226 (189–271)
Overall postoperative complication 4 (14)
Clavien-Dindo classification
 I 0 (0)
 II 1 (3)
 III 2 (7)
 IV 1 (3)
30-day Mortality 0 (0)
Adjuvant chemotherapya 15 (56)

Values are presented as number (%) or median (interquartile range).

aAmong 27 malignant cases.

Table 3.
Surgical outcomes for left-sided obstructed tumors
Surgical outcome Colonic stenting (n=29) Emergency surgery (n=63)
Emergency operation 5 (17) 63 (100)
Surgery type
 Open surgery 8 (28) 63 (100)
 Laparoscopic surgery 21 (72) 0 (0)
Stoma required 5 (17) 42 (67)
Stoma reversed 0/5 (0) 16/42 (38)

Values are presented as number (%).

Table 4.
Median length of stay after definitive resection
Variable Length of hospital stay (day)
High-dependency care 1 (1–1)
General ward 7 (5–13.5)
Total 8 (6–14.5)

Values are presented as median (interquartile range).

Table 5.
Example of a breakdown of estimated costs between colonic stenting and emergency surgery
Cost (USD) Colonic stenting Emergency surgery
Index admission
 Bed 1,075a 3,367b
 Stent 1,339 -
 Surgical cost 5,434 35,778
 Stoma supply - 385
Second admission
 Bed 3,009 1,433
 Surgical cost 19,056c 5,470d
Total 29,913 46,433

Colonic stenting, obstructed tumor with definitive surgery without stoma. Emergency surgery, obstructed tumor with subsequent stoma reversal.

aThree-day stay.

bNine-day stay.

cDefinitive surgery.

dStoma reversal.

Table 6.
Representative example of the cost of colonic stenting compared to another representative example of emergency resection
Cost (USD) Colonic stenting Emergency surgery
Success
 With stoma
  Reversed 36,816 46,433
  Not reversed 30,298 39,529
 Without stoma 29,913 39,145
Failure -
 With stoma
  Reversed 54,281
  Not reversed 47,377
 Without stoma 46,992
  • 1. Capona R, Hassab T, Sapci I, Aiello A, Liska D, Holubar S, et al. Surgical intervention for mechanical large bowel obstruction at a tertiary hospital: which patients receive a stoma and how often are they reversed? Am J Surg 2021;221:594–7.ArticlePubMed
  • 2. Bray F, Ferlay J, Soerjomataram I, Siegel RL, Torre LA, Jemal A. Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin 2018;68:394–424.ArticlePubMedPDF
  • 3. Morino M, Arezzo A, Farnesi F, Forcignanò E. Colonic stenting in the emergency setting. Medicina (Kaunas) 2021;57:328. ArticlePubMedPMC
  • 4. Schwartzberg DM, Valente MA. Surgical dilemmas associated with malignant large bowel obstructions. Clin Colon Rectal Surg 2022;35:197–203.ArticlePubMedPMC
  • 5. van Hooft JE, Veld JV, Arnold D, Beets-Tan RG, Everett S, Götz M, et al. Self-expandable metal stents for obstructing colonic and extracolonic cancer: European Society of Gastrointestinal Endoscopy (ESGE) Guideline: update 2020. Endoscopy 2020;52:389–407.ArticlePubMed
  • 6. Arezzo A, Passera R, Lo Secco G, Verra M, Bonino MA, Targarona E, et al. Stent as bridge to surgery for left-sided malignant colonic obstruction reduces adverse events and stoma rate compared with emergency surgery: results of a systematic review and meta-analysis of randomized controlled trials. Gastrointest Endosc 2017;86:416–26.ArticlePubMed
  • 7. Donlon NE, Kelly ME, Narouz F, McCormick PH, Larkin JO, Mehigan BJ. Colonic stenting as a bridge to surgery in malignant large bowel obstruction: oncological outcomes. Int J Colorectal Dis 2019;34:613–9.ArticlePubMedPDF
  • 8. van Silfhout L, Smeekens EA, van Eekeren RR, Burger JP. Outcomes of stenting as a bridge to surgery in malignant colonic obstruction, with emphasis on perforation rate and clinical success. Surg Laparosc Endosc Percutan Tech 2020;30:332–8.ArticlePubMed
  • 9. Kim SH, Jang SH, Jeon HJ, Choi HS, Kim ES, Keum B, et al. Colonic stenting as a bridge to surgery for obstructive colon cancer: is it safe in the long term? Surg Endosc 2022;36:4392–400.ArticlePubMedPDF
  • 10. Han L, Song X, Yu B, Zhou M, Zhang L, Sun G. Safety evaluation of preoperative stent insertion and clinical analysis on comparison of outcomes between preoperative stent insertion and emergency surgery in the treatment of obstructive left-sided colorectal cancer. Pak J Med Sci 2020;36:376–81.ArticlePubMedPMCPDF
  • 11. Sarkar S, Geraghty J, Rooney P. Colonic stenting: a practical update. Frontline Gastroenterol 2013;4:219–26.ArticlePubMedPMC
  • 12. Quinn PL, Arjani S, Ahlawat SK, Chokshi RJ. Cost-effectiveness of palliative emergent surgery versus endoscopic stenting for acute malignant colonic obstruction. Surg Endosc 2021;35:2240–7.ArticlePubMedPDF
  • 13. van Hooft JE, Fockens P, Marinelli AW, Timmer R, van Berkel AM, Bossuyt PM, et al. Early closure of a multicenter randomized clinical trial of endoscopic stenting versus surgery for stage IV left-sided colorectal cancer. Endoscopy 2008;40:184–91.ArticlePubMed
  • 14. Pattarajierapan S, Sukphol N, Junmitsakul K, Khomvilai S. Oncologic safety of colonic stenting as a bridge to surgery in left-sided malignant colonic obstruction: current evidence and prospects. World J Clin Oncol 2022;13:943–56.ArticlePubMedPMC
  • 15. Lauro A, Binetti M, Vaccari S, Cervellera M, Tonini V. Obstructing left-sided colonic cancer: is endoscopic stenting a bridge to surgery or a bridge to nowhere? Dig Dis Sci 2020;65:2789–99.ArticlePubMedPDF
  • 16. Min CK, Kim HO, Lee D, Jung KU, Lee SR, Kim H, et al. Obstructive left colon cancer should be managed by using a subtotal colectomy instead of colonic stenting. Ann Coloproctol 2016;32:215–20.ArticlePubMedPMCPDF
  • 17. Khomvilai S, Pattarajierapan S. Comparison of long-term outcomes of colonic stenting as a “bridge to surgery” and emergency surgery in patients with left-sided malignant colonic obstruction. Ann Coloproctol 2023;39:17–26.ArticlePubMedPDF
  • 18. Ceresoli M, Allievi N, Coccolini F, Montori G, Fugazzola P, Pisano M, et al. Long-term oncologic outcomes of stent as a bridge to surgery versus emergency surgery in malignant left side colonic obstructions: a meta-analysis. J Gastrointest Oncol 2017;8:867–76.ArticlePubMedPMC
  • 19. Gibor U, Perry Z, Tirosh D, Netz U, Rosental A, Fich A, et al. Comparison of the long-term oncological outcomes of stent as a bridge to surgery and surgery alone in malignant colonic obstruction. Isr Med Assoc J 2017;19:736–40.PubMedPDF
  • 20. Luengo-Fernandez R, Leal J, Gray A, Sullivan R. Economic burden of cancer across the European Union: a population-based cost analysis. Lancet Oncol 2013;14:1165–74.ArticlePubMed
  • 21. Henderson RH, French D, Maughan T, Adams R, Allemani C, Minicozzi P, et al. The economic burden of colorectal cancer across Europe: a population-based cost-of-illness study. Lancet Gastroenterol Hepatol 2021;6:709–22.ArticlePubMed
  • 22. Yuan GL, Liang LZ, Zhang ZF, Liang QL, Huang ZY, Zhang HJ, et al. Hospitalization costs of treating colorectal cancer in China: a retrospective analysis. Medicine (Baltimore) 2019;98:e16718.ArticlePubMedPMC
  • 23. Bradley CJ, Dahman B, Bear HD. Insurance and inpatient care: differences in length of stay and costs between surgically treated cancer patients. Cancer 2012;118:5084–91.ArticlePubMed
  • 24. Binkert CA, Ledermann H, Jost R, Saurenmann P, Decurtins M, Zollikofer CL. Acute colonic obstruction: clinical aspects and cost-effectiveness of preoperative and palliative treatment with self-expanding metallic stents: a preliminary report. Radiology 1998;206:199–204.ArticlePubMed
  • 25. Lueders A, Ong G, Davis P, Weyerbacher J, Saxe J. Colonic stenting for malignant obstructions: a review of current indications and outcomes. Am J Surg 2022;224(1 Pt A): 217–27.ArticlePubMed
  • 26. Little MW, Oakley T, Briggs JH, Sutcliffe JA, Allouni AK, Makris G, et al. Technical and clinical outcomes following colonic stenting: a seven-year analysis of 268 procedures. Cardiovasc Intervent Radiol 2016;39:1471–8.ArticlePubMedPDF
  • 27. Bayraktar B, Ozemir IA, Kefeli U, Demiral G, Sagiroğlu J, Bayraktar O, et al. Colorectal stenting for palliation and as a bridge to surgery: a 5-year follow-up study. World J Gastroenterol 2015;21:9373–9.ArticlePubMedPMC
  • 28. Weiser MR. AJCC 8th edition: colorectal cancer. Ann Surg Oncol 2018;25:1454–5.ArticlePubMedPDF
  • 29. Boyle DJ, Thorn C, Saini A, Elton C, Atkin GK, Mitchell IC, et al. Predictive factors for successful colonic stenting in acute large-bowel obstruction: a 15-year cohort analysis. Dis Colon Rectum 2015;58:358–62.ArticlePubMed
  • 30. Hanaoka M, Ogo T, Kawamura Y, Miura T, Aburatani T, Sugimoto H, et al. Self-expandable metal stent as a bridge to surgery for colorectal cancer: safety and oncological outcomes. In Vivo 2020;34:1325–31.ArticlePubMedPMC
  • 31. Neo VS, Jain SR, Yeo JW, Ng CH, Gan TR, Tan E, et al. Controversies of colonic stenting in obstructive left colorectal cancer: a critical analysis with meta-analysis and meta-regression. Int J Colorectal Dis 2021;36:689–700.ArticlePubMedPDF
  • 32. Bento JH, Bianchi ET, Tustumi F, Leonardi PC, Junior UR, Ceconello I. Surgical management of malignant intestinal obstruction: outcome and prognostic factors. Chirurgia (Bucur) 2019;114:343–51.ArticlePubMed
  • 33. Harvey PR, Rees J, Baldwin S, Waheed H, Tanner JR, Evison F, et al. Outcomes of colorectal stents when used as a bridge to curative resection in obstruction secondary to colorectal cancer. Int J Colorectal Dis 2019;34:1295–302.ArticlePubMedPDF
  • 34. Biondo S, Gálvez A, Ramírez E, Frago R, Kreisler E. Emergency surgery for obstructing and perforated colon cancer: patterns of recurrence and prognostic factors. Tech Coloproctol 2019;23:1141–61.ArticlePubMedPDF
  • 35. Okuda Y, Shimura T, Yamada T, Hirata Y, Yamaguchi R, Sakamoto E, et al. Colorectal obstruction is a potential prognostic factor for stage II colorectal cancer. Int J Clin Oncol 2018;23:1101–11.ArticlePubMedPDF
  • 36. Hempel S, Kalauch A, Oehme F, Wolk S, Welsch T, Weitz J, et al. Wound complications after primary and repeated midline, transverse and modified Makuuchi incision: a single-center experience in 696 patients. Medicine (Baltimore) 2021;100:e25989.ArticlePubMedPMC
  • 37. Bhimani N, Wong GY, Molloy C, Dieng M, Kelly PJ, Hugh TJ. Lifetime direct healthcare costs of treating colorectal cancer: a systematic review. Eur J Health Econ 2023;24:513–37.ArticlePubMedPDF
  • 38. Garg R, Cheng V, Ellis U, Verma V, McTaggart-Cowan H, Peacock S, et al. Direct medical costs of young-onset colorectal cancer: a worldwide systematic review. BMC Health Serv Res 2022;22:1100. ArticlePubMedPMCPDF
  • 39. Singh H, Latosinsky S, Spiegel BM, Targownik LE. The cost-effectiveness of colonic stenting as a bridge to curative surgery in patients with acute left-sided malignant colonic obstruction: a Canadian perspective. Can J Gastroenterol 2006;20:779–85.ArticlePubMedPMCPDF
  • 40. Salamone G, Falco N, Atzeni J, Tutino R, Licari L, Gulotta G. Colonic stenting in acutely obstructed left-sided colon cancer Clinical evaluation and cost analysis. Ann Ital Chir 2014;85:556–62.PubMed

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        Colonic stenting: is the bridge to surgery worth its cost? A cost-effectiveness analysis at a single Asian institution
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      Colonic stenting: is the bridge to surgery worth its cost? A cost-effectiveness analysis at a single Asian institution
      Image Image
      Fig. 1. Number of patients who underwent stent insertion.
      Fig. 2. Outcomes and costs of patients (USD) who underwent colonic stenting as compared to emergency surgery.
      Colonic stenting: is the bridge to surgery worth its cost? A cost-effectiveness analysis at a single Asian institution
      Variable Value (n=29)
      Demographic
       Age (yr) 66 (57–71)
       ASA physical status
        I 2 (7)
        II 21 (69)
        III 5 (17)
        IV 1 (3)
      Pathological cause
       Malignant cause of obstruction 27 (93)
       Length of symptoms (day) 2 (3–7)
       TNM stagea
        II 17 (63)
        III 6 (22)
        IV 4 (15)
      Lymphovascular invasiona 13 (48)
      Perineural invasiona 10 (37)
      Tumor location
       Transverse colon 1 (3)
       Splenic flexure 1 (3)
       Descending colon 8 (28)
       Sigmoid  19 (66)
      Outcome Value (n=29)
      Technical success 26 (90)
      Clinical success 24 (83)
      Stent complication
       Perforation 3 (10)
       Migration 0 (0)
      Time to surgery (day) 13 (9–17)
      Type of definitive surgery
       Open surgery 8 (28)
       Laparoscopic surgery 21 (72)
      Primary anastomosis
       Without stoma 24 (83)
       With stoma 3 (10)
      Time to first bowel motion (day) 3 (2–4)
      Procedure time (min) 226 (189–271)
      Overall postoperative complication 4 (14)
      Clavien-Dindo classification
       I 0 (0)
       II 1 (3)
       III 2 (7)
       IV 1 (3)
      30-day Mortality 0 (0)
      Adjuvant chemotherapya 15 (56)
      Surgical outcome Colonic stenting (n=29) Emergency surgery (n=63)
      Emergency operation 5 (17) 63 (100)
      Surgery type
       Open surgery 8 (28) 63 (100)
       Laparoscopic surgery 21 (72) 0 (0)
      Stoma required 5 (17) 42 (67)
      Stoma reversed 0/5 (0) 16/42 (38)
      Variable Length of hospital stay (day)
      High-dependency care 1 (1–1)
      General ward 7 (5–13.5)
      Total 8 (6–14.5)
      Cost (USD) Colonic stenting Emergency surgery
      Index admission
       Bed 1,075a 3,367b
       Stent 1,339 -
       Surgical cost 5,434 35,778
       Stoma supply - 385
      Second admission
       Bed 3,009 1,433
       Surgical cost 19,056c 5,470d
      Total 29,913 46,433
      Cost (USD) Colonic stenting Emergency surgery
      Success
       With stoma
        Reversed 36,816 46,433
        Not reversed 30,298 39,529
       Without stoma 29,913 39,145
      Failure -
       With stoma
        Reversed 54,281
        Not reversed 47,377
       Without stoma 46,992
      Table 1. Demographics and pathological causes of patients undergoing colonic stenting

      Values are presented as median (interquartile range) or number (%).

      ASA, American Society of Anesthesiologists.

      aAmong 27 malignant cases.

      Table 2. Post-stenting outcomes of patients who underwent colonic stenting as a bridge to surgery

      Values are presented as number (%) or median (interquartile range).

      Among 27 malignant cases.

      Table 3. Surgical outcomes for left-sided obstructed tumors

      Values are presented as number (%).

      Table 4. Median length of stay after definitive resection

      Values are presented as median (interquartile range).

      Table 5. Example of a breakdown of estimated costs between colonic stenting and emergency surgery

      Colonic stenting, obstructed tumor with definitive surgery without stoma. Emergency surgery, obstructed tumor with subsequent stoma reversal.

      Three-day stay.

      Nine-day stay.

      Definitive surgery.

      Stoma reversal.

      Table 6. Representative example of the cost of colonic stenting compared to another representative example of emergency resection


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