Optimal treatment for severe neurogenic bowel dysfunction after chronic spinal cord injury: a decision analysis

• Published in: British journal of surgery 2007-09, Vol.94 (9), p.1139-1150
• Main Authors: Furlan, J. C., Urbach, D. R., Fehlings, M. G.
• Format: Article
• Language: English
• Subjects: Autonomic Nervous System - physiopathology; Biological and medical sciences; Cerebrospinal fluid. Meninges. Spinal cord; Chronic Disease; Constipation - physiopathology; Constipation - surgery; Decision Support Techniques; General aspects; Humans; Medical sciences; Nervous system (semeiology, syndromes); Neurology; Quality of Life; Sensitivity and Specificity; Severity of Illness Index; Spinal Cord Injuries - complications; Spinal Cord Injuries - physiopathology; Treatment Outcome
• ISSN: 0007-1323; 1365-2168
• DOI: 10.1002/bjs.5781

Background: When conservative management fails in patients with chronic spinal cord injury (SCI) and neurogenic bowel dysfunction, clinicians have to choose from a variety of treatment options which include colostomy, ileostomy, Malone anterograde continence enema (MACE) and sacral anterior root stimulator (SARS) implantation. This study employed a decision analysis to examine the optimal treatment for bowel management of young individuals with chronic refractory constipation in the setting of chronic SCI. Methods: A decision analysis was created to compare the four surgical strategies using baseline analysis, one‐way and two‐way sensitivity analyses, ‘worst scenario’ and ‘best scenario’ sensitivity analyses, and probabilistic sensitivity analyses. Quality‐adjusted life expectancy (QALE) was the primary outcome. Results: The baseline analysis indicated that patients who underwent the MACE procedure had the highest QALE value compared with the other interventions. Sensitivity analyses showed that these results were robust. Conclusion: The MACE procedure may provide the best long‐term outcome in terms of the probability of improving bowel function, reducing complication rates and the incidence of autonomic dysreflexia, and being congruent with patients' preferences. The analysis was sensitive to changes in assumptions about quality of life/utility, and thus the results could change if more specific estimates of utility became available. Copyright © 2007 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd. MACE may be best in the long term