Cost Effectiveness of Endoscopic Resection vs Transanal Resection of Complex Benign Rectal Polyps.

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. METHODS: 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. RESULTS: 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%. CONCLUSIONS: 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.

Considering Value in Rectal Cancer Surgery: An Analysis of Costs and Outcomes Based on the Open, Laparoscopic, and Robotic Approach for Proctectomy.

OBJECTIVE: The aim of the study was to compare value (outcomes/costs) of proctectomy in patients with rectal cancer by 3 approaches: open, laparoscopic, and robotic. BACKGROUND: The role of minimally invasive proctectomy in rectal cancer is controversial. In the era of value-based medicine, costs must be considered along with outcomes. METHODS: Primary rectal cancer patients undergoing curative intent proctectomy at our institution between 2010 and 2014 were included. Patients were grouped by approach [open surgery, laparoscopic surgery, and robotic surgery (RS)] on an intent-to-treat basis. Groups were compared by direct costs of hospitalization for the primary resection, 30-day readmissions, and ileostomy closure and for short-term outcomes. RESULTS: A total of 488 patients were evaluated; 327 were men (67%), median age was 59 (27-93) years, and restorative procedures were performed in 333 (68.2%). Groups were similar in demographics, tumor characteristics, and treatment details. Significant outcome differences between groups were found in operative and anesthesia times (longer in the RS group), and in estimated blood loss, intraoperative transfusion, length of stay, and postoperative complications (all higher in the open surgery group). No significant differences were found in short-term oncologic outcomes. Direct cost of the hospitalization for primary resection and total direct cost (including readmission/ileostomy closure hospitalizations) were significantly greater in the RS group. CONCLUSIONS: The laparoscopic and open approaches to proctectomy in patients with rectal cancer provide similar value. If robotic proctectomy is to be widely applied in the future, the costs of the procedure must be reduced.

An outcome and cost analysis of anal fistula plug insertion vs endorectal advancement flap for complex anal fistulae.

AIM: The study aimed to compare the rate of success and cost of anal fistula plug (AFP) insertion and endorectal advancement flap (ERAF) for anal fistula. METHOD: Patients receiving an AFP or ERAF for a complex single fistula tract, defined as involving more than a third of the longitudinal length of of the anal sphincter, were registered in a prospective database. A regression analysis was performed of factors predicting recurrence and contributing to cost. RESULTS: Seventy-one patients (AFP 31, ERAF 40) were analysed. Twelve (39%) recurrences occurred in the AFP and 17 (43%) in the ERAF group (P = 1.00). The median length of stay was 1.23 and 2.0 days (P < 0.001), respectively, and the mean cost of treatment was €5439 ± €2629 and €7957 ± €5905 (P = 0.021), respectively. On multivariable analysis, postoperative complications, underlying inflammatory bowel disease and fistula recurring after previous treatment were independent predictors of de novo recurrence. It also showed that length of hospital stay ≤ 1 day to be the most significant independent contributor to lower cost (P = 0.023). CONCLUSION: Anal fistula plug and ERAF were equally effective in treating fistula-in-ano, but AFP has a mean cost saving of €2518 per procedure compared with ERAF. The higher cost for ERAF is due to a longer median length of stay.

Cost-effectiveness of surveillance strategies after treatment for high-grade anal dysplasia in high-risk patients.

BACKGROUND: Anal cancer is one of the most common cancers affecting human immunodeficiency virus (HIV)-infected male patients. Currently, there is no consensus on posttreatment surveillance of HIV-infected men who have sex with men (MSM) who have been treated for high-grade intraepithelial neoplasia (HGAIN), the likely precursor to anal cancer. OBJECTIVE: The aim of this study was to assess the cost-effectiveness of a range of strategies for anal cancer surveillance in HIV-infected MSM previously treated for HGAIN. METHODS: We developed a Markov model to project quality-adjusted life expectancy, lifetime costs, and the incremental cost-effectiveness ratios of 5 strategies using high-resolution anoscopy (HRA) and/or anal cytology testing after treatment. RESULTS: Performing HRA alone at 6- and 12-month visits was associated with a cost-effectiveness ratio of $4446 per quality-adjusted life year gained. In comparison, combined HRA and anal cytology at both visits provided greater health benefit at a cost of $17,373 per quality-adjusted life year gained. Our results were robust over a number of scenarios and assumptions including patients' level of immunosuppression. Results were most sensitive to test characteristics and cost, as well as progression rates of normal to HGAIN and HGAIN to cancer. CONCLUSIONS: Our results suggest that combined HRA and anal cytology at 6 and 12 months may be a cost-effective surveillance strategy after treatment of HGAIN in HIV-infected MSM.

Transanal glove port is a safe and cost-effective alternative for transanal endoscopic microsurgery.

BACKGROUND: Transanal endoscopic microsurgery (TEM) is a minimally invasive technique for excision of rectal tumours that avoids conventional pelvic resectional surgery along with its risks and side-effects. Although appealing, the associated cost and complex learning curve limit TEM utilization by colorectal surgeons. Single-port laparoscopic principles are being recognized as transferable to transanal work and hybrid techniques are in evolution. Here the clinical application of a new technique for transanal access is reported. METHODS: Consecutive non-selected patients eligible for TEM over a 3-month period (and selected patients thereafter) were offered a procedure performed via a 'glove TEM port'. This access device was constructed on-table using a circular anal dilator (CAD), wound retractor and standard surgical glove, along with standard, straight laparoscopic trocar sleeves and instruments. RESULTS: Fourteen patients underwent full-thickness resection of benign (8) or malignant (6) rectal pathology. CAD insertion failed in one patient and conventional TEM assistance was needed in another, leaving 12 procedures completed successfully by glove TEM alone as planned (completion rate 86 per cent overall, 92 per cent after initiation). The median (range) duration of operation and resected specimen area were 93 (30-120) min and 12 (3-152) cm(2) respectively. There was no intraoperative and minimal postoperative morbidity, with a median follow-up of 5.7 (2.7-9.4) months. CONCLUSION: The glove TEM port is a safe, inexpensive and readily available access tool that may obviate the use of specialized equipment for transanal resection of rectal lesions.

[Transanal single-port surgery for local excision of rectal tumours]. / Flexibele toegangspoort voor excisie rectumtumoren.

Transanal endoscopic microsurgery (TEM) is the technique of choice for rectum-preserving treatment of rectal tumours. However, the instruments are relatively expensive and TEM is a highly-complex technique. From 2010 a few case reports describing a new technique for local excision of rectal tumours using a single-access laparoscopic port have appeared. These single-access ports are flexible multichannel ports for transumbilical laparoscopic surgery. Even though not developed for transanal use these ports are ideal because of their shape and the material they are made from. Transanal surgery using a single-access port is a relatively simple procedure and does not require any investment in new instruments. This new technique will enable more surgeons to carry out transanal endoscopic surgery.

Whole-body MR imaging versus sequential multimodal diagnostic algorithm for staging patients with rectal cancer: cost analysis.

PURPOSE: To compare the direct costs of two diagnostic algorithms for pretherapeutic TNM staging of rectal cancer. MATERIALS AND METHODS: In a study including 33 patients (mean age: 62.5 years), the direct fixed and variable costs of a sequential multimodal algorithm (rectoscopy, endoscopic and abdominal ultrasound, chest X-ray, thoracic/abdominal CT in the case of positive findings in abdominal ultrasound or chest X-ray) were compared to those of a novel algorithm of rectoscopy followed by MRI using a whole-body scanner. MRI included T 2w sequences of the rectum, 3D T 1w sequences of the liver and chest after bolus injection of gadoxetic acid, and delayed phases of the liver. The personnel work times, material items, and work processes were tracked to the nearest minute by interviewing those responsible for the process (surgeon, gastroenterologist, two radiologists). The costs of labor and materials were determined from personnel reimbursement data and hospital accounting records. Fixed costs were determined from vendor pricing. RESULTS: The mean MRI time was 55 min. CT was performed in 19/33 patients (57%) causing an additional day of hospitalization (costs 374 euro). The costs for equipment and material were higher for MRI compared to sequential algorithm (equipment 116 vs. 30 euro; material 159 vs. 60 euro per patient). The personnel costs were markedly lower for MRI (436 vs. 732 euro per patient). Altogether, the absolute cost advantage of MRI was 31.3% (711 vs. 1035 euro for sequential algorithm). CONCLUSION: Substantial savings are achievable with the use of whole-body MRI for the preoperative TNM staging of patients with rectal cancer.

Cost analysis of transanal endoscopic microsurgery for rectal tumours.

OBJECTIVE: Transanal endoscopic microsurgery (TEM) is considered to be a safe and effective treatment for selected rectal neoplasms. We demonstrate that in addition to the recognized clinical benefits of the less invasive TEM approach, there are substantial economic benefits. METHOD: We reviewed our prospective database of patients undergoing TEM excision of a rectal lesion between July 1997 and December 2003. A cost analysis was undertaken, including procedural and related costs of TEM and compared with the relevant open procedures. RESULTS: 124 patients (80 men, 44 women) with a median age of 71.5 years underwent TEM excision of rectal lesions (52 cancers and 72 adenomas). The morbidity rate was 8% and mortality was zero. A controlled case series of 52 patients undergoing open resection for early rectal cancers with similar characteristics as above was compared in terms of clinical outcome. The morbidity rate in these patients was 29.5%. The cost analysis comparison was undertaken using National Health Service mean reference costs for major large intestinal surgery, Intensive care unit/high dependency unit and hospital accommodation for each procedure. The average cost of open resection was 4135 pound, vs 567 pound for TEM excision. Our total saving over the series was 525,576 pound. Although the initial capital cost of the TEM equipment is high at approximately 40,000 pound given the massive cost savings, these initial equipment costs are recovered within a rapid time frame. CONCLUSION: This study has shown that TEM is a safe and extremely cost-effective approach for excision of selected rectal tumours including rectal adenomas and early well differentiated rectal cancers (pTis & pT1).

Transanal endoscopic microsurgery--impact on the practice of a colorectal surgeon in a district general hospital.

INTRODUCTION: The objective was to assess the impact on the management of colorectal patients treated in a district general hospital within the first year after the introduction of transanal endoscopic microsurgery (TEM). PATIENTS AND METHODS: Data were collected for consecutive unselected patients who underwent TEM. Comparative data were derived from a matched group of patients who underwent anterior resection, peranal procedures (PAR) or transanal resection (TAR) in this unit. RESULTS: Twenty-two patients underwent TEM (11 men and 11 women; aged, 29-87 years; median, 75 years). Eighteen patients had a pre-operative diagnosis of benign rectal neoplasms; three were found to have invasive carcinoma, which might have been missed during TAR. Four patients had a pre-operative diagnosis of rectal cancer and TEM provided local tumour control in three cases. The operating time ranged between 20-150 min (mean, 65 min; median, 57 min). Hospital stay ranged between 0-10 days (mean, 3.7 days; median, 3 days), with a total of 97 in-patient days for the entire group of patients. Twenty-four operations were performed (22 TEM and two salvage anterior resections), with an estimated cost of 1544 pounds sterling for consumables used. Alternative treatments in the absence of TEM were considered to involve 10 anterior resections, 5 closures of ileostomy, 30 TAR procedures and one PAR procedure, with an estimated 306 days of in-patient admission, 46 operations and 6245 pounds sterling spent on consumables. CONCLUSIONS: Availability of TEM allows more efficient treatment for a significant number of patients with rectal tumours. The cost of the equipment is offset by a significant decrease in the length of in-patient admissions.

Transanal endoscopic excision of rectal adenomas.

Transanal endoscopic microsurgery (TEM) is a minimally invasive surgical technique for performing local excision of rectal lesions in the mid and upper rectum that would otherwise be inaccessible for local excision by the direct transanal approach. In the absence of this approach, low anterior resection would be required, which is major abdominal surgery. The justification for excising adenomas of the colon and rectum is their malignant potential, which correlates with the size of the lesion. This retrospective review examines our experience using TEM for excision of adenomas of the rectum from February 1991 to the present. The decision for using TEM is based on a precise localization of the lesion with particular attention to the upper margin of the lesion and its diameter. A total of 56 adenomas were removed. The average diameter was 4.9 cm (range, 3-8 cm). The average distance from the anal verge was 7.92 cm (range, 5-12 cm). Carcinoma in situ was seen in 7 lesions, and the remaining lesions were benign. Morbidity was minimal, with one conversion to an open procedure for an intraperitoneal perforation that required a low anterior resection. No patient required transfusion and there was no mortality. The hospital stay was short, with half of the patients being discharged the same day. The average cost from July 1996 to December 1999 was 7775 dollars for TEM versus 34,018 dollars for LAR. Subsequent follow-up average was 38.8 months (range, 1-100 months), during which time two patients had recurrence of their adenomas. This was successfully treated with reexcision. In conclusion, TEM is an accurate, safe, and relatively inexpensive technique when compared to low anterior resection. This technique significantly reduces the proportion of adenomas requiring abdominal surgery.

Combining ultrasonic dissection and the Storz operation rectoscope.

BACKGROUND: Transanal endoscopic microsurgery (TEM) allows a precise, full-thickness resection of rectal tumors anywhere within the rectum. Unfortunately, the standard TEM technique needs complex and rather expensive equipment, demands high skill, and is attended by bleeding and oozing that may be challenging. A modified TEM procedure combining the new Storz operation rectoscope and ultrasonic dissection has been developed to overcome the limitations of the original technique. METHODS: The Storz operation rectoscope features a 5-mm telescope combined with a single-monitor display. Standard laparoscopic instruments and the LCSC5 Ultracision Maniple are used for dissection and coagulation. Full-thickness resection is performed most often. Closure of the defect is accomplished by interrupted 3-0 polydoxanone sutures secured by extracorporeal slipknots. RESULTS: Altogether, 18 TEMs have been performed according to the modified technique: 9 for malignant and 9 for benign lesions. The median operating time was 92.5 min for resection of malignant lesions and 40 min for resection of benign lesions. Two postoperative complications occurred: a bleeding and a partial dehiscence. The median follow-up periods were 35 months for malignant disease and 19.5 months for benign disease. No recurrence was observed. CONCLUSION: For tumors located up to 15 cm from the anal verge, TEM with the Storz rectoscope and ultrasonic dissection is indicated. Despite the complication described, coagulation is optimal and ultrasonic scissors allow working in a fairly bloodless field. The overall costs of the equipment are significantly lower.

Hemorrhoid banding using videoendoscopic anoscopy and a single-handed ligator: an effective, inexpensive alternative to endoscopic band ligation.

OBJECTIVE: We evaluated a technique of hemorrhoid banding using videoscopic anoscopy and a single-handed ligator that offers substantial cost savings over endoscope-mounted devices. METHODS: Patients with rectal bleeding from grade II/III hemorrhoids had videoscopic anoscopy, which provided a magnified view, allowing accurate localization of the hemorrhoids and the dentate line before banding, and a photographic record, if required. Banding was performed using a suction ligator that could be operated by one hand, allowing the other to control the anoscope. RESULTS: Of 39 patients with second- and third-degree hemorrhoids, 34 (87%) had no further bleeding after a single banding session and a further three had no recurrence after a second session. The only complications were pain (one patient) and infection (one patient). CONCLUSIONS: This method is convenient and effective, costing per procedure less than one-tenth of endoscope-mounted band ligators. We recommend its use in preference if magnified views and a photographic record are required. However, its cost and complexity, compared with traditional hemorrhoid banding, may mean that the latter is preferred in the office setting.

Type of health care coverage and the likelihood of being screened for cancer.

OBJECTIVES: This study explored whether type of outpatient health coverage affected the likelihood of men and women aged 20 to 64 years receiving recommended cancer screening procedures. METHODS: Data from the 1989 and 1990 California Behavioral Risk Factor Surveillance Surveys were used to compare Pap smear, mammogram, fecal occult blood test, and proctoscopic examination rates for adults with three different types of private health care coverage (Group/staff model health maintenance organization, Independent Practice Association Model health maintenance organization, indemnity plan) and no outpatient health insurance. Logistic regression models were used to control for sociodemographic and health characteristics and whether individuals had a usual health care provider. RESULTS: Individuals with Group Model health maintenance organization coverage were significantly more likely than those with indemnity plans to have had recent cervical, breast, and colorectal cancer screening, whereas screening likelihood for those with Independent Practice Association model health maintenance organization coverage did not differ substantially from those with indemnity plans. Individuals with no outpatient coverage were less likely to be screened than those with outpatient coverage. The most consistently significant predictor across cancer screening procedures for both men and women was having a usual doctor who knew their medical history. CONCLUSIONS: Adults who had private outpatient insurance were more likely to undergo recommended cancer detection procedures than those who did not. Adults who belonged to a health maintenance organization, which emphasizes and pays for a broader spectrum preventive care, were more likely to receive Pap smears, mammograms, and fecal occult blood tests than those covered by indemnity plans. Receiving care primarily from one doctor significantly increased the likelihood of having screening procedures, irrespective of type of health plan.

Evaluation and therapy of the patient with fecal occult blood loss: a decision analysis.

We performed a decision analysis to evaluate cost per cancer detected, cost per neoplasm detected, and cost per treatable lesion of two common diagnostic strategies, barium enema-proctoscopy or colonoscopy as the first diagnostic test, for patients with fecal occult blood loss. The prevalence of polyps, cancer, and angiodysplasia, and the colonoscopy success rate were obtained from consecutive colonoscopy records. Costs were estimated from hospital charges; sensitivity and specificity of barium enema and colonoscopy were obtained from the literature. For treatable lesions (cancer, polyps, and angiodysplasia), the colonoscopy first strategy had a higher sensitivity (80% vs. 57%) and a higher specificity (95% vs. 80%) than the barium enema first strategy. Cost effectiveness measures were similar for the two strategies. Colonoscopy as the first diagnostic test had a lower cost per treatable lesion ($2,319 vs. $2,895) and a lower cost per neoplasm detected ($2,694 vs. $2,896), whereas the barium enema first strategy had a lower cost per cancer detected ($10,050 vs. $10,297). The lower cost per treatable lesion of the colonoscopy first strategy was not affected by changes in the prevalence of lesions, test characteristics, costs of tests, or colonoscopy success rate over clinically relevant ranges. The higher cost of colonoscopy was offset by its greater sensitivity and its capacity for biopsy and therapy. Therefore, since the cost per treatable lesion is lower and the sensitivity, specificity, and predictive value is superior, colonoscopy is recommended as the preferred initial test in evaluating a patient with fecal occult blood loss.

Fiberoptic colonoscopic examination in surgical patients with colorectal cancer.

A diagnostic and surveillance program using colonscopy in patients with colorectal cancer was established at North Carolina Memorial Hospital. The records of all patients who had preoperative or postoperative colonoscopic examination between 1976 and 1979 were reviewed. Fifty-five patients had colonscopic examination preoperatively. No additional disease was found in 39. In 15 patients, unsuspected additional disease was detected, and one patient had a suspected polyp ruled out by colonoscopic examination. One of these patients was found to have a synchronous primary cancer, not demonstrated by barium enema. Surgical treatment was modified in nine (16%) of these 55 patients by the preoperative colonoscopic findings. Sixty patients had colonoscopy six months to six years postoperatively. No additional disease was found in 47. Adenomatous polyps were found in eight. Two patients had recurrent cancer proved by colonoscopy, and three had a second primary cancer detected only by colonoscopy. Treatment was directly influenced by colonoscopy in eight (13.3%) of these 60 patients. These studies had a favorable cost/benefit ratio in patients with colorectal cancer and support a program of preoperative colonoscopy in patients with colorectal cancer and reexamination within two to three years after operation.