RESUMEN
BACKGROUND: Colorectal anastomotic leakage causes severe consequences for patients and healthcare system as it will lead to increased consumption of hospital resources and costs. Technological improvements in anastomotic devices could reduce the incidence of leakage and its economic impact. The aim of the present study was to assess if the use of a new powered circular stapler is cost-effective. METHOD: This observational study included patients undergoing left-sided circular stapled colorectal anastomosis between January 2018 and December 2021. Propensity score matching was carried out to create two comparable groups depending on whether the anastomosis was performed using a manual or powered circular device. The rate of anastomotic leakage, its severity, the consumption of hospital resources, and its cost were the main outcome measures. A cost-effectiveness analysis comparing the powered circular stapler versus manual circular staplers was performed. RESULTS: A total of 330 patients were included in the study, 165 in each group. Anastomotic leakage rates were significantly different (p = 0.012): 22 patients (13.3%) in the manual group versus 8 patients (4.8%) in the powered group. The effectiveness of the powered stapler and manual stapler was 98.27% and 93.69%, respectively. The average cost per patient in the powered group was 6238.38, compared with 9700.12 in the manual group. The incremental cost-effectiveness ratio was - 74,915.28 per patient without anastomotic complications. CONCLUSION: The incremental cost of powered circular stapler compared with manual devices was offset by the savings from lowered incidence and cost of management of anastomotic leaks.
Asunto(s)
Anastomosis Quirúrgica , Fuga Anastomótica , Colon , Análisis Costo-Beneficio , Recto , Engrapadoras Quirúrgicas , Grapado Quirúrgico , Humanos , Fuga Anastomótica/prevención & control , Fuga Anastomótica/economía , Fuga Anastomótica/etiología , Femenino , Engrapadoras Quirúrgicas/economía , Masculino , Anastomosis Quirúrgica/efectos adversos , Anastomosis Quirúrgica/economía , Anastomosis Quirúrgica/instrumentación , Anastomosis Quirúrgica/métodos , Persona de Mediana Edad , Anciano , Incidencia , Grapado Quirúrgico/economía , Grapado Quirúrgico/métodos , Grapado Quirúrgico/efectos adversos , Grapado Quirúrgico/instrumentación , Colon/cirugía , Recto/cirugía , Puntaje de Propensión , Adulto , Análisis de Costo-EfectividadRESUMEN
BACKGROUND: Anastomotic leakage (AL) remains a burdensome complication following colorectal surgery, with increased morbidity, oncological compromise, and mortality. AL may impose a substantial financial burden on hospitals and society due to extensive resource utilization. Estimated costs associated with AL are important when exploring preventive measures and treatment strategies. The purpose of this study was to systematically review the existing literature on (socio)economic costs associated with AL after colorectal surgery, appraise their quality, compare reported outcomes, and identify knowledge gaps. METHODS: Health economic evaluations reporting costs related to AL after colorectal surgery were identified through searching multiple online databases until June 2023. Pairs of reviewers independently evaluated the quality using an adapted version of the Consensus on Health Economic Criteria list. Extracted costs were converted to 2022 euros () and also adjusted for purchasing power disparities among countries. RESULTS: From 1980 unique abstracts, 59 full-text publications were assessed for eligibility, and 17 studies were included in the review. The incremental costs of AL after correcting for purchasing power disparity ranged from 2250 (+39.9%, Romania) to 83,633 (+ 513.1%, Brazil). Incremental costs were mainly driven by hospital (re)admission, intensive care stay, and reinterventions. Only one study estimated the economic societal burden of AL between 1.9 and 6.1 million. CONCLUSIONS: AL imposes a significant financial burden on hospitals and social care systems. The magnitude of costs varies greatly across countries and data on the societal burden and non-medical costs are scarce. Adherence to international reporting standards is essential to understand international disparities and to externally validate reported cost estimates.
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Fuga Anastomótica , Humanos , Fuga Anastomótica/economía , Fuga Anastomótica/etiología , Costos de la Atención en Salud/estadística & datos numéricos , Cirugía Colorrectal/efectos adversos , Cirugía Colorrectal/economía , Costo de Enfermedad , Recto/cirugíaRESUMEN
OBJECTIVES: Our goal was to assess the postoperative 90-day hospital costs of patients with prolonged air leak (PAL) including costs incurred after discharge from the initial index hospitalization. METHODS: We performed a retrospective analysis of 982 patients undergoing lobectomy (898) or segmentectomy (78) (April 2014-August 2018). A total of 167 operations were open, 780 were video-assisted thoracoscopic surgery and 28 were robotic. A PAL was defined as an air leak >5 days. The 90-day postoperative costs included all fixed and variable costs incurred during the 90 days following surgery. The postoperative costs of patients with and without PAL were compared. The independent association of PAL with postoperative 90-day costs was tested after adjustment for patient-related factors and other complications by a multivariable regression analysis. RESULTS: PAL occurred in 261 patients (27%). Their postoperative stay was 4 days longer than that of those without PAL (9.6 vs 5.7; P < 0.0001). Compared to patients without PAL, those with PAL had 27% higher index postoperative costs [7354, standard deviation (SD) 7646 vs 5759, SD 7183, P < 0.0001] and 40% higher 90-day postoperative costs (18 340, SD 23 312 vs 13 102, SD 10 264; P < 0.0001). The relative postoperative costs (the difference between 90-day and index postoperative costs) were 50% higher in PAL patients compared to non-PAL patients (P < 0.0001) and accounted for 60% of the total 90-day costs. Multivariable regression analysis showed that PAL remained an independent factor associated with 90-day costs (P < 0.0001) along with the occurrence of other cardiopulmonary complications (P < 0.0001), male gender (P = 0.018), low carbon monoxide lung diffusion capacity (P = 0.043) and thoracotomy approach (P = 0.022). CONCLUSIONS: PAL is associated not only with increased index hospitalization costs but also with increased costs after discharge. Evaluation of the cost-effectiveness of measures to prevent air leaks should also include post-discharge costs.
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Cuidados Posteriores/economía , Fuga Anastomótica/economía , Costos de Hospital , Neoplasias Pulmonares/cirugía , Neumonectomía/efectos adversos , Complicaciones Posoperatorias/economía , Cirugía Torácica Asistida por Video/efectos adversos , Adulto , Anciano , Femenino , Estudios de Seguimiento , Humanos , Neoplasias Pulmonares/economía , Masculino , Persona de Mediana Edad , Alta del Paciente , Neumonectomía/economía , Estudios Retrospectivos , Cirugía Torácica Asistida por Video/economía , Factores de TiempoRESUMEN
BACKGROUND: Anastomotic leaks cause a significant clinical and economic burden on patients undergoing bariatric and colorectal surgeries. Current literature shows a wide variation in incidence of anastomotic leaks and a significant gap in associated economic metrics. This analysis utilized claims data to quantify the full episode-of-care cost burden of leaks following colorectal and bariatric surgeries. METHODS: Medicare Fee-for-Service and commercial claims data from a large U.S.-based health plan were queried for cost and utilization of members that underwent bariatric and colorectal surgical procedures between January 1, 2013 and August 31, 2015. Outcomes were collected for members with anastomotic leaks versus those without leaks during the initial hospital stay (index) and within 30 days of the procedure. These outcomes included leak frequency, payer reimbursement, and length of stay (LOS). RESULTS: The colorectal Medicare analysis identified 239,350 patients undergoing colorectal surgery. For patients with a leak compared to those without, index admission costs were $30,670 greater ($48,982 vs. $18,312; p < 0.0001) and the index LOS was 12 days longer (19 vs. 7 days; p < 0.0001). This finding was similar for the bariatric patients (n = 62,292) where cost was $30,885 higher ($43,918 vs. $13,033; p < 0.0001) and LOS was 15 days longer (17 vs. 2 days; p < 0.0001). Furthermore, readmissions and associated costs were also substantially higher for those with an index leak. The commercial analysis of both the bariatric and colorectal populations trended similarly to the Medicare population in regards to all outcomes measured. CONCLUSION: Patients experiencing anastomotic leaks during and after bariatric and colorectal surgery have significantly higher costs and longer LOS both at the initial stay and within 30 days of the procedure. It is important that providers and hospitals understand the economic consequences of these procedures and implement technologies and techniques to prevent/reduce anastomotic leaks.
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Fuga Anastomótica/economía , Cirugía Bariátrica/efectos adversos , Cirugía Bariátrica/economía , Cirugía Colorrectal/efectos adversos , Cirugía Colorrectal/economía , Costo de Enfermedad , Adulto , Anciano , Fuga Anastomótica/etiología , Femenino , Humanos , Pacientes Internos , Tiempo de Internación/economía , Masculino , Medicare/economía , Persona de Mediana Edad , Readmisión del Paciente , Estudios Retrospectivos , Factores de Riesgo , Estados Unidos , Adulto JovenRESUMEN
BACKGROUND: We used a population-based database to: (1) compare clinical and economic outcomes between minimally invasive surgery (MIS) and open surgery (OS) for colectomy; and (2) evaluate contemporary trends in MIS rates. METHODS: Retrospective Premier Healthcare Database review of patients undergoing elective inpatient colectomy between January 1, 2010 and September 30, 2017 (first = index admission). Patients were classified into MIS (laparoscopic/robotic) or OS groups, and by left or right colectomy. Propensity score matching (1:1 ratio) of MIS and OS groups was used to address potential confounding from patient/hospital/provider characteristics. Study outcomes, measured during index admission, included major perioperative complications [anastomotic leak (AL), bleeding, infection, and a composite of infection/AL], operating room time (ORT), length of stay (LOS), and total hospital costs. RESULTS: Among 134,970 study-eligible patients, MIS rates increased from ~ 2% (2010) to 19-23% (2017), driven by a > tenfold increase in robotic surgery. The matched MIS and OS colectomy groups comprised 46,708 (left) and 44,560 (right) total patients. Risks of AL, bleeding, and infection were lower for MIS versus OS (all p < 0.001). In left: AL occurred in 7.9% of MIS versus 9.9% of OS; bleeding 7.8% versus 9.7%; infection 3.3% versus 5.8%; infection/AL 9.8% versus 13.3%. In right: AL 8.9% versus 11.1%; bleeding 9.8% versus 10.8%; infection 3.0% versus 5.1%; infection/AL 10.5% versus 10.4%. Although ORTs were longer with MIS (left: 240.8 vs. 216.2 min; right: 192.8 vs. 178.0 min), LOS was shorter (left: 5.4 vs. 7.1 days; right: 5.5 vs. 7.1 days), and total hospital costs were lower (left: $18,564 vs. $19,960; right: $17,375 vs. $19,417) versus OS (all p < 0.001). CONCLUSIONS: Compared with OS, MIS was associated with significantly lower risk of major perioperative complications (including AL), lower LOS, and lower total hospital costs, despite longer OR times. MIS colectomy rates have increased over time; recent gains appear to be due to uptake of robotic surgery.
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Fuga Anastomótica/prevención & control , Colectomía/métodos , Recursos en Salud/economía , Costos de Hospital , Procedimientos Quirúrgicos Mínimamente Invasivos/métodos , Evaluación de Resultado en la Atención de Salud , Puntaje de Propensión , Adolescente , Adulto , Anciano , Fuga Anastomótica/economía , Fuga Anastomótica/epidemiología , Femenino , Hospitalización/economía , Humanos , Incidencia , Tiempo de Internación/economía , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Estados Unidos/epidemiología , Adulto JovenRESUMEN
BACKGROUND: Complications after surgery for esophageal cancer are associated with significant resource utilization. The aim of this study was to analyze the economic burden of two frequently used endoscopic treatments for anastomotic leak management after esophageal surgery: Treatment with a Self-expanding Metal Stent (SEMS) and Endoscopic Vacuum Therapy (EVT). MATERIALS AND METHODS: Between January 2012 and December 2016, we identified 60 German-Diagnosis Related Group (G-DRG) cases of patients who received a SEMS and / or EVT for esophageal anastomotic leaks. Direct costs per case were analyzed according to the Institute for Remuneration System in Hospitals (InEK) cost-accounting approach by comparing DRG payments on the case level, including all extra fees per DRG catalogue. RESULTS: In total, 60 DRG cases were identified. Of these, 15 patients were excluded because they received a combination of SEMS and EVT. Another 6 cases could not be included due to incomplete DRG data. Finally, N = 39 DRG cases were analyzed from a profit-center perspective. A further analysis of the most frequent DRG code -G03- including InEK cost accounting, revealed almost twice the deficit for the EVT group (N = 13 cases, - 9.282 per average case) compared to that for the SEMS group (N = 9 cases, - 5.156 per average case). CONCLUSION: Endoscopic treatments with SEMS and EVT for anastomotic leaks following oncological Ivor Lewis esophagectomies are not cost-efficient for German hospitals. Due to longer hospitalization and insufficient reimbursements, EVT is twice as costly as SEMS treatment. An adequate DRG cost compensation is needed for SEMS and EVT.
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Costo de Enfermedad , Neoplasias Esofágicas/economía , Esofagectomía/economía , Esófago/cirugía , Adulto , Anciano , Anciano de 80 o más Años , Fuga Anastomótica/economía , Endoscopía/economía , Neoplasias Esofágicas/patología , Neoplasias Esofágicas/cirugía , Esófago/patología , Femenino , Humanos , Masculino , Persona de Mediana Edad , Stents Metálicos Autoexpandibles/economía , VacioRESUMEN
BACKGROUND: Although diverting stomas have reduced anastomotic leak rates after sphincter-preserving proctectomy in some series, the effectiveness of routine diversion among a broad population of rectal cancer patients remains controversial. We hypothesized that routine temporary diversion is not associated with decreased rates of leak or reintervention in cancer patients at large undergoing sphincter-sparing procedures. STUDY DESIGN: The Florida State Inpatient Database (AHRQ, Healthcare Cost and Utilization Project) was queried for patients undergoing sphincter-preserving proctectomy for cancer (2005 to 2014). Matched cohorts defined by diversion status were created using propensity scores based on patient and hospital characteristics. Incidence of anastomotic leak, nonelective reintervention, and readmission were compared, and cumulative 90-day inpatient costs were calculated. RESULTS: Of 8,620 eligible sphincter-sparing proctectomy patients, 1,992 matched pairs were analyzed. Leak rates did not significantly vary between groups (4.5% vs 4.3%; p = 0.76), but diversion was associated with significantly higher odds of nonelective reintervention (2.37; 95% CI 1.90 to 2.96) and readmission (1.55; 95% CI 1.33 to 1.81) compared with undiverted patients. Median costs were higher among those diverted (US$21,325 vs US$15,050; p < 0.01). CONCLUSIONS: No association between diversion and anastomotic leak was found. However, temporary diversion was associated with increased incidence of nonelective reinterventions, readmissions, and higher costs. We therefore challenge the paradigm of routine diversion in rectal cancer operations. Additional study is needed to identify which patients would benefit most from diversion.
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Canal Anal/cirugía , Tratamientos Conservadores del Órgano/métodos , Proctectomía/métodos , Neoplasias del Recto/cirugía , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Fuga Anastomótica/economía , Fuga Anastomótica/epidemiología , Fuga Anastomótica/etiología , Fuga Anastomótica/prevención & control , Bases de Datos Factuales , Femenino , Florida , Estudios de Seguimiento , Costos de Hospital/estadística & datos numéricos , Humanos , Masculino , Análisis por Apareamiento , Persona de Mediana Edad , Tratamientos Conservadores del Órgano/economía , Readmisión del Paciente/economía , Readmisión del Paciente/estadística & datos numéricos , Proctectomía/economía , Puntaje de Propensión , Neoplasias del Recto/economía , Reoperación/economía , Reoperación/estadística & datos numéricos , Estudios Retrospectivos , Factores de Riesgo , Adulto JovenRESUMEN
OBJECTIVES: The economic burden of surgical complications is borne in distinctly different ways by hospitals and payers. This study quantified the incidence and economic burden - from both the hospital and payer perspective - of selected major colorectal surgery complications in patients undergoing low anterior resection (LAR) for colorectal cancer. METHODS: Retrospective, observational study of patient undergoing LAR for colorectal cancer between 1/1/2010 and 7/1/2015. Analyses were replicated in two large healthcare administrative databases: Premier (hospital discharge and billing data; hospital perspective) and Optum (insurance claims data; payer perspective). Multivariable analyses evaluated the association between infection (surgical site or bloodstream), anastomotic leak, and bleeding complications and the following outcomes: hospital length of stay (LOS), non-home discharge, 90-day all-cause readmission, index admission costs to the hospital, index admission payer expenditures, and index admission +90-day post-discharge payer expenditures. RESULTS: 9,738 eligible LAR patients were included (7,479 in Premier; 2,259 in Optum). Overall, the incidences of infection, anastomotic leak, and bleeding complications were 6.4%, 10.6%, and 10.9%, respectively, during the index hospitalization. Each complication was associated with statistically significant longer LOS, higher risk of non-home discharge, higher risk of 90-day readmission, greater costs to the hospital, and higher payer expenditures. CONCLUSIONS: In-hospital infection, anastomotic leak, and bleeding were associated with a substantial economic burden, for both hospitals and payers, in patients undergoing LAR for colorectal cancer. This study provides information which may be used to quantify the potential economic value and impact of innovations in surgical care and delivery that reduce the incidence and burden of these complications.
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Neoplasias Colorrectales/economía , Readmisión del Paciente/economía , Complicaciones Posoperatorias/economía , Evaluación de Procesos, Atención de Salud/economía , Adulto , Fuga Anastomótica/economía , Colon/cirugía , Neoplasias Colorrectales/epidemiología , Neoplasias Colorrectales/cirugía , Femenino , Humanos , Tiempo de Internación/economía , Masculino , Persona de Mediana Edad , Alta del Paciente/economía , Readmisión del Paciente/estadística & datos numéricos , Complicaciones Posoperatorias/epidemiología , Evaluación de Procesos, Atención de Salud/estadística & datos numéricos , Estudios Retrospectivos , Factores de RiesgoRESUMEN
OBJECTIVE: The purpose of this retrospective cohort study was to evaluate resource consumption of clinically significant esophageal anastomotic leaks. METHODS: Between September 1, 2008, to December 31, 2014, a prospectively maintained database was queried to identify patients with grade III to IV anastomotic leaks after esophagectomy for esophageal cancer. Inflation-adjusted standardized costs were applied to billed services related to leak diagnosis and treatment, from time of leak detection to resumption of oral diet. A matched analysis was used to compare average expenditures in patients without vs. those with an anastomotic leak. RESULTS: Of 448 patients undergoing esophagectomy after neoadjuvant treatment, 399 patients met inclusion criteria. Twenty-four grade III to IV anastomotic leaks were identified (6% leak rate). Five transhiatal esophagectomies accounted for 20.8% of cases, whereas 9 Ivor Lewis and 10 McKeown esophagectomies accounted for 37.5% and 41.7%, respectively. The median time required to treat an anastomotic leak was 73 days (range 14-701). The additional median standardized cost per leak was $68,296 (mean $119,822). Matched analysis demonstrated that mean treatment costs were 2.6 times greater for patients with an anastomotic leak. This was primarily attributed to prolonged hospitalization, with post-leak detection length of stay ranging from 7 to 73 days. The largest contributors to cost for all patients were intensive care stay (30%), hospital room (17%), pharmacy (16%), and surgical intervention (13%). CONCLUSIONS: Grade III to IV esophageal anastomotic leaks more than double the cost of an esophagectomy and have a significant cost burden. Focus should be placed on preventative measures to avoid leaks at the time of the index operation.
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Fuga Anastomótica/economía , Fuga Anastomótica/terapia , Neoplasias Esofágicas/economía , Neoplasias Esofágicas/cirugía , Esofagectomía/economía , Costos de Hospital , Anciano , Fuga Anastomótica/etiología , Costo de Enfermedad , Cuidados Críticos/economía , Bases de Datos Factuales , Costos de los Medicamentos , Esofagectomía/efectos adversos , Femenino , Gastos en Salud , Humanos , Tiempo de Internación/economía , Masculino , Persona de Mediana Edad , Reoperación/economía , Estudios Retrospectivos , Factores de Riesgo , Factores de Tiempo , Tiempo de Tratamiento , Resultado del TratamientoRESUMEN
INTRODUCTION: Routine use of postoperative upper gastrointestinal (UGI) contrast studies after sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) is controversial. We sought to determine the usefulness of routine UGI contrast studies during postoperative day (POD) 1 in patients who underwent bariatric surgery. METHODS: We performed a retrospective study of patients who underwent SG or RYGB between January 1, 2016, and October 31, 2017. Demographics, surgical data, and immediate surgical adverse effects were collected. We compared patients who underwent routine UGI contrast studies on POD 1 versus patients who did not. RESULTS: A total of 284 patients were analyzed; 197 (69.4%) patients underwent RYGB, while 87 (30.6%) underwent SG. Routine UGI contrast study was performed in 96 (48.7%) patients in the RYGB group versus 31 (35.6%) in the SG group. The overall adverse effect rate was 2 (0.7%); postoperative UGI contrast study was negative in both cases. Mean (SD) length of stay (LOS) for patients who underwent UGI contrast study versus those who did not was similar in the RYGB group (1.8 [1.6] days vs 1.8 [0.9] days, respectively) and the SG group (2 [1.18] days vs 1.9 [0.9] days). The average cost of a postoperative UGI contrast study was $600, resulting in an additional overall cost of $76,800. CONCLUSION: Use of routine UGI contrast studies after bariatric procedures does not appear to add clinical value for the detection of leaks. Furthermore, systematic use of postoperative UGI contrast studies neither seem to reduce LOS, nor appear to increase procedure costs.
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Cirugía Bariátrica/efectos adversos , Obesidad Mórbida/cirugía , Complicaciones Posoperatorias/diagnóstico por imagen , Adulto , Anciano de 80 o más Años , Fuga Anastomótica/diagnóstico por imagen , Fuga Anastomótica/economía , Fuga Anastomótica/etiología , Cirugía Bariátrica/economía , Cirugía Bariátrica/métodos , Medios de Contraste , Femenino , Florida , Gastrectomía/efectos adversos , Gastrectomía/economía , Gastrectomía/métodos , Derivación Gástrica/efectos adversos , Derivación Gástrica/economía , Derivación Gástrica/métodos , Costos de Hospital/estadística & datos numéricos , Humanos , Tiempo de Internación/estadística & datos numéricos , Masculino , Persona de Mediana Edad , Obesidad Mórbida/economía , Cuidados Posoperatorios/economía , Cuidados Posoperatorios/métodos , Complicaciones Posoperatorias/economía , Complicaciones Posoperatorias/etiología , Radiografía Abdominal/economía , Estudios Retrospectivos , Procedimientos Innecesarios , Adulto JovenRESUMEN
BACKGROUND: Anastomotic leakage after colorectal surgery is a complication that requires additional treatments strongly affecting the economic outcomes. We evaluated the use of resources and the economic burden associated with anastomotic leaks following colorectal surgery. METHODS: Between January 2015 and December 2016, we retrospectively evaluated patients who underwent colorectal surgery with primary anastomosis. We compared the medical resource utilization and the DRG-based reimbursement of cases with uncomplicated surgery and cases complicated by anastomotic leakage. RESULTS: Of the 95 patients included in the study, 87 (92%) presented an uneventful postoperative course and 8 patients (8%) developed an anastomotic leakage requiring surgery. The statistical analysis showed no significant differences in terms of demographics, risks factor, and operative results, except the length of hospital stay (9.7 vs. 29.1 days, p < 0.01). The cost for 87 uncomplicated cases was 1,535,297 EUR (average cost of 17,647 EUR), whereas the cost of the 8 patients with anastomotic leakage was 575,822 EUR (average cost of 71,978 EUR) (p < 0.01). For each patient, the hospital had 542 EUR profit in the uncomplicated group and a 12,181 EUR loss in the anastomotic leakage group (p < 0.01). The multiple R-squared line regression analysis showed that factors independently related to costs were age (p = 0.05) and length of hospital stay (p = 0.01). CONCLUSIONS: In terms of economic impact, the occurrence of an anastomotic leakage has a large negative influence on medical resource utilization, so that, despite the complication-related increase of DRG-reimbursement, every complicated case represents a financial burden for the hospital.
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Fuga Anastomótica/economía , Procedimientos Quirúrgicos del Sistema Digestivo/efectos adversos , Costos de la Atención en Salud , Anciano , Anastomosis Quirúrgica/efectos adversos , Fuga Anastomótica/etiología , Femenino , Humanos , Tiempo de Internación/tendencias , Masculino , Persona de Mediana Edad , Periodo Posoperatorio , Estudios RetrospectivosRESUMEN
BACKGROUND: Chyle leak is an uncommon complication after pancreatic surgery. The chyle leak incidence, definition, diagnosis, and treatment had been reported heterogeneously so far. Recently a consensus definition and grading system was published by the International Study Group for Pancreatic Surgery. This study aims to evaluate the differences in the clinical and economic burden of chyle leak applying the new definition. METHODS: All data from patients who underwent pancreatic surgery for any disease from January 2014 to December 2016 were retrieved from the institutional prospective database. The 2017 International Study Group for Pancreatic Surgery definition and classification were applied. The classification was validated analyzing the differences in major complications, length of stay, and hospitalization costs. RESULTS: A total of 945 patients was the final population. A chyle leak was reported in 43 patients (4.5%). Grade A chyle leak occurred in 10 patients (23.3%), Grade B chyle leak in 31 patients (72.1%), and Grade C chyle leak in 2 patients (4.6%). Chyle leak occurred as unique postoperative complication in 29 cases (67.4%). The economic analysis showed that the average costs of the 3 grades were 2,806, 7,150 and 15,684 euros respectively (P < .001). Furthermore, the length of stay, the rates of septic events, and major complications were significantly different among the 3 grades (Pâ¯=â¯.008, Pâ¯=â¯.004, and P < .001, respectively). Of note, we did not find any intraoperative factor associated with chyle leak. CONCLUSION: The present study confirms the validity of the International Study Group for Pancreatic Surgery classification of chyle leak. The 3 grades of chyle leak proposed identify reliably clinical and economical differences among the chyle leak cases.
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Fuga Anastomótica/diagnóstico , Fuga Anastomótica/epidemiología , Quilo , Pancreatectomía/efectos adversos , Enfermedades Pancreáticas/cirugía , Pancreaticoduodenectomía/efectos adversos , Anciano , Fuga Anastomótica/economía , Estudios de Cohortes , Femenino , Costos de Hospital , Humanos , Tiempo de Internación , Masculino , Persona de Mediana Edad , Enfermedades Pancreáticas/complicaciones , Enfermedades Pancreáticas/diagnóstico , Reproducibilidad de los Resultados , Índice de Severidad de la EnfermedadRESUMEN
BACKGROUND: Gastric leak is the most feared surgical postoperative complication after sleeve gastrectomy. An endoscopic procedure is usually required to treat the leak. No data are available on the cost-effectiveness of different stent types in this procedure. METHODS: Between April 2005 and July 2016, patients with a confirmed gastric leak undergoing endoscopic treatment using a covered stent (CS) or double-pigtail stent (DPS) were included. The primary objective of the study was to assess overall costs of the stent types after primary sleeve gastrectomy. Secondary objectives were the cost-effectiveness of each stent type expressed as an incremental cost-effectiveness ratio (ICER); the incremental net benefit; the probability of efficiency, defined as the probability of being cost-effective at a threshold of 30 000, and identification of the key drivers of ICER derived from a multivariable analysis. RESULTS: One hundred and twelve patients were enrolled. The overall mean costs of gastric leak were 22 470; the mean(s.d.) cost was 24 916(12 212) in the CS arm and 20 024(3352) in the DPS arm (P = 0·018). DPS was more cost-effective than CS (ICER 4743 per endoscopic procedure avoided), with an incremental net benefit of 25 257 and a 27 per cent probability of efficiency. Key drivers of the ICER were the inpatient ward after diagnosis of gastric leak (surgery versus internal medicine), type of institution (private versus public) and duration of hospital stay per endoscopic procedure. CONCLUSION: DPS for the treatment of gastric leak is more cost-effective than CS and should be proposed as the standard regimen whenever possible.
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Fuga Anastomótica/cirugía , Gastrectomía/métodos , Gastroscopía/economía , Laparoscopía/métodos , Obesidad Mórbida/cirugía , Implantación de Prótesis/economía , Stents , Adulto , Fuga Anastomótica/economía , Análisis Costo-Beneficio , Femenino , Francia , Gastrectomía/economía , Gastroscopía/métodos , Humanos , Laparoscopía/economía , Tiempo de Internación/tendencias , Masculino , Obesidad Mórbida/economía , Implantación de Prótesis/métodos , Reoperación/economía , Estudios RetrospectivosRESUMEN
Temporary diverting stoma might be a protective factor for the prevention of anastomotic leakage (AL) after anterior resection. Its role in leakage recovery is unknown. This study aimed to evaluate the effect of temporary diverting stoma on anastomotic leakage severity and recovery. We analyzed 323 patients who underwent anterior resection for rectal cancer and developed anastomotic leakage, in which 44 had temporary diverting stoma. Association between diverting stoma and occurrence of anastomotic leakage, recovery time, length of hospital stay, overall costs, local and distant relapse-free survival were further studied. In non-severe AL group, temporary diverting stoma improved leakage recovery by 4 days (mean: 20.7 days vs. 16.1 days, p = 0.031), especially in patients who did not receive neoadjuvant treatment (mean time: 20.9 days vs. 14.4 days, p = 0.016). However, it did not delay the occurrence of anastomotic leakage. Moreover, no significant difference was found in the overall length of hospital stay and costs among patients with versus without a diverting stoma. In severe AL group, however, no difference was detected. The advantage of shortened leakage recovery did not reduce the local and distant relapse-free survival. In conclusion, our findings indicated the recovery benefit from diverting stoma in patients with anterior resection.
Asunto(s)
Fuga Anastomótica/etiología , Procedimientos Quirúrgicos del Sistema Digestivo/efectos adversos , Neoplasias del Recto/cirugía , Estomas Quirúrgicos , Fuga Anastomótica/economía , Femenino , Humanos , Incidencia , Tiempo de Internación , Masculino , Persona de Mediana Edad , Recurrencia Local de Neoplasia/epidemiología , Neoplasias del Recto/economía , Análisis de Supervivencia , Factores de TiempoRESUMEN
BACKGROUND: Leaks after laparoscopic sleeve gastrectomy (LSG) are serious complications of this procedure. The objective of the present study was to evaluate the costs of leaks after LSG. SETTING: Private hospital, France. METHODS: A retrospective analysis was conducted on a prospective cohort of 2012 cases of LSG between September 2005 and December 2014. Data were collected on all diagnostic and therapeutic measures necessary to manage leaks, ward, and intensive care unit (ICU) length of stay. Additional outpatient care was also analyzed. RESULTS: Twenty cases (0.99%) of gastric leak were recorded. Fifteen patients had available data for cost analysis. Of these, 13 patients were women (86.7%) with a mean age of 41.4 years (range 22-61) and mean BMI of 43.2 kg/m2 (range 34.8-57.1). The leaks occurred after 7.4 days (±2.3) postoperatively. Only one gastric leak was recorded for the last 800 cases in which absorbable staple line reinforcement was used. Mean intra-hospital cost was 34398 (range 7543-91,632 ). Prolonged hospitalization in ICU accounted for the majority of hospital costs (58.9%). Mean additional outpatient costs for leaks were 41,284 (range 14,148-75,684). CONCLUSIONS: Leaks after LSG are an expensive complication. It is therefore important to take all necessary measures to reduce their incidence. Our data should be considered when analyzing the cost effectiveness of staple line reinforcement usage.
Asunto(s)
Fuga Anastomótica/economía , Gastrectomía/efectos adversos , Costos de la Atención en Salud/estadística & datos numéricos , Laparoscopía/efectos adversos , Adulto , Fuga Anastomótica/etiología , Fuga Anastomótica/terapia , Análisis Costo-Beneficio , Femenino , Francia , Gastrectomía/economía , Gastrectomía/métodos , Humanos , Incidencia , Laparoscopía/economía , Laparoscopía/métodos , Tiempo de Internación/economía , Tiempo de Internación/estadística & datos numéricos , Masculino , Persona de Mediana Edad , Obesidad Mórbida/cirugía , Readmisión del Paciente/economía , Readmisión del Paciente/estadística & datos numéricos , Estudios Prospectivos , Estudios Retrospectivos , Estómago/cirugía , Adulto JovenRESUMEN
OBJECTIVE: The purpose of this study was to estimate the economic burden of postoperative complications after esophagectomy for cancer, in order to optimally allocate resources for quality improvement initiatives in the future. METHODS: A retrospective analysis of prospectively collected clinical and financial outcomes after esophageal cancer surgery in a tertiary referral center in the Netherlands was performed. Data was extracted from consecutive patients registered in the Dutch Upper GI Cancer Audit between 2011 and 2014 (n = 201). Costs were measured up to 90-days after hospital discharge and based on Time-Driven Activity-Based Costing. The additional costs were estimated using multiple linear regression models. RESULTS: The average total cost for one patient after esophagectomy was 37,581 (±31,372). The estimated costs of an esophagectomy without complications were 23,476 (±6496). Mean costs after minor (47%) and severe complications (29%) were 31,529 (±23,359) and 59,167 (±42,615) (p < 0.001), respectively. The 5% most expensive patients were responsible for 20.3% of the total hospital costs assessed in this study. Patient characteristics associated with additional costs in multivariable analysis included, age >70 (+2,922, p = 0.036), female gender (+4,357, p = 0.005), COPD (+5,415, p = 0.002), and a history of thromboembolic events (+6,213, p = 0.028). Complications associated with a significant increase in costs in multivariable analysis included anastomotic leakage (+4,123, p = 0.008), cardiac complications (+5,711, p = 0.003), chyle leakage (+6,188, p < 0.001) and postoperative bleeding (+31,567, p < 0.001). CONCLUSIONS: Complications and severity of complications after esophageal surgery are associated with a substantial increase in costs. Although not all postoperative complications can be prevented, implementation of preventive measures to reduce complications could result in a considerable cost reduction and quality improvement.
Asunto(s)
Neoplasias Esofágicas/cirugía , Esofagectomía , Costos de Hospital , Complicaciones Posoperatorias/economía , Factores de Edad , Anciano , Fuga Anastomótica/economía , Comorbilidad , Bases de Datos Factuales , Neoplasias Esofágicas/epidemiología , Femenino , Cardiopatías/economía , Humanos , Modelos Lineales , Masculino , Análisis Multivariante , Países Bajos/epidemiología , Hemorragia Posoperatoria/economía , Enfermedad Pulmonar Obstructiva Crónica/epidemiología , Mejoramiento de la Calidad , Estudios Retrospectivos , Factores Sexuales , Tromboembolia/epidemiologíaRESUMEN
BACKGROUND: The most significant driver of healthcare utilization for bariatric surgery is the index admission and readmissions within the first 30 days after a procedure. Identifying areas to create efficiencies during this period is essential to decreasing overall healthcare costs. OBJECTIVE: The objective of the study was to characterize the short-term costs of bariatric surgery within a regionalized center of excellence bariatric care system. SETTING: The Ontario Bariatric Network is a regionalized bariatric care system with 4 high-volume Bariatric Centers of Excellence. METHODS: We performed a population-based retrospective analysis including all adult patients who received a bariatric surgical procedure in Ontario from April 2009 until March 2012. Total hospital cost and number of days in hospital was calculated for all index admissions and all readmissions within 30 days of a bariatric surgical procedure. An inverse Gaussian generalized linear model was utilized to model the effect of covariates on costs. A Poisson regression was used to determine the effect on covariates on total days in hospital. RESULTS: After multivariable adjustment, the sleeve gastrectomy procedure decreased costs by $1447 over gastric bypass (95% confidence interval [CI] $1578 to-$1315]); P<.001). This effect increased when adjusting only for preoperative factors with a cost savings of nearly $2000 ($1953) (95% CI-$3250 to-$533; P = .003). Conversely, complications were the major drivers of increased cost as anastomotic leaks added $24,397 (95% CI $20,688-$28,106; P<.001) to healthcare costs. In addition, medical complications, such as respiratory failure/infection ($19,465) (95% CI $11,007-$27,924; P<.001), were also significant cost drivers. CONCLUSION: Major drivers of increased resource utilization included major surgical and medical complications, such as anastomotic leaks and respiratory failure/infection. Days in hospital were affected more by medical complications than surgical complications. Sleeve gastrectomy resulted in a clear short-term cost advantage over Roux-en-Y gastric bypass (RYGB), and this was likely related to the procedure itself as opposed to differences across procedures in co-morbidity and complication rates.
Asunto(s)
Cirugía Bariátrica/economía , Adulto , Análisis de Varianza , Fuga Anastomótica/economía , Ahorro de Costo , Costos y Análisis de Costo , Femenino , Hospitales Públicos/economía , Humanos , Tiempo de Internación/economía , Masculino , Obesidad Mórbida/economía , Obesidad Mórbida/cirugía , Ontario , Complicaciones Posoperatorias/economía , Estudios Prospectivos , Estudios Retrospectivos , Centros Quirúrgicos/economíaRESUMEN
BACKGROUND AND OBJECTIVES: Pasireotide decreases leak rates after pancreatic resection, though significant drug cost may be prohibitive. We conducted a cost-effectiveness analysis to determine whether prophylactic pasireotide possesses a reasonable cost profile. METHODS: A cost-effectiveness model compared pasireotide administration after pancreatic resection versus usual care, populated by probabilities of clinical outcomes from a randomized trial and hospital costs (2013 US$) from a university pancreatic disease center. Sensitivity analyses were performed to identify influential clinical components of the model. RESULTS: With the cost of pasireotide included, per patient costs of pancreatectomy, including those for readmission, were lower in the intervention arm (41,769 versus 42,159$; net savings of 390$, or 1%). This was associated with a 56% reduction in pancreatic fistula/pancreatic leak/abscess (PF/PL/A; 21.9-9.2%). Pasireotide cost would need to increase by over 15.4% to make the intervention strategy more costly than usual care. Sensitivity analyses exploring variability of key model inputs demonstrated that the three strongest drivers of cost were (i) cost of pasireotide; (ii) probability of readmission; and (iii) probability of PF/PL/A. CONCLUSIONS: Prophylactic pasireotide administration following pancreatectomy is cost savings, reducing expensive post-operative sequealae (major complications and readmissions). Pasireotide should be utilized as a cost-saving measure in pancreatic resection. J. Surg. Oncol. 2016;113:784-788. © 2016 Wiley Periodicals, Inc.
Asunto(s)
Análisis Costo-Beneficio , Hormonas/uso terapéutico , Costos de Hospital , Pancreatectomía , Complicaciones Posoperatorias/prevención & control , Somatostatina/análogos & derivados , Absceso Abdominal/economía , Absceso Abdominal/epidemiología , Absceso Abdominal/etiología , Absceso Abdominal/prevención & control , Fuga Anastomótica/economía , Fuga Anastomótica/epidemiología , Fuga Anastomótica/prevención & control , Ahorro de Costo , Árboles de Decisión , Esquema de Medicación , Hormonas/economía , Humanos , Modelos Económicos , Ohio , Fístula Pancreática/economía , Fístula Pancreática/epidemiología , Fístula Pancreática/etiología , Fístula Pancreática/prevención & control , Complicaciones Posoperatorias/economía , Complicaciones Posoperatorias/epidemiología , Somatostatina/economía , Somatostatina/uso terapéutico , Resultado del TratamientoRESUMEN
INTRODUCTION: Despite leakages remaining a worrisome complication, laparoscopic sleeve gastrectomy (LSG) has become the preferred choice for most bariatric surgeons in Italy. In light of the emerging trend to discharge patients on postoperative day (POD) 1 or to consider LSG as an outpatient procedure, we felt it useful in selected cases to define a treatment protocol aimed to manage patients presenting with an acute postoperative leakage. PATIENTS AND METHODS: Starting from 2007, 295 LSGs have been performed at our institution. Six patients, including 5 from our series (1.6%), were treated for a leak. The first patient presented a leak on POD 3, whereas the next 2 patients were re-admitted on POD 11 and 12, respectively. They all underwent a conservative treatment. The last 3 patients, according to a suggested algorithm, underwent a prompt surgical repair. RESULTS: The conservatively treated patients were discharged following 22 ± 7.7 days, whereas patients treated by surgery were discharged following 10 ± 0.8 days (P = .09). By not considering the cost of primary LSG, which is about 5600 in our region, the expense for every patient treated by re-intervention was about 2500 . The cost for each patient treated by stenting was about 4700 . The cost for each patient treated conservatively was about 5700 . CONCLUSIONS: According to our series and in agreement with published data, it is reasonable in selected cases to consider a wider role for early surgery. A timely surgical approach following an appropriate algorithm may offer a resolutive and cost-effective answer to the management of acute leaks following LSG.
Asunto(s)
Algoritmos , Fuga Anastomótica/terapia , Toma de Decisiones Clínicas , Técnicas de Apoyo para la Decisión , Gastrectomía , Laparoscopía , Obesidad Mórbida/cirugía , Enfermedad Aguda , Adulto , Fuga Anastomótica/diagnóstico , Fuga Anastomótica/economía , Femenino , Gastrectomía/economía , Gastrectomía/métodos , Humanos , Italia , Laparoscopía/economía , Tiempo de Internación/economía , Masculino , Persona de Mediana Edad , Obesidad Mórbida/economía , Estudios RetrospectivosRESUMEN
BACKGROUND: Leaks and bleeding are serious postoperative complications after a sleeve gastrectomy (SG). The objective of the present study was to evaluate the costs of leaks and bleeding after SG. METHODS: A retrospective analysis was conducted of a prospective cohort of primary SGs between August 2006 and September 2013 in a bariatric center. All SGs were performed consistently without reinforcement of the staple line. Abscesses adjacent to the staple line were also regarded as leaks. Data were collected on all diagnostic and therapeutic measures necessary to manage leaks or bleeding, days of hospitalization and parenteral feeding, number of blood products, antibiotics, and additional outpatient department visits. RESULTS: One thousand two hundred sixty one patients underwent a SG. Leaks occurred in 32 (2.5%) and bleeding in 27 (2.1%) patients. Median additional costs for leaks were