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Cost-effectiveness of Defunctioning Stomas in Low Anterior Resections for Rectal Cancer—Invited Critique

Cost-effectiveness of Defunctioning Stomas in Low Anterior Resections for Rectal Cancer—Invited... Cost matters. Extra safety must be paid for. Koperna's article provides an excellent example. Protecting an LAR increases the cost of an anterior resection in Mistelbach, Austria, from US $10 000 to US $15 000. An unprotected leak requiring a Hartmann operation costs US $50 000. A clinician might add that it may cost the patient his or her life and is very likely to mean a permanent stoma—costing perhaps US $4000 per year thereafter. Patients care little about initial cost: they want the lowest possible long-term outcome costs—0 for a cure with no stoma! I believe that outcome cost accounting would be even more valuable. In this article it is most interesting that the principal cost drivers after LAR are 1 initial cost (defunctioning) and 1 short-term outcome cost (leakage). However, most surgeons construct a defunction because they are afraid of the occasional death from leakage—this defies cost analysis except on very large series. On my total mesorectal excision travels, these deaths from delayed leaks by 1 surgeon were called "weekend mortalities" in Holland; the surgeon was away, another team was on call, and the deep pelvis sepsis was missed until multiorgan failure rendered intervention ineffective. Analyze all that for cost! It is clinical issues that matter most to clinicians and to patients, for example, is it really necessary to dismantle a leaking anastomosis by the Hartmann operation? Surely the combination of a transluminal lavage with effective defunctioning may save it and, thus, avoid either complex pelvic surgery later or a permanent stoma? Once the primacy of clinical priorities is accepted, the analysis of cost becomes sensible and ethical. Koperna asserts that the leakage rate needs to exceed 15% to justify the addition of a temporary stoma on financial grounds. This corresponds nicely with clinical common sense that points to the defunctioning of all irradiated pelvises and all ultralow anastomoses or those about which there is special anxiety. Finally, let us not forget that those without protection must be kept under some kind of cautious surveillance for at least 3 weeks. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Surgery American Medical Association

Cost-effectiveness of Defunctioning Stomas in Low Anterior Resections for Rectal Cancer—Invited Critique

Archives of Surgery , Volume 138 (12) – Dec 1, 2003

Cost-effectiveness of Defunctioning Stomas in Low Anterior Resections for Rectal Cancer—Invited Critique

Abstract

Cost matters. Extra safety must be paid for. Koperna's article provides an excellent example. Protecting an LAR increases the cost of an anterior resection in Mistelbach, Austria, from US $10 000 to US $15 000. An unprotected leak requiring a Hartmann operation costs US $50 000. A clinician might add that it may cost the patient his or her life and is very likely to mean a permanent stoma—costing perhaps US $4000 per year thereafter. Patients care little about initial cost: they...
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Publisher
American Medical Association
Copyright
Copyright © 2003 American Medical Association. All Rights Reserved.
ISSN
0004-0010
eISSN
1538-3644
DOI
10.1001/archsurg.138.12.1339
Publisher site
See Article on Publisher Site

Abstract

Cost matters. Extra safety must be paid for. Koperna's article provides an excellent example. Protecting an LAR increases the cost of an anterior resection in Mistelbach, Austria, from US $10 000 to US $15 000. An unprotected leak requiring a Hartmann operation costs US $50 000. A clinician might add that it may cost the patient his or her life and is very likely to mean a permanent stoma—costing perhaps US $4000 per year thereafter. Patients care little about initial cost: they want the lowest possible long-term outcome costs—0 for a cure with no stoma! I believe that outcome cost accounting would be even more valuable. In this article it is most interesting that the principal cost drivers after LAR are 1 initial cost (defunctioning) and 1 short-term outcome cost (leakage). However, most surgeons construct a defunction because they are afraid of the occasional death from leakage—this defies cost analysis except on very large series. On my total mesorectal excision travels, these deaths from delayed leaks by 1 surgeon were called "weekend mortalities" in Holland; the surgeon was away, another team was on call, and the deep pelvis sepsis was missed until multiorgan failure rendered intervention ineffective. Analyze all that for cost! It is clinical issues that matter most to clinicians and to patients, for example, is it really necessary to dismantle a leaking anastomosis by the Hartmann operation? Surely the combination of a transluminal lavage with effective defunctioning may save it and, thus, avoid either complex pelvic surgery later or a permanent stoma? Once the primacy of clinical priorities is accepted, the analysis of cost becomes sensible and ethical. Koperna asserts that the leakage rate needs to exceed 15% to justify the addition of a temporary stoma on financial grounds. This corresponds nicely with clinical common sense that points to the defunctioning of all irradiated pelvises and all ultralow anastomoses or those about which there is special anxiety. Finally, let us not forget that those without protection must be kept under some kind of cautious surveillance for at least 3 weeks.

Journal

Archives of SurgeryAmerican Medical Association

Published: Dec 1, 2003

Keywords: cost effectiveness,stomas,rectal carcinoma,low anterior resection of rectum,rectosigmoidectomy

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