‘Elephant in the room’ adds to rectal surgery costs

Anastomotic leakage occurs after one in 10 anterior resection procedures and costs English hospitals up to £ 3.5 milion (US$ 5.5m; € 4.0m) per year, research shows.

The researchers also found that hospitals significantly underestimate the costs associated with the complication and are therefore inadequately reimbursed by commissioners.

They say their results highlight a need for greater attention to and prevention of the problem.

"Anastomotic leakage after rectal surgery has been the 'elephant in the room' for too long," write Shazad Ashraf (John Radcliffe Hospital, Oxford, UK) and colleagues.

The study included all 285 elective anterior resection procedures for rectal cancer performed in Oxford between 2007 and 2009.

Overall, 31 (10.9%) patients developed anastomotic leakage. One (3.2%) patient in this group died within 30 days of surgery compared with five (2.1%) patients who did not experience leakage.

Anastomotic leakage resulted in a significantly greater mean length of hospital stay (30.3 vs 9.2 days), a higher risk for re-operation (1.78 vs 0.04 procedures/case) and greater requirement for intensive care (19.4 vs 3.6%) compared with no leakage.

The authors estimate that the inpatient costs for a patient who experiences anastomotic leakage are £ 17,220 (US$ 27,100; € 20,010) compared with £ 6,319 (US$ 9,950; € 7,350) for patients without leakage. However, providers were only reimbursed £ 9,605 (US$ 15,120; € 11,170) for each patient developing the complication.

The authors say this discrepancy could be costing secondary care providers in England as much as £ 2.4 million (US$ 3.8m; € 2.8m) per year.

Ashraf and colleagues note that 51.6% of patients with anastomotic leakage accounted for 83.3% of the additional costs. These patients had the most severe form of leakage, requiring laparotomy and the formation of a stoma.

Writing in Colorectal Disease, the authors say that more must be done to prevent anastomotic leakage, for the sake of patients as well as for economic reasons. Recent data, including their own, strongly suggest that creation of a diverting stoma can reduce the risk for leakage. They also say that early identification and rescue of patients who develop significant peritoneal contamination is needed.

"These measures taken together will inevitably lead to a decrease in the rate of this complication, subsequently reducing associated morbidity and economic cost," they conclude.

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