Cost-effectiveness of sigmoid resection with primary anastomosis or end colostomy for perforated diverticulitis: an analysis of the randomized Ladies trial

Abstract

Background: Several studies have been published favouring sigmoidectomy with primary anastomosis over Hartmann's procedure for perforated diverticulitis with purulent or faecal peritonitis (Hinchey grade III or IV), but cost-related outcomes were rarely reported. The present study aimed to evaluate costs and cost-effectiveness within the DIVA arm of the Ladies trial. Methods: This was a cost-effectiveness analysis of the DIVA arm of the multicentre randomized Ladies trial, comparing primary anastomosis over Hartmann's procedure for Hinchey grade III or IV diverticulitis. During 12-month follow-up, data on resource use, indirect costs (Short Form Health and Labour Questionnaire) and quality of life (EuroQol Five Dimensions) were collected prospectively, and analysed according to the modified intention-to-treat principle. Main outcomes were incremental cost-effectiveness (ICER) and cost-utility (ICUR) ratios, expressed as the ratio of incremental costs and the incremental probability of being stoma-free or incremental quality-adjusted life-years respectively. Results: Overall, 130 patients were included, of whom 64 were allocated to primary anastomosis (46 and 18 with Hinchey III and IV disease respectively) and 66 to Hartmann's procedure (46 and 20 respectively). Overall mean costs per patient were lower for primary anastomosis (€20 544, 95 per cent c.i. 19 569 to 21 519) than Hartmann's procedure (€28 670, 26 636 to 30 704), with a mean difference of €-8126 (-14 660 to-1592). The ICER was €-39 094 (95 per cent bias-corrected and accelerated (BCa) c.i.-1213 to-116), indicating primary anastomosis to be more cost-effective. The ICUR was €-101 435 (BCa c.i.-1 113 264 to 251 840). Conclusion: Primary anastomosis is more cost-effective than Hartmann's procedure for perforated diverticulitis with purulent or faecal peritonitis.

Hartmann’s procedure versus sigmoidectomy with primary anastomosis for perforated diverticulitis with purulent or fecal peritonitis: Three-year follow-up of a randomised controlled trial

“…This accounts for less burden for patients and is in line with a better quality of life that was found at the long-term follow-up of the DIVERTI trial [19]. Moreover, it also correlates to a more cost-effective therapy as was concluded earlier by Lambrichts et al [20] Furthermore no differences in outcome were found between patients being diagnosed with Hinchey III or IV. Other surgical strategies such as damage control surgery with blind closure of both colonic ends after sigmoid resection [21], postponing the decision on definitive reconstruction are interesting alternatives, however confirmation from literature is warranted.…”

Evaluating the outcomes of primary anastomosis with hand-sewn full-circular reinforcement in managing perforated left-sided colonic diverticulitis

“…One reason for this is that the rate of stoma closure is higher in Group L which incurs higher costs. It has been reported that PA is more cost-effective than HP for perforated diverticulitis with purulent or fecal peritonitis [ 24 ]. In patients under 80 years old, total treatment costs were significantly lower in Group L than in Group F. Accordingly, particularly in these patients the reinforcement method might be cost-effective.…”

Essential updates 2020/2021: Colorectal diseases (benign)—Current topics in the surgical and medical treatment of benign colorectal diseases

“… 72 Moreover, the overall mean costs per patient were also lower for PRA (€20 544) than for HP (€28 670), with a mean difference of €8126. 73 Based on these data, PRA should be considered, if possible.…”