Routine pathology examination in the era of value-based healthcare: the case of haemorrhoids specimens

Abstract

Routine pathologic examination of specimens is a common practice with ill-defined value. The present study is the first to investigate the incidence and cost of incidental microscopic lesions in both haemorrhoidectomy and stapled haemorrhoidopexy specimens. Pathological reports of specimens obtained from haemorrhoidectomy and stapled haemorrhoidopexy procedures performed from January 2003 to May 2017 were analysed. Specimens resulting from patients treated for any disease other than haemorrhoids alone were excluded from the study. Unexpected diagnoses in the pathological report were defined as incidental diagnoses. A cost analysis was then performed. In the considered period we performed a total of 3017 procedures complying with our criteria. We found 65 (2.15%) unexpected lesions. Of the incidental diagnosis, 30 (0.99%) altered either the follow-up or the treatment. The incidences of both findings were extremely higher in haemorrhoidectomies specimens (p < 0.0001). We estimated that the cost of 14 years of routine pathological examination of haemorrhoids specimens was 133,351.4 euros, each consequential incidental diagnosis costing 4445.03 euros. The incidence of unexpected lesions in routine pathologic examination of haemorrhoidectomy and haemorrhoidopexy specimens is low but not negligible. The vast majority of incidental findings were found among haemorrhoidectomy specimens. Even though the real value of routine pathological examination of haemorrhoids specimens is still uncertain, from a clinical standpoint we were glad to suggest each patients the best follow-up and/or treatment. Future studies should assess preoperative patient's risk stratification and careful intraoperative macroscopic inspection strategies for selective pathology examination of haemorrhoids specimens.

Stapled Hemorrhoidopexy: “Mucosectomy or Not Only Mucosectomy, This Is the Problem”

“…Unfortunately, despite the large number of studies dedicated to the evaluation of follow-up, complications, and costs, there are still no studies that focus on the characteristics of the tissue removed during surgery. Pathology examinations of hemorrhoids and prolapse specimen can, in some cases, reveal incidental findings ( 14 ), but the majority of the reports describe the anal ring generically, as a portion of rectal wall, with no further specification. We decided to do a new examination with the aim of providing a more accurate description of the different rectal wall layers by characterizing actual tissue excised during surgery.…”

Anal excision of perianal fibroadenoma: Expect the unexpected

“…The differential diagnoses are usually haemorrhoids (i.e. fibrotic piles), 8 abscess or anal cancer.…”

Cost effectiveness of routine histology for haemorrhoidectomy specimens

“…2 The routine histopathological assessment of haemorrhoidectomy specimens is commonplace in clinical practice and may be seen as an opportunity to detect incidental anal cancer. 3 However, there is controversy in the literature regarding its utility and its cost-effectiveness in Australia has not been examined. [3][4][5][6][7][8][9][10] In an Italian study of 3017 haemorrhoidectomies sent for histology, 65 (2.15%) showed unexpected lesions and in 30 (0.99%) it changed follow-up or treatment.…”

“…3 However, there is controversy in the literature regarding its utility and its cost-effectiveness in Australia has not been examined. [3][4][5][6][7][8][9][10] In an Italian study of 3017 haemorrhoidectomies sent for histology, 65 (2.15%) showed unexpected lesions and in 30 (0.99%) it changed follow-up or treatment. 3 The cost per incidental lesion was 4445.03 Euros ($5,377 USD).…”

“…[3][4][5][6][7][8][9][10] In an Italian study of 3017 haemorrhoidectomies sent for histology, 65 (2.15%) showed unexpected lesions and in 30 (0.99%) it changed follow-up or treatment. 3 The cost per incidental lesion was 4445.03 Euros ($5,377 USD). 3 Other retrospective cohort studies have shown unsuspected neoplastic or dysplastic lesions in 0.014%-1.9% of haemorrhoidectomy specimens.…”