The cost burden of clinically significant esophageal anastomotic leaks—a steep price to pay

Agzarian, John; Visscher, Sue L.; Knight, Ariel W.; Allen, Mark S.; Cassivi, Stephen D.; Nichols, Francis C.; Shen, K. Robert; Wigle, Dennis A.; Blackmon, Shanda H.

doi:10.1016/j.jtcvs.2018.10.137

Cited by 29 publications

(23 citation statements)

References 23 publications

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“…Here, we arrive A few studies have addressed the economic burden arising from complications after esophagectomy. 12,13,19,20 All of these only recently published studies conclude that complications are associated with a substantial increase in costs. While Goense et al observed a per case cost increase of €4.123 for AL, 12 the median standardized costs per leak described by Agzarian et al were significantly higher with $68.296.…”

Section: Discussionmentioning

confidence: 99%

Economic Burden of Endoscopic Vacuum Therapy Compared to Alternative Therapy Methods in Patients with Anastomotic Leakage After Esophagectomy

Eichelmann

Ismail

Merten

et al. 2021

Journal of Gastrointestinal Surgery

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Background Endoscopic vacuum therapy (EVT) has become a promising option in the management of anastomotic leakage (AL) after esophagectomy. However, EVT is an effortful approach associated with multiple interventions. In this study, we conduct a comparative cost analysis for methods of management of AL. Methods All patients who experienced AL treated by EVT, stent, or reoperation following Ivor Lewis esophagectomy for esophageal cancer were included. Cases that were managed by more than one modality were excluded. For the remaining cases, in-patient treatment cost was collected for material, personnel, (par)enteral nutrition, intensive care, operating room, and imaging. Results 42 patients were treated as follows: EVT n = 25, stent n = 13, and reoperation n = 4. The mean duration of therapy as well as length of overall hospital stay was significantly shorter in the stent than the EVT group (30 vs. 44d, p = 0.046; 34 vs. 53d, p = 0.02). The total mean cost for stent was €33.685, and the total cost for EVT was €46.136, resulting in a delta increase of 37% for EVT vs. stent cost. 75% (€34.320, EVT), respectively, 80% (€26.900, stent) of total costs were caused by ICU stay. Mean pure costs for endoscopic management were relatively low and comparable between both groups (EVT: €1.900, stent: €1.100, p = 0.28). Conclusion Management of AL represents an effortful approach that results in high overall costs. The expenses directly related to EVT and stent therapy were however comparatively low with more than 75% of costs being attributable to the ICU stay. Reduction of ICU care should be a central part of cost reduction strategies.

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Section: Discussionmentioning

confidence: 99%

Economic Burden of Endoscopic Vacuum Therapy Compared to Alternative Therapy Methods in Patients with Anastomotic Leakage After Esophagectomy

Eichelmann

Ismail

Merten

et al. 2021

Journal of Gastrointestinal Surgery

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“…The incidence of AL is approximately 6-24% in patients undergoing oesophagogastrostomy [2,6], with an increased postoperative mortality rate of 7.2-18.2% compared with that of 3.1-6.2% in patients without leakage. The cost burden was two-times higher for high-grade leakages in an analysis of cervical oesophagogastric anastomotic leaks after transhiatal oesophagectomy [7]. The early detection of AL is crucial since delayed treatment is associated with significant morbidity, a prolonged hospital stay, and mortality.…”

Section: Introductionmentioning

confidence: 99%

A novel nomogram to predict the risk of anastomotic leakage in patients after oesophagectomy

et al. 2020

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Background: Anastomotic leakage is a dangerous postoperative complication of oesophageal surgery. The present study aimed to develop a simple and practical scoring system to predict the risk of anastomotic leakage after oesophageal resection. Methods: A consecutive series of 330 patients who underwent oesophageal cancer surgery from January 2016 to January 2018 at the Shanghai Chest Hospital were included to develop a prediction model. Anastomotic leakage was evaluated using oesophagography, computed tomography, or flexible endoscopy. Least absolute shrinkage and selection operator regression based on a generalized linear model was used to select variables for the anastomotic leakage risk model while avoiding overfitting. Multivariable logistic regression analysis was applied to build forest plots and a prediction model. The concordance index or the area under the curve was used to judge the discrimination, and calibration plots verified the consistency. Internal validation of the model was conducted, and the clinical usefulness and threshold screening of the model were evaluated by decision curve analysis. Results: The factors included in the predictive nomogram included Sex, diabetes history, anastomotic type, reconstruction route, smoking history, CRP level and presence of cardiac arrhythmia. The model displayed a discrimination performance with a concordance index of 0.690 (95% confidence interval: 0.620-0.760) and good calibration. A concordance index value of 0.664 was maintained during the internal validation. The calibration curve showed good agreement between the actual observations and the predicted results. Conclusion: The present prediction model, which requires only seven variables and includes Sex, diabetes history, anastomotic type, reconstruction route, smoking history, CRP level and presence of cardiac arrhythmia, may be useful for predicting anastomotic leakage in patients after oesophagectomy.

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“…Surgical reoperation for anastomotic leak prolongs hospitalization, significantly delays oral nutrition, and contributes to a greater cost of care. 7 Efforts to use endoscopic stenting to reduce morbidity associated with anastomotic leak have been reported. We previously reported favorable results on 9 patients who developed postoperative esophageal anastomotic leak and underwent endoscopic stenting.…”

Section: Introductionmentioning

confidence: 99%

The Role of Endoscopic Stent in Management of Postesophagectomy Leaks

Smith

Daly

Smith

et al. 2020

The American Surgeon™

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Introduction Anastomotic leak is a dreaded complication following esophagectomy. Conventional management for leaks includes invasive reoperation and even gastrointestinal diversion. Objective The aim of this study was to examine our contemporary outcome of using endoscopic esophageal stenting as primary therapy for management of anastomotic leak following minimally invasive esophagectomy (MIE). Methods We reviewed data on 11 patients who developed an esophageal leak following 111 MIE between January 2011 and December 2019. Of the 11 anastomotic leaks, 10 patients had an anastomotic disruption and underwent endoscopic esophageal stenting as primary therapy for management of leaks, while 1 patient had an anastomotic disruption complicated by an associated tracheoesophageal fistula that required surgical reoperation and subsequent colonic interposition. Main outcome measures focused on the 10 patients who were managed with endoscopic stenting, including length of hospital stay following leak management, need for thoracotomy or gastrointestinal diversion for leak, stent complications, and leak-associated mortality. Results Of the 10 patients who underwent endoscopic esophageal stenting as primary therapy for management of leaks, there were 8 males with a median age of 66 years. The median time to diagnosis of anastomotic leak was 10 days postoperatively. One of the ten patients also underwent percutaneous drain placement, while none of the patients required thoracotomy. Median duration of stent placement was 39 (range, 29-105) days. Median length of stay after stent placement was 10 (range, 4-43) days. The median number of stent exchange was 1 (range, 1-3) stent. Gastrointestinal continuity was maintained in all patients. The 90-day leak-associated mortality was 9.1% (1 of 11 patients). Conclusions Endoscopic stenting is an effective primary therapy in the management of postesophagectomy leak and avoids the need for an invasive, reoperative thoracotomy or gastrointestinal diversion procedure.

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The cost burden of clinically significant esophageal anastomotic leaks—a steep price to pay

Cited by 29 publications

References 23 publications

Economic Burden of Endoscopic Vacuum Therapy Compared to Alternative Therapy Methods in Patients with Anastomotic Leakage After Esophagectomy

Economic Burden of Endoscopic Vacuum Therapy Compared to Alternative Therapy Methods in Patients with Anastomotic Leakage After Esophagectomy

A novel nomogram to predict the risk of anastomotic leakage in patients after oesophagectomy

The Role of Endoscopic Stent in Management of Postesophagectomy Leaks

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