Shannon Nicholas Brian, Seow-En Isaac, Tan Emile Kwong-Wei
Department of Colorectal Surgery, Singapore General Hospital, Singapore.
ANZ J Surg. 2023 Apr;93(4):963-969. doi: 10.1111/ans.18148. Epub 2022 Nov 10.
Following ultralow anterior resection for distal rectal cancers, a coloanal anastomosis is usually created along with a defunctioning ileostomy (DI). Recent evidence suggests that abdominoperineal pull-through with delayed coloanal anastomosis (DCAA) is a viable alternative to immediate coloanal anastomosis (ICAA), minimizing the risk of anastomotic leakage and avoiding the need for stoma creation with the risk of stoma-associated morbidity. However, DCAA requires a longer initial hospitalization. We aimed to perform a cost-effectiveness analysis to compare DCAA versus ICAA for elective rectal cancer surgery.
A decision tree model was used to compare the cost-effectiveness of the two strategies. Cost data were obtained from the 2019 to 2020 United Kingdom National Health Service reference costs. Model probabilities were derived from published studies. Univariate and probabilistic sensitivity analyses were used to evaluate the robustness of the results.
DCAA was the overall cheaper strategy at £13 541 compared with £14 856 for ICAA in the base case analysis. This was explained by the decreased overall costs of hospitalization/surgery, reduction in costs associated with anastomotic or stoma-related complications, specifically dehydration-induced hospital readmissions and avoidance of stoma maintenance costs. Sensitivity analysis demonstrated that DCAA remained consistently more inexpensive except when the duration of total parenteral nutrition exceeded 14 days.
Despite a longer index hospitalization with higher initial costs, this economic analysis demonstrates that DCAA without stoma is overall more cost-effective compared with ICAA with DI following ultralow anterior resection. Cost savings should be considered an additional benefit when selecting the DCAA approach for rectal cancer surgery.
对于远端直肠癌进行超低位前切除术后，通常会进行结肠肛管吻合术并同时行去功能化回肠造口术（DI）。最近的证据表明，经腹会阴拖出术加延迟结肠肛管吻合术（DCAA）是即时结肠肛管吻合术（ICAA）的可行替代方案，可将吻合口漏的风险降至最低，并避免造口带来的相关并发症风险。然而，DCAA需要更长的初始住院时间。我们旨在进行成本效益分析，以比较DCAA与ICAA用于择期直肠癌手术的情况。
使用决策树模型比较两种策略的成本效益。成本数据来自2019年至2020年英国国家医疗服务体系参考成本。模型概率来自已发表的研究。采用单因素和概率敏感性分析来评估结果的稳健性。
在基础病例分析中，DCAA是总体成本更低的策略，为13541英镑，而ICAA为14856英镑。这是由于住院/手术的总体成本降低、与吻合口或造口相关并发症的成本减少，特别是脱水导致的再次入院以及避免了造口维护成本。敏感性分析表明，除了全胃肠外营养持续时间超过14天时，DCAA始终更便宜。
尽管初始住院时间更长且初始成本更高，但这项经济分析表明，超低位前切除术后，无造口的DCAA总体上比有DI的ICAA更具成本效益。在选择DCAA方法进行直肠癌手术时，成本节约应被视为一项额外的益处。
