Adhesions are common and costly after open pouch surgery


Adhesions are common and costly after open pouch surgery
Sileri P, Sthory R, McVeigh E, Child T, Cunningham C, Mortensen NJ, Lindsey I


Record Status This is a critical abstract of an economic evaluation that meets the criteria for inclusion on NHS EED. Each abstract contains a brief summary of the methods, the results and conclusions followed by a detailed critical assessment on the reliability of the study and the conclusions drawn. CRD summary The aim was to assess the economic and clinical impacts of the incidence of adhesive small-bowel obstruction-related complications in patients after open pouch surgery compared with laparoscopic surgery. The authors concluded that open surgery was associated with significantly more complications and higher costs than laparoscopic surgery, even though laparoscopic surgery had higher theatre costs. Given limitations in the study design, source of clinical data and reporting of economic data, the authors’ conclusions should be considered with a degree of caution. Type of economic evaluation Cost-effectiveness analysis Study objective The objective was to assess the economic and clinical impacts of the incidence of adhesive small-bowel obstruction-related complications in patients after open pouch surgery compared with laparoscopic surgery. Interventions Open ileal pouch surgery was compared with laparoscopic ileal pouch surgery for patients with ulcerative colitis. Location/setting UK/hospital Methods Analytical approach: This economic evaluation was based on a retrospective analysis of patients’ charts at the authors’ institution for patients diagnosed with ulcerative colitis. The time horizon of the analysis was not clear. The authors did not explicitly report the perspective of the study. Effectiveness data: All patients undergoing open pouch surgery between January 1984 and December 2003 and those undergoing laparoscopic pouch surgery between August 2003 and December 2004 were included in the analysis. The study sample comprised 276 patients (with median follow-up of 6.3 years and mean age of 36.3 years) after open pouch surgery and 14 patients (median follow-up of two years and mean age of 42 years) after laparoscopic pouch surgery. Data recorded for patients undergoing open pouch surgery included: time interval of small bowel obstruction since surgery; staging of ulcerative colitis surgery; presence and severity of adhesion at 2nd stage surgery; length of re-admission; and findings at adhesiolysis surgery. The data for laparoscopic surgery included: the presence and severity of adhesion at 2nd stage surgery; and readmission and re-operations for small bowel obstruction in the first year after surgery. Monetary benefit and utility valuations: None Measure of benefit: No summary benefit measure was used. The primary health outcomes compared were the re-operation and readmission rates. Cost data: The cost categories considered in the analysis were those associated with the operation (disposable material, operating theatre), the overall hospitalization, and infertility. The authors stated that the costs of readmission and re-operation for adhesive small bowel obstruction were derived from a published study. The costs were in US dollars ($). The price year was not reported. Analysis of uncertainty: Statistical analyses were carried out to test the statistical significance on the clinical outcomes. Results Open pouch surgery was associated with a readmission rate of 28%; the median length of stay was 7.4 days. The re-operation rate was 10% (43% within one year). Compared with open pouch surgery patients, laparoscopic surgery patients were associated with less adhesiolysis at second-stage surgery (0% versus 36%, p<0.0001) and less small bowel obstruction episodes within one year after surgery (0% versus 36%, p<0.0001). The laparoscopic approach was associated with net cost savings of $1,832 per pouch constructed. Authors' conclusions The authors concluded that open pouch surgery was associated with significantly more complications (particularly adhesions) and higher costs than the laparoscopic surgery, even though the laparoscopic surgery had higher theatre costs. CRD commentary Interventions: : The authors justified the selection of the comparators. The open ileal pouch surgery was considered to be the gold standard, and both open and laparoscopic ileal pouch surgery have been used at the authors' institution. Effectiveness/benefits: The clinical evidence was based on a retrospective review of patient charts. This design is usually considered weak because of potential selection bias and confounding. The appropriateness of the sample size was not demonstrated by power calculations. Also, the evidence came from patients in a single hospital and the sample size of the laparoscopic group was small, so it may not be representative in other settings. Overall, the reporting of the assessment of clinical end points was good. Costs: The analysis of costs was restricted to the categories related to operation and overall hospitalization. Details on the cost analysis, such as unit costs, quantities of resources used and price year, were not reported. As the cost estimates were derived from a published study and reported in US dollars, it was not clear that the estimates were relevant to the UK setting. Analysis and results: A cost-consequences framework was used, so a number of primary and secondary clinical end points were measured and not combined with the costs. The most that can be done in analysing uncertainty in cost-consequences analyses is performing statistical tests, which was done on clinical differences but not on cost differences. The authors conducted statistical analysis on the clinical results but not on the costs. The authors acknowledged the limitations of the study. Concluding remarks: Due to limitations in the study design, source of clinical data and reporting of economic data, the authors’ conclusions should be considered with a degree of caution. Funding Not stated. Bibliographic details Sileri P, Sthory R, McVeigh E, Child T, Cunningham C, Mortensen NJ, Lindsey I. Adhesions are common and costly after open pouch surgery. Journal of Gastrointestinal Surgery 2008; 12(7): 1239-1245 PubMedID 18278539 DOI 10.1007/s11605-008-0481-3 Original Paper URL http://www.springerlink.com/content/l63t843237523871/ Other publications of related interest Cornish JA, Tan E, Teare J, Teoh TG, Rai R, Darzi AW, Paraskevas P, Clark S, Tekkis PP. The effect of restorative proctocolectomy on sexual function, urinary function, fertility, pregnancy and delivery: a systematic review. Diseases of the colon and rectum 2007;50(8):1128-1138. Ellis H, Moran BJ, Thompson JN, et al. Adhesion-related hospital readmissions after abdominal and pelvic surgery: a retrospective cohort study. Lancet 1999;353(9163):476-1480. Fazio VW, Ziv Y, Church JM, Oakley JR, Laverty IC, Milsom JW, Schroeder TK. Ileal pouch-anal anastomoses complications and function in 1005 patients. Annals of surgery 1995;222(2):120-127. Nieuwenhuijzen M, Reijnen MM, Kuijpers JH, van Goor H. Small bowel obstruction after total or subtotal colectomy: a 10-year retrospective review. British journal of surgery 1998;85(9):1242-1245. Pattaras JG, Moore RG, Landman J, et al. Incidence of postoperative adhesion formation after transperitoneal genitourinary laparoscopic surgery. Urology 2002;59(1):37-41. Indexing Status Subject indexing assigned by NLM MeSH Adult; Colonic Diseases /surgery; Colonic Pouches /pathology; Cost-Benefit Analysis; Female; Follow-Up Studies; Great Britain /epidemiology; Humans; Ileal Diseases /epidemiology /etiology /prevention & Incidence; Intestinal Obstruction /epidemiology /etiology /prevention & Laparoscopy /economics /methods; Male; Postoperative Complications; Prognosis; Prospective Studies; Tissue Adhesions /economics /epidemiology /prevention & control; control; control AccessionNumber 22008102577 Date bibliographic record published 24/06/2009 Date abstract record published 28/10/2009

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