Title: Morbidity Mortality Cost, In Survival Estimates of Gastrointestinal Anastamotic Leaks
Authors: Dr A.Y.Kshirsagar, Dr Tanmay Mehta, Dr Nitinchandra Khairnair, Dr Rajath Rakshit R
DOI: https://dx.doi.org/10.18535/jmscr/v5i2.25
Abstract
Objective: to evaluate the clinical and economic burden associated with anastomotic leaks following intestinal anastamosis.
Methods: Retrospective data (January 2014 to December 2016) were analyzed from patients who had undergone gastrointestinal anastamosis with and without postoperative leaks, using the Premier Perspective™ database. Data on in-hospital mortality, length of stay (LOS), re-admissions, postoperative infection, and costs were analyzed using univariate and multivariate analyses, and the propensity score matching (PSM) and generalized linear models (GLM).
Results: Of the patients 6,174 (6.18 %) had anastomotic leaks within 30 days after gastrointestinal anastamosis surgery. Patients with leaks had 1.3 times higher 30-day re-admission rate Anastomotic leaks are one of the most serious complications that occur after gastrointestinal surgery. They add to potential postoperative patient morbidities and to overall costs of post-operative patient care, including associated hospital re-admissions. Further, reoperations and complications such as leaks are considered a quality indicator in colorectal surgery.1
Patients developing anastomotic leaks after undergoing gastrointestinal anastamosis exhibit poorer long-term functional results; in the case of malignancy, increased local recurrence rates and reduced 5-year survival are seen.2-4 The clinical manifestations of anastomotic leaks will often warrant hospital re-admission, placing a considerable additional burden on patients and healthcare providers. Overall, anastomotic leaks after colorectal surgery have devastating implications, with significantly greater chances of wound infection and mortality rates of up to 32 %.5, 6 In addition to potential negative clinical outcomes, there is a significant economic and healthcare utilization burden to be considered. While postoperative complications have a dramatic impact on full in-hospital costs per case and are the stron- gest indicator of costs,7 there remains a gap in the literature in pairing clinical sequelae of postoperative anastomotic leaks to economic outcomes.
Reported leak rates for colorectal surgery range from 1.5 to 16 % globally; however, definitions of leaks differ between published studies.8 Furthermore, a review by Kingham and Pachter reported that experienced gastro surgeons often quote 3 to 6 % as a generally acknowledged overall leakage rate. They also compared the definitions across different stud- ies and concluded that there was no uniformly accepted set of criteria.9 They observed that definitions varied based on com- binations of clinical signs, biochemical markers, radiological findings, and intraoperative findings. Our focus was on clin- ical leaks, as they affect morbidity and mortality. Nonclinical leaks diagnosed by radiology have no clinical effects and resolve without interventions.
Our study was undertaken to quantify the incidence of anastomotic leaks in patients under- going colorectal surgery and to assess the clinical and economic burden of anastomotic leaks in terms of extended hospital stay, re-admissions, in-hospital mortality, postoperative infection, and total costs following gastrointestinal anastamosis.
Methods
Study Design: This study was designed as a retrospective data analysis of hospital-based patients to analyze the health outcomes and medical resource utilization of patients with anastomotic leaks following gastrointestinal surgery s and 0.8-1.9 times higher postoperative infection rates as compared with patients without leaks. Anastomotic leaks incurred additional LOS and hospital costs of 7.3 days and rupees 24,129 respectively,
only within the first hospitalization. Per 1,000 patients undergoing gastrointestinal surgery, the economic burden associated with anastomotic leaks—including hospitalization and re-admission—was established as 9,500 days in prolonged LOS and rupees 28,60,000 in additional costs. Similar results were obtained from both the PSM and GLM for assessing total costs for hospitalization and re-admission.
Conclusions: Anastomotic leaks in gastrointestinal surgery increase the total clinical and economic burden by a factor of 0.6-1.9 for a 30-day re-admission, postoperative infection, LOS, and hospital costs.
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