Management of complications in surgery of the colon

Cost analysis of inguinal hernia repair: the influence of clinical and hernia-specific factors

Introduction

As in the rest of the world, in Germany, inguinal hernia operations are among the most common operations. From an economic standpoint, very little is known about the influence of demographic, clinical or hernia-related parameters on the cost of inguinal hernia repair. We, therefore, evaluated individual patient parameters associated with higher costs with a special focus on multimorbidity.

Methods

A total of 916 patients underwent hernia repair for primary or recurrent inguinal hernia between 2014 and 2017 at a single university center and were included in the analysis. The clinical and financial data of these patients were analyzed to identify cost-increasing parameters.

Results

A majority of patients were male (90.7%), with a mean age of 55 years. The surgical methods utilized were mainly the TAPP (57.2%) and Lichtenstein (41.7%) procedures, with an average duration of surgery of 85 min and an average duration of anesthesia of 155 min. The mean cost of all procedures was 3338.3 € (± 1608.1 €).

Older age, multimorbidity, emergency operations with signs of incarceration, longer hospital stays and postoperative complications were significant cost-driving factors. On the other hand, sex, the side of the hernia (left vs. right) and the presence of recurrent hernias had no influence on the overall direct costs.

Conclusion

From a purely economic point of view, older age and multimorbidity are demographic cost-driving factors that cannot be influenced. The national hospital reimbursement system needs to consider and compensate for these factors. Emergency operations need to be prevented by early elective treatment. Long postoperative stays and postoperative complications need to be prevented by proper preoperative check-ups and accurate treatment.

Placement of a covered polyester stent prevents complications from a colorectal anastomotic leak and supports healing: randomized controlled trial in a large animal model

BACKGROUND

Anastomotic leaks after colorectal operation continue to be a significant cause of morbidity. A covered endoluminal stent could seal a leak and eliminate the need for diversion. The aim of this study was to test the efficacy of a temporary covered stent to prevent leak related complications.

METHODS

Sixteen adult pigs (80-120 lbs) underwent open transection of the rectosigmoid followed by anastomosis with a circular stapler. Eight animals (study group) underwent endoscopic placement of a 21-mm covered polyester stent. Eight control group animals were left without stents. In all animals, a 2-cm leak was created along the anterior portion of the anastomosis. The animals were killed after 2 weeks and evaluated for abdominal infection, fistulae, and adhesions. The anastomosis was excised and the following parameters were assessed by a pathologist blinded to treatment: mucosal interruption (mm), inflammatory response, collagen type I and III, granulation, and fibrosis (grade 0-4).

RESULTS

Stents were spontaneously expelled between postoperative days 6 and 9. At necropsy, none of the animals in the study group had leak related complications, whereas in the control group, 5 (63%) developed intraabdominal infection (4 abscesses, 1 fistula) at the anastomosis (P = .002). Dense adhesions to the anastomosis were found in 7 (88%) control animals. On histology, anastomotic sites in the study group had significantly less mucosal interruption and granulation. Two pigs in the study group died on postoperative day 7, one due to evisceration and one from bladder necrosis. The mortality result is not different from controls (P = .47), both events seem to be unrelated to stent placement.

CONCLUSION

Temporary placement of a covered polyester stent across a colorectal anastomosis prevents leak-related complications and supports the healing of anastomotic leaks.