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Implications and Cost of Pancreatic Leak Following Distal Pancreatic Resection

J. R. Rodriguez1, S. G. Soto1, P. Pandharipande2, G. S. Gazelle, S. P. Thayer1, A. L. Warshaw1, C. Fernandez-del Castillo1, Center for Clinical Effectiveness in Surgery and Institute for Technology Assessment, Massachusetts General Hospital, Harvard Medical School, Boston, MA

Rationale and Objective: Leakage from the pancreatic stump (PL) is the most common complication following distal pancreatectomy, and its incidence has remained unchanged for the last 15 years. The purpose of this study was to assess the economic impact of PL and subsequent increased health care resource utilization after elective distal pancreatic resections.
Patients and Methods: The medical records of 109 patients who underwent distal pancreatic resections (with or without splenectomy) at our institution from January 2002 to August 2004 were identified. Patients who had a concomitant organ resection or any additional procedures were excluded. A total of 66 elective distal pancreatectomy patients comprised our study group. Their clinical course was detailed retrospectively utilizing hospital and clinic charts and our institutional Clinical Application System (CAS). Hospital costs were analyzed using cost accounting database software (Eclipsys©) and professional costs were evaluated by averaging reimbursements across insurers. We then developed a decision analytic model to evaluate threshold costs of hypothetical interventions that could produce an absolute reduction in the proportion of patients with PL.
Results: Overall postoperative morbidity occurred in 34 patients (51.5%) with no deaths. The total number of patients with complications directly related to PL was 22 (33.3%). These complications included fistulas (19.7%, n=13), peripancreatic collections (12.1%, n=8), abscesses (10.6%, n=7) and wound problems related to PL (7.6%, n=5). The mean number of total hospital days for the non PL group was 5.2 days (1.7 days SD, range 3-12 days) versus 16.6 days for the PL group (14.6 days SD, range 4-49 days) (p=0.001). Of these patients, 13 (59.1%) visited the emergency department following discharge an average of 1.8 times (range 1-6), and 16 (72.7%) were readmitted for a mean of 13.8 hospital days (range 1-38 days). They averaged 1.7 (range 1-5) readmissions and 4.9 office visits (range 1-20) with a median follow up of 69.5 days (range 14-347); 18 patients (81.8%) required Visiting Nurse services throughout their postoperative course. The average patient with leak-related problems incurred a total cost that was 2 times greater than the non PL group; Mean costs were $28,209 ($17,687 SD, range $10,571-$68,966) versus $14,030 ($5,508 SD, range $8,934-$43,104) (p=0.001) respectively. Interventions aimed at decreasing the incidence of PL should take into account this cost differential, and can be represented by the following equation: CI = r 14,179 where CI is the hypothetical cost of intervention and r is an absolute reduction in the proportion of patients with PL (see graph).
Conclusions: Complications derived from PL following distal pancreatectomy double the cost and dramatically increase health care resource utilization. There is an urgent need to develop strategies which reduce the incidence of this common complication. We provide an economic model to serve as a guide in the development of these technologies.

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