A Novel Cost-Benefit Analysis of Prophylactic Octreotide for Pancreatic Resections
Tsafrir Vanounou, Wande Pratt, Mark P Callery, Charles M Vollmer, Jr.
Beth Israel Deaconess Medical Center, Harvard Medical School
Introduction: The efficacy of prophylactic octreotide has been rigorously scrutinized; yet, few studies illustrate its impact in patients at high risk for pancreatic fistula. Applying a previously validated clinical classification scheme (ISGPF) for postoperative pancreatic fistula severity, we examined whether prophylactic octreotide could effectuate a clinical and/or fiscal benefit following pancreatic resection.
Methods: 252 consecutive patients underwent pancreaticoduodenectomy (n=181) or distal pancreatectomy (n=71) from 10/01 to 2/06. Prophylactic octreotide was administered at the surgeon’s discretion intraoperatively and continued postoperatively. Clinically relevant fistulas required therapeutic interventions or resulted in severe clinical sequelae. Risk factors for fistula included (1) soft gland, (2) small duct, or (3) ampullary, duodenal, cystic, or islet cell pathology. Beyond traditional clinical review, a novel economic cost-benefit analysis of octreotide prophylaxis was performed with concentration on high-risk glands (=1 risk factor).
Results: Prophylactic octreotide in low-risk glands (no risk factors) was neither clinically effective nor cost efficient following pancreaticoduodenectomy, contributing to $1,103 in overspending per patient—approximately equivalent to the cost of octreotide administration. However, in patients with high-risk glands, octreotide prophylaxis reduced the incidence and morbidity of clinically relevant fistulas (20% vs. 36%, Table). These improved clinical outcomes were associated with decreased resource utilization, particularly radiology and laboratory costs, and translated to considerable cost-savings ($18,319) per patient. Distal pancreatectomies behaved similarly.
Conclusions: Octreotide prophylaxis is an effective approach to mitigate the negative impact of pancreatic fistulas. However, prophylactic octreotide should be given exclusively to patients with high-risk glands to obtain maximal clinical value and cost benefit.
Table. Clinical and Economic Outcomes for Pancreaticoduodenectomy