Clinical and economic burden of colorectal and bariatric anastomotic leaks

Abstract

Background

Anastomotic leaks cause a significant clinical and economic burden on patients undergoing bariatric and colorectal surgeries. Current literature shows a wide variation in incidence of anastomotic leaks and a significant gap in associated economic metrics. This analysis utilized claims data to quantify the full episode-of-care cost burden of leaks following colorectal and bariatric surgeries.

Methods

Medicare Fee-for-Service and commercial claims data from a large U.S.-based health plan were queried for cost and utilization of members that underwent bariatric and colorectal surgical procedures between January 1, 2013 and August 31, 2015. Outcomes were collected for members with anastomotic leaks versus those without leaks during the initial hospital stay (index) and within 30 days of the procedure. These outcomes included leak frequency, payer reimbursement, and length of stay (LOS).

Results

The colorectal Medicare analysis identified 239,350 patients undergoing colorectal surgery. For patients with a leak compared to those without, index admission costs were $30,670 greater ($48,982 vs. $18,312; p < 0.0001) and the index LOS was 12 days longer (19 vs. 7 days; p < 0.0001). This finding was similar for the bariatric patients (n = 62,292) where cost was $30,885 higher ($43,918 vs. $13,033; p < 0.0001) and LOS was 15 days longer (17 vs. 2 days; p < 0.0001). Furthermore, readmissions and associated costs were also substantially higher for those with an index leak. The commercial analysis of both the bariatric and colorectal populations trended similarly to the Medicare population in regards to all outcomes measured.

Conclusion

Patients experiencing anastomotic leaks during and after bariatric and colorectal surgery have significantly higher costs and longer LOS both at the initial stay and within 30 days of the procedure. It is important that providers and hospitals understand the economic consequences of these procedures and implement technologies and techniques to prevent/reduce anastomotic leaks.

This is a preview of subscription content, log in to check access.

References

  1. 1.

    Park JS, Huh JW, Park YA et al (2016) Risk factors of anastomotic leakage and long-term survival after colorectal surgery. Medicine (Baltimore) 95(8):e2890. https://doi.org/10.1097/MD.0000000000002890

    Article  Google Scholar 

  2. 2.

    Chadi SA, Fingerhut A, Berho M et al (2016) Emerging trends in the etiology, prevention, and treatment of gastrointestinal anastomotic leakage. J Gastrointest Surg 20(12):2035–2051

    Article  Google Scholar 

  3. 3.

    Phillips B (2016) Reducing gastrointestinal anastomotic leak rates: review of challenges and solutions. Open Access Surg. https://doi.org/10.2147/OAS.S54936

    Article  Google Scholar 

  4. 4.

    Trencheva K, Morrissey KP, Wells M et al (2013) Identifying important predictors for anastomotic leak after colon and rectal resection: prospective study on 616 patients. Ann Surg 257(1):108–113. https://doi.org/10.1097/SLA.0b013e318262a6cd

    Article  PubMed  Google Scholar 

  5. 5.

    Berger ER, Huffman KM, Fraker T et al (2018) Prevalence and risk factors for bariatric surgery readmissions: findings from 130,007 admissions in the metabolic and bariatric surgery accreditation and quality improvement program. Ann Surg 267(1):122–131. https://doi.org/10.1097/SLA.0000000000002079

    Article  PubMed  Google Scholar 

  6. 6.

    Hammond J, Lim S, Wan Y et al (2014) The burden of gastrointestinal anastomotic leaks: an evaluation of clinical and economic outcomes. J Gastrointest Surg 18(6):1176–1185. https://doi.org/10.1007/s11605-014-2506-4

    Article  PubMed  PubMed Central  Google Scholar 

  7. 7.

    Krell RW, Girotti ME, Fritze D et al (2013) Hospital readmissions after colectomy: a population-based study. J Am Coll Surg 217(6):1070–1079. https://doi.org/10.1016/j.jamcollsurg.2013.07.403

    Article  PubMed  Google Scholar 

  8. 8.

    Lipska MA, Bissett IP, Parry BR et al (2006) Anastomotic leakage after lower gastrointestinal anastomosis: men are at a higher risk. ANZ J Surg 76(7):579–585

    Article  Google Scholar 

  9. 9.

    Haddad A, Tapazoglou N, Singh K et al (2012) Role of intraoperative esophagogastroenteroscopy in minimizing gastrojejunostomy-related morbidity: experience with 2,311 laparoscopic gastric bypasses with linear stapler anastomosis. Obes Surg 22(12):1928–1933. https://doi.org/10.1007/s11695-012-0757-2

    Article  PubMed  PubMed Central  Google Scholar 

  10. 10.

    Rickles AS, Iannuzzi JC, Mironov O et al (2013) Visceral obesity and colorectal cancer: are we missing the boat with BMI? J Gastrointest Surg 17(1):133–143. https://doi.org/10.1007/s11605-012-2045-9

    Article  PubMed  Google Scholar 

  11. 11.

    Bliss LA, Maguire LH, Chau Z et al (2015) Readmission after resections of the colon and rectum: predictors of a costly and common outcome. Dis Colon Rectum 58(12):1164–1173. https://doi.org/10.1097/DCR.0000000000000433

    Article  PubMed  PubMed Central  Google Scholar 

  12. 12.

    Branagan G, Finnis D, Wessex Colorectal Cancer Audit Working Group (2005) Prognosis after anastomotic leakage in colorectal surgery. Dis Colon Rectum 48(5):1021–1026

    Article  Google Scholar 

  13. 13.

    Shogan BD, Carlisle EM, Alverdy JC et al (2013) Do we really know why colorectal anastomoses leak? J Gastrointest Surg 17(9):1698–2705

    Article  Google Scholar 

  14. 14.

    Karliczek A, Harlaar NJ, Zeebregts CJ et al (2009) Surgeons lack predictive accuracy for anastomotic leakage in gastrointestinal surgery. Int J Colorectal Dis 24(5):569–576. https://doi.org/10.1007/s00384-009-0658-6

    CAS  Article  PubMed  Google Scholar 

  15. 15.

    Ricciardi R, Roberts PL, Marcello PW et al (2009) Anastomotic leak testing after colorectal resection: what are the data? Arch Surg 144(5):407–411. https://doi.org/10.1001/archsurg.2009.43

    Article  PubMed  Google Scholar 

  16. 16.

    Allaix ME, Lena A, Degiuli M et al (2018) Intraoperative air leak test reduces the rate of postoperative anastomotic leak: analysis of 777 laparoscopic left-sided colon resections. Surg Endosc. https://doi.org/10.1007/s00464-018-6421-8

    Article  PubMed  Google Scholar 

  17. 17.

    Ivanov D, Cvijanović R, Gvozdenović L (2011) Intraoperative air testing of colorectal anastomoses. Srp Arh Celok Lek 139(5–6):333–338

    Article  Google Scholar 

  18. 18.

    Li VK, Wexner SD, Pulido N et al (2009) Use of routine intraoperative endoscopy in elective laparoscopic colorectal surgery: can it further avoid anastomotic failure? Surg Endosc 23(11):2459–2465. https://doi.org/10.1007/s00464-009-0416-4

    Article  PubMed  Google Scholar 

Download references

Acknowledgements

The authors would like thank Mr. Keith Needham, Manager with Baker Tilly, and Mr. Christopher Adams, MPH, Senior Consultant with Baker Tilly for their analytical support on this important piece of economic research.

Funding

Olympus Corporation of the Americas, Central Valley, PA.

Author information

Affiliations

Authors

Corresponding author

Correspondence to David Gregory.

Ethics declarations

Disclosures

Dr. Lee is a consultant for Olympus Corporation of the Americas, Ms. Cool has no conflict of interest or financial ties to disclose. Mr. Gregory is a partner with Baker Tilly and Baker Tilly receives management consulting fees from Olympus for various data analytic support activities.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Appendix

Appendix

Coding for anastomotic leak, bariatric and colorectal procedures

ICD-9 code Description
ICD-9: anastomotic leak case identification codes
 041.04 Streptococcus infection in conditions classified elsewhere and of unspecified site, Group D [Enterococcus]
 041.49 Other and unspecified Escherichia coli [E. coli] unspecified site exclude?
 041.85 Other specified bacterial infections in conditions classified elsewhere and of unspecified site, other gram-negative organisms unspecified site exclude?
 539.81 Infection due to other bariatric procedure
 567.0 Peritonitis and retroperitoneal infections: peritonitis in infectious diseases classified elsewhere
 567.21 Other suppurative peritonitis: peritonitis (acute) generalized
 567.22 Other suppurative peritonitis: peritoneal abscess
 569.5 Abscess of intestine
 569.81 Fistula of intestine, excluding rectum and anus
 569.83 Perforation of intestine
 790.7 Bacterimia
 998.31 Disruption of internal operation (surgical) wound
 998.59 Other postoperative infection
 998.6 Persistent postoperative fistula
 038.4 Septicemia due to other gram-negative organisms
 038.8 Other specified septicemia
 038.9 Unspecified septicemia
 54.11 Exploratory laparotomy (procedure code)
 54.12 Reopening of recent laparotomy site (procedure code)
 54.0 Incision of abdominal wall (procedure code)
 54.19 Other laparotomy (procedure code)
 54.91 Percutaneous abdominal drainage (procedure code)
ICD-9: bariatric procedure codes
 43.82 Laparoscopic sleeve gastrectomy
 43.89 Open and other partial gastrectomy
 44.31 High gastric bypass
 44.38 Laparoscopic gastroenterostomy
 44.39 Other gastroenterostomy without gastrectomy
 43.6 Partial gastrectomy with anastomosis to duodenum
 43.7 Partial gastrectomy with anastomosis to jejunum
 44.5 Revision of gastric anastomosis
ICD-9: colorectal procedure codes
 17.31 Laparoscopic multiple segmentation of large intestine
 17.32 Laparoscopic cecectomy
 17.33 Laparoscopic right hemicolectomy
 17.34 Laparoscopic resection of transverse colon
 17.35 Laparoscopic left hemicolectomy
 17.36 Laparoscopic sigmoidectomy
 17.39 Other laparoscopic partial excision of large intestine
 45.71 Open and multiple segmentation resection of large intestine
 45.72 Open and other cecetomy
 45.73 Open and right hemicolectomy
 45.74 Open and other transverse colon
 45.75 Open and left hemicolectomy
 45.76 Open and other sigmoidectomy
 45.79 Other and unspecified partial excision of large intestine
 45.81 Laparoscopic total intra-abdominal colectomy
 45.82 Open total intra-abdominal colectomy
 45.83 Other and unspecified total intra-abdominal colectomy
 45.9 Intestinal anastomosis, not specified
 45.91 Small to small intestinal anastomosis
 45.92 Anastomosis to rectal
 45.93 Other small to large intestinal anastomosis
 45.94 Large to large intestinal anastomosis
 45.95 Anastomosis to anus
 46.94 Revision of anastomosis of large intestine

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Lee, S.W., Gregory, D. & Cool, C.L. Clinical and economic burden of colorectal and bariatric anastomotic leaks. Surg Endosc 34, 4374–4381 (2020). https://doi.org/10.1007/s00464-019-07210-1

Download citation

Keywords

  • Anastomotic leaks
  • Intraoperative endoscopy
  • Cost analysis