Costs Related to Diverting Ileostomy After Rectal Cancer Surgery: A Population-Based Healthcare Cost Analysis Based on Nationwide Registers.

Low anterior resection for rectal cancer often includes a diverting loop-ileostomy to avoid the severe consequences of anastomotic leakage. Reversal of the stoma is often delayed, which can incur health-care costs on different levels. The aim is to, on population basis, determine stoma-related costs, and to investigate habitual and socioeconomic factors associated to the level of cost. Multi-register design with data from the Swedish Rectal Cancer Registry, the National Prescribed Drug Register, Statistics Sweden and cost-administrative data from the National Board of Health and Welfare. Data was gathered for 3564 patients with rectal cancer surgery 2007 to 2013, for 3 years following the surgery. Factors influencing the cost of inpatient care and stoma-related consumables were assessed with linear regression analyses. All monthly costs were higher for females (consumables P < .001 and in-patient care P = .031). Post-secondary education (P = .003) and younger age (P = .020) was associated with a higher cost for consumables while suffering a surgical complication was associated with increased cost for inpatient care (P < .001). Patients who had their stoma longer had lower monthly costs (consumables P < .001 and in-patient care P < .001). Female gender, longer duration of stoma, young age, and higher education are associated with higher costs for the care of a diverting stoma after rectal cancer surgery. This study does not allow for analyses of causality but the results together with deepened analyses of underlying reasons form a proper basis for decisions in health care planning and allocation of resources. These findings may have implications on the debate of equal care for all.

The Dynamics of Circulating Heparin-Binding Protein: Implications for Its Use as a Biomarker.

Heparin-binding protein (HBP) is a promising biomarker for the development and severity of sepsis. To guide its use, it is important to understand the factors that could lead to false-positive or negative results, such as inappropriate release and inadequate clearance of HBP. HBP is presumably released only by neutrophils, and the organs responsible for its elimination are unknown. In this study, we aimed to determine whether non-neutrophil cells can be a source of circulating HBP and which organs are responsible for its removal. We found that in two cohorts of neutropenic patients, 12% and 19% of patients in each cohort, respectively, had detectable plasma HBP levels. In vitro, three leukemia-derived monocytic cell lines and healthy CD14+ monocytes constitutively released detectable levels of HBP. When HBP was injected intravenously in rats, we found that plasma levels of HBP decreased rapidly, with a distribution half-life below 10 min and an elimination half-life of 1-2 h. We measured HBP levels in the liver, spleen, kidneys, lungs, and urine using both ELISA and immunofluorescence quantitation, and found that the majority of HBP was present in the liver, and a small amount was present in the spleen. Immunofluorescence imaging indicated that HBP is associated mainly with hepatocytes in the liver and monocytes/macrophages in the spleen. The impact of hematologic malignancies and liver diseases on plasma HBP levels should be explored further in clinical studies.

Higher frequency of anastomotic leakage with stapled compared to hand-sewn ileocolic anastomosis in a large population-based study.

BACKGROUND: The stapling technique was recommended in a recent Cochrane analysis based on relatively small randomized trials between 1970 and 2009. Data from a large Swedish population-based quality register were analyzed in order to compare the leakage frequency between stapled and hand-sewn ileocolic anastomoses in colon cancer surgery. METHODS: Three-thousand four-hundred and twenty-eight patients with an ileocolic anastomosis were entered in a Swedish regional quality register for colon cancer, including the type of anastomosis used. The patients were analyzed by logistic regression regarding risk for leakage, and Cox proportional hazard regression for survival associated with the technique used for anastomosis. Analyses were made for gender, age, elective or emergency surgery, duration of surgery, bleeding, cancer stage, and local radicality. RESULTS: Most anastomoses were hand sewn (1,908 of 3,428, 55.7 %, p < 0.001), whereas stapling was more common among emergency cases (342 of 618, 55.3 %, p < 0.001). Clinically relevant leakage appeared in 58 patients (1.7 %), of whom 51 (87.9 %) were re-operated. Leakage was found to be more frequent after stapled anastomosis (2.4 vs. 1.2 %, p = 0.006), and in multivariate analysis, stapled anastomosis was the only risk factor (OR = 2.04 95 % CI 1.19-3.50). There was no difference in overall survival related to the technique. CONCLUSION: Hand-sewn anastomosis is not associated with a higher leakage rate when comparing to a stapling procedure and is recommended for routine and emergency right-sided colon cancer surgery. This recommendation is based on what appears to be a lower leakage rate, similar survival and lower material cost.