Comparative cost analysis between endoscopic resection and surgery for submucosal colorectal cancer

배경/목적: 얕은 점막하층 침윤 조기대장암에 대한 내시경절제술은 외과수술과 유사한 정도의 우수한 치 료 성적을 보이지만, 두 치료방법의 비용-효과에 대한 비교 분석 연구는 부족하다. 이 연구에서 는 점막하층 침윤 조기대장암에서 내시경절제술과 외과수술 후 예후 및 누적 비용을 비교, 분석 하고자 하였다. 방법: 점막하층 침윤 조기대장암으로 내시경절제술 또는 외과수술을 시행 받은 환자 484 명의 의무기 록을 후향적으로 검토하였다. 내시경절제술 또는 외과수술을 위해 처음 입원한 기간 동안의 비 용을 조사하였고, 퇴원 후 추적 기간 동안 외래 방문, 검사 및 재입원에 소요된 비용을 조사하였 다. 내시경절제술 및 외과수술 후 합병증과 암 재발 등 치료 성적도 분석하였다. 두 치료 군의 기 본 특성 차이를 교정하기 위해 성향점수 짝맞춤 분석(propensity score matching analysis)을 통한 보정 후 비용-효과를 재차 분석하였다. 결과: 155 쌍의 성향점수 짝맞춤 분석에서 내시경절제술 및 외과수술 치료군 사이에 시술 관련 합병 증 발생률(6.5% vs. 3.9%, p = 0.304)과 암 재발률(0.6% vs. 1.3%, p = 1.000)에 차이가 없었다. 그러 나, 재입원 비율은 내시경절제술 군에서 높았는데(40.6% vs. 11.0%, p<0.001), 내시경절제술 군 155 명 중 64 명에서 내시경절제술 후 깊은 점막하층 침윤 등 불량 예후 인자가 발견되어 추가적 외과수술을 필요로 했기 때문이다. 내시경절제술 및 외과수술을 위해 처음에 입원한 기간 동안 비용은 외과수술 군에서 더 높았으며(6698.4±1385.8 vs. 1335.6±928.5 USD, p < 0.001), 추적 관찰 기간 동안 비용은 내시경절제술 군에서 더 높았다(5035.7±6415.5 vs. 2488.7±2057.3 USD, p < 0.001). 총 누적비용은 내시경절제술 군에서 더 낮았다(6371.3±6487.1 vs. 9187.1±2739.5 USD, p < 0.001). 484 명의 전체 코호트 분석에서도 동일한 경향을 보였다. 결론: 점막하층 침윤 조기대장암의 치료에서 내시경절제술은 외과수술과 유사한 시술 관련 합병증, 암 재발률 등의 치료 성적을 보이면서 총 누적비용은 더 낮았다. 따라서, 내시경절제술은 얕은 점막하층 침윤이 의심되는 조기대장암의 표준치료법으로 우선 선택될 수 있을 것으로 생각한 다.|Background and aims: Only few studies analyzed the cost of endoscopic resection (ER) and surgical resection (SR) in the treatment of submucosal colorectal cancer (SMCRC). We performed a detailed cost analysis of ER and SR for SMCRC. Methods: Medical records of 484 patients with SMCRC who underwent ER or SR were reviewed. The total costs during index admission and follow-up as well as clinical outcomes between the two groups were compared in the whole cohort and propensity score-matched cohort. Results: In propensity score-matched analysis (n = 155 in each group), the ER and SR groups did not show significant differences in the rates of procedure-related adverse events (6.5% vs 3.9%, P = .304) and recurrence (0.6 % vs 1.3 %, P > .99). Readmission was more common in the ER group (40.6% vs 11.0%, P < .001) because 64 (41.3%) patients underwent additional surgery for endoscopic non-curative resection. The ER group had a lower cost during the index admission (1335.6 vs 6698.4 USD, P < .001), whereas the SR group had a lower cost during follow-up (2488.7 vs 5035.7 USD, P < .001). The total cumulative cost was lower in the ER group (6371.3 vs 9187.1 USD, P < .001). The same trend was observed in the whole cohort without propensity score-matching. Conclusions: The total cumulative cost for treatment and follow-up for SMCRC was lower in the ER group, which had comparable oncologic outcomes as the SR group. ER can be considered a cost-effective option for initial treatment for SMCRC.Maste

The Clinical Significance of Anastomotic Ulcers After Ileocolic Resection to Predict Postoperative Recurrence of Crohn’s Disease

Background The Rutgeerts score is used to predict postoperative recurrence in CD patients after ileocolic resection and is primarily based on endoscopic findings at the neoterminal ileum. However, the optimal assessment of anastomotic ulcers (AUs) remains subject to debate. Aims We aimed to investigate the association between anastomotic ulcers (AUs) and endoscopic recurrence in postoperative Crohn’s disease (CD) patients. Methods This single-center retrospective study, conducted between 2000 and 2016, evaluated postoperative CD patients with endoscopic remission at the first ileocolonoscopy within 1 year after ileocolic resection and those who underwent subsequent ileocolonoscopic follow-up. The study outcome was the clinical significance of AUs in predicting endoscopic recurrence. Results Among 116 patients who were in endoscopic remission defined as the RS of i0 to i1 at the index postoperative ileocolonoscopy, 84.5% (98/116) underwent subsequent ileocolonoscopies. During the median 30.0 months (interquartile range, 21.3?53.3) of follow-up after the first ileocolonoscopy, 56.1% (55/98) of patients showed endoscopic recurrence. Furthermore, 65.8% (48/73) with AUs and 75.5% (40/53) with major AUs, defined as either an ulcer occupying ≥ 1/4 of the circumference, ≥ 3 ulcers confined to anastomotic ring, or any ulcers extending to the ileocolonic mucosa, showed endoscopic recurrence. On multivariable analysis, AUs (adjusted hazard ratio [aHR], 4.33; 95% confidence interval [CI], 1.87?10.0; P < 0.001) and major AUs (aHR, 3.64; 95% CI, 1.95?79; P < 0.001) were associated with endoscopic recurrence. Conclusions AUs are associated with a significantly high risk of endoscopic recurrence in postoperative CD patients who are in endoscopic remission

Prevalence and risk factors of bowel symptoms in Korean patients with ulcerative colitis in endoscopic remission: a retrospective study

Background: Many patients with ulcerative colitis (UC) in clinical remission frequently complain of bowel symptoms such as increased stool frequency (SF) and rectal bleeding (RB). However, studies on these patient-reported outcomes in patients with inactive UC are limited, especially in Korea. Therefore, we investigated the prevalence and risk factors of bowel symptoms in Korean patients with inactive UC. Methods: We investigated the prevalence of bowel symptoms in patients with endoscopically quiescent UC between June 1989 and December 2016 using a well-characterized referral center-based cohort. The Mayo clinic score (MCS) was used to evaluate bowel symptoms at the most recent visit near the date of endoscopy. Clinical characteristics of the patients were compared based on the presence or absence of bowel symptoms. Results: Overall, 741 patients with endoscopically quiescent UC were identified, of whom 222 (30%) and 48 (6.5%) had an SF and RB subscore of >= 1, respectively. Patients with bowel symptoms (SF + RB >= 1; n = 244 [32.9%]) had higher rates of left-sided colitis (E2) or extensive colitis (E3) than patients without bowel symptoms (SF + RB = 0; n = 497 [67.1%]; P = 0.002). Multivariate analysis revealed that female sex (odds ratio [OR]: 1.568; 95% confidence interval [CI]: 1.023-2.402; P = 0.039) and E2 or E3 (OR 1.411; 95% CI 1.020-1.951; P = 0.038) were the significant risk factors for increased SF. Conclusions: This study revealed that one-third of patients with endoscopically quiescent UC reported increased SF. Female sex and disease extent may be associated with bowel symptoms