Intrathoracic versus cervical anastomosis after totally or hybrid minimally invasive transthoracic oesophagectomy for oesophageal cancer: cost-effectiveness analysis alongside the randomized ICAN trial.
Eric Matthée, Sander Ubels, Bastiaan Klarenbeek, Moniek H P Verstegen, Gerjon Hannink, Frans van Workum, Camiel Rosman, Janneke P C Grutters
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Abstract
Background: There is a worldwide trend towards minimally invasive oesophagectomy with intrathoracic anastomosis in oesophageal cancer surgery. Minimally invasive oesophagectomy with intrathoracic anastomosis has been shown to result in fewer anastomotic leaks, but cost-effectiveness is yet to be established. The aim of this study was to determine the cost-effectiveness of transthoracic minimally invasive oesophagectomy with intrathoracic anastomosis compared with cervical anastomosis.
Methods: A prospective economic evaluation was performed alongside the ICAN trial, a randomized clinical superiority trial. Patients with mid/distal oesophageal or gastro-oesophageal junction cancer were randomly assigned to transthoracic minimally invasive oesophagectomy with either intrathoracic or cervical anastomosis. Quality-adjusted life-years, mean healthcare, and societal costs were assessed for both groups at 9 and 21 months after surgery.
Results: A total of 245 patients randomized for transthoracic minimally invasive oesophagectomy with either intrathoracic (122) or cervical (123) anastomosis were included in the cost-effectiveness analysis. After 9 months, the intrathoracic group yielded 0.58 (95% confidence interval (c.i.) 0.55 to 0.61) quality-adjusted life-years per patient, compared with 0.56 (0.52 to 0.58) quality-adjusted life-years for the cervical group. After 9 months, both mean healthcare costs (20 573 (95% c.i. 17 623 to 24 177) versus 28 039 (23 574 to 33 116) euros), and societal costs (24 590 (21 237 to 29 074) versus 33 383 (27 885 to 38 805) euros), per patient were lower in the intrathoracic anastomosis group. Similarly, at 21 months no statistically significant difference was found (mean difference 0.08 (-0.05 to 0.2) quality-adjusted life-years), whereas minimally invasive oesophagectomy with intrathoracic anastomosis was less costly than that with cervical anastomosis (mean difference -9930 (-16 301 to -2521) euros). The higher costs in the cervical anastomosis group were mainly due to longer lengths of stay owing to complications.
Conclusion: Transthoracic minimally invasive oesophagectomy with intrathoracic anastomosis was found to be cost-effective compared with transthoracic minimally invasive oesophagectomy with cervical anastomosis.
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