RT Journal
A1 Heald RJ
T1 COst-effectiveness of defunctioning stomas in low anterior resections for rectal cancer—invited critique
JF Archives of Surgery
JO Archives of Surgery
YR 2003
FD December 1
VO 138
IS 12
SP 1339
OP 1339
DO 10.1001/archsurg.138.12.1339
UL http://dx.doi.org/10.1001/archsurg.138.12.1339
AB 
Patients care little about initial cost: they want the lowest possible long-term outcome costs—0 for a cure with no stoma! I believe that outcome cost accounting would be even more valuable. In this article it is most interesting that the principal cost drivers after LAR are 1 initial cost (defunctioning) and 1 short-term outcome cost (leakage). However, most surgeons construct a defunction because they are afraid of the occasional death from leakage—this defies cost analysis except on very large series. On my total mesorectal excision travels, these deaths from delayed leaks by 1 surgeon were called "weekend mortalities" in Holland; the surgeon was away, another team was on call, and the deep pelvis sepsis was missed until multiorgan failure rendered intervention ineffective. Analyze all that for cost!