A decision analysis comparing three strategies for peritoneal lavage cytology testing in staging of gastric cancer in China.

BACKGROUND: Positive peritoneal cytology (PCY) indicates metastasis (M1) in gastric cancer (GC) patients; both the American and Chinese guidelines recommend laparoscopic peritoneal lavage (LPL) for cytology. However, relatively high costs impair the widespread use of LPL in some resource-limited regions in China, and the cost-effectiveness of PCY testing remains unclear. Therefore, we performed a decision analysis to evaluate the cost-effectiveness of PCY testing by comparing the guideline-recommended intraoperative LPL, a newly proposed preoperative percutaneous peritoneal lavage (PPL), and a third strategy of exploratory laparotomy with no cytology testing (ELNC) among GC patients. METHODS: We developed a decision-analytic Markov model of the aforementioned three strategies for a hypothetical cohort of GC patients with curative intent after initial imaging, from the perspective of Chinese society. We estimated costs, quality-adjusted life years (QALYs), and incremental cost-effectiveness ratios (ICERs) as primary outcomes; we also conducted one-way and probabilistic sensitivity analyses to investigate the model's robustness. RESULTS: We found that ELNC was dominated (i.e., more expensive and less effective) by PPL and LPL. LPL was the most cost-effective method with an ICER of US$17,200/QALY compared to PPL, which was below the Chinese willingness-to-pay (WTP) threshold of US$29,313 per QALY gained. In sensitivity analyses, PPL was more likely to be cost-effective with a lower WTP threshold. CONCLUSIONS: Cytology testing through either LPL or PPL was less expensive and more effective than ELNC among GC patients. Moreover, LPL was the most cost-effective modality at the current WTP threshold, while PPL could potentially be cost-effective in lower-income areas.

Cost analysis of laparoscopic lavage compared with sigmoid resection for perforated diverticulitis in the Ladies trial.

BACKGROUND: Laparoscopic peritoneal lavage is an alternative to sigmoid resection in selected patients presenting with purulent peritonitis from perforated diverticulitis. Although recent trials have lacked superiority for lavage in terms of morbidity, mortality was not compromised, and beneficial secondary outcomes were shown. These included shorter duration of surgery, less stoma formation and less surgical reintervention (including stoma reversal) for laparoscopic lavage versus sigmoid resection respectively. The cost analysis of laparoscopic lavage for perforated diverticulitis in the Ladies RCT was assessed in the present study. METHODS: This study involved an economic evaluation of the randomized LOLA (LaparOscopic LAvage) arm of the Ladies trial (comparing laparoscopic lavage with sigmoid resection in patients with purulent peritonitis due to perforated diverticulitis). The actual resource use per individual patient was documented prospectively and analysed (according to intention-to-treat) for up to 1 year after randomization. RESULTS: Eighty-eight patients were randomized to either laparoscopic lavage (46) or sigmoid resection (42). The total medical costs for lavage were lower (mean difference € - 3512, 95 per cent bias-corrected and accelerated c.i. -16 020 to 8149). Surgical reintervention increased costs in the lavage group, whereas stoma reversal increased costs in the sigmoid resection group. Differences in favour of laparoscopy were robust when costs were varied by ±20 per cent in a sensitivity analysis (mean cost difference € - 2509 to -4438). CONCLUSION: Laparoscopic lavage for perforated diverticulitis is more cost-effective than sigmoid resection.

Technology-driven triage of abdominal trauma: the emerging era of nonoperative management.

Selective nonoperative management of blunt or penetrating abdominal trauma is safe, has eliminated the complications associated with nontherapeutic laparotomies, and is cost-effective. Appropriately selected investigations, such as focused abdominal sonography for trauma, diagnostic peritoneal lavage, spiral computed tomography (CT) scan, diagnostic laparoscopy, or thoracoscopy and angiography, play a critical role in the triage of patients. Future technological advances, such as improvement of the ultrasonic hardware and software that provide automated interpretation and the availability of portable CT scan machines in the emergency room, may improve the speed and accuracy of the initial evaluation. Improvement of the optical system of minilaparoscopes may allow reliable bedside laparoscopy for suspected diaphragmatic injuries.

Diagnostic peritoneal lavage in the evaluation of abdominal trauma using the dipstick.

OBJECTIVE: To determine the accuracy and sensitivity of diagnostic peritoneal lavage in the assessment of intra-abdominal injury using the dipstick method. DESIGN: Prospective study, involving the performance of diagnostic peritoneal lavage in the out patient department and surgical wards prior to surgical intervention. SETTING: Kenyatta National Hospital-General Surgical and Orthopaedic wards and outpatient department. The study was conducted over a duration of six months, starting from January 1995 to July 1995. RESULTS: Ninety six patients with penetrating (68) and blunt (28) abdominal trauma underwent diagnostic peritoneal lavage as evaluation of the severity of abdominal trauma. Dipstick (combur 9 strips) was used to evaluate lavage effluent for red blood cells, white blood cells, protein and bilirubin. Forty three patients had positive diagnostic peritoneal lavage (DPL) results, of which 40 (93%) had positive findings at laparatomy and three (7%) had negative findings at laparatomy. The remaining 53 patients had negative DPL results and were managed conservatively. One patient with a negative DPL result became symptomatic and had a positive laparatomy. Conservatively managed patients were discharged after 24 hours observations without any complications. DPL had an accuracy and sensitivity of 93% and specificity of 98%. CONCLUSION: Diagnostic peritoneal lavage is a cheap, safe and reliable method for assessment of abdominal trauma. The method is easy to perform by trained junior doctors in the OPD, or as a bedside procedure. Use of this method reduced negative laparotomy rate from 50% to 6.9% and average duration of stay from 6.5 days to 1.9 days. This method is recommended as a basic tool in the assessment of abdominal trauma patients.

Complementary roles of diagnostic peritoneal lavage and computed tomography in the evaluation of blunt abdominal trauma.

OBJECTIVE: To assess in randomized prospective format sensitivity, laparotomy rate, and cost-effectiveness of using diagnostic peritoneal lavage (DPL) in a complementary role with computed tomography (CT) in the evaluation of blunt abdominal trauma. METHODS: Blunt trauma patients greater than 18 years of age were eligible for entry in the study. The study period was from February 1999 to July 2000 at an urban Level I trauma center. All patients were hemodynamically stable upon study entry and had abdominal tenderness with Glasgow Coma Scale (GCS) scores > 13 or GCS < 14. Patients were randomized to a DPL arm (DPL-CT) versus a CT arm. If randomized to the CT arm, patients underwent abdominal/pelvis CT. If CT was positive for solid organ injury, patients were observed. If free fluid was identified on CT without solid organ injury, patients were explored. If randomized to DPL-CT, patients underwent closed infraumbilical DPL, except pelvic fractures that were done with the open supraumbilical technique. If the DPL result was > 20,000 RBCs/mm3, patients underwent abdominal/pelvis CT. If the CT following DPL was consistent with solid organ injury, patients were observed. If the CT following DPL identified free fluid without solid organ injury and DPL was > 100,000 RBCs/mm3, patients were explored. RESULTS: Two hundred fifty-two patients were entered; 127 patients were randomized to DPL-CT and 125 to CT. Of the 125 patients randomized to CT, 102 (82%) CT scans were negative, 19 (15%) were positive for solid organ injury, and 3 (2%) had free fluid. Three (2%) of the initial negative CT scan patients underwent delayed laparotomy for missed injuries. Of the 127 patients randomized to DPL-CT, 26 (20%) required CT scan, of which 13 (10%) were positive for solid organ injury and 13 (10%) for free fluid. Positive DPL results that were indications for CT ranged from 21,000 to 1 million RBCs/mm3. Eight of the 13 DPL-CT patients with free fluid on CT had DPL results less than 100,000 RBCs/mm3 and did not require laparotomy. There were no known missed injuries in the DPL-CT arm. Seven (6%) laparotomies were performed in the DPL-CT arm and 10 (8%) in the CT arm. The average cost to the patient for abdominal evaluation in the CT arm was 1611 dollars and 650 dollars in the DPL-CT arm. CONCLUSION: Screening DPL with complementary CT has a low nontherapeutic laparotomy rate and is a sensitive and cost-effective method for the evaluation of blunt abdominal trauma.

Evaluating blunt abdominal trauma with sonography: a cost analysis.

Ultrasonography (US) is becoming increasingly utilized in the United States for the evaluation of blunt abdominal trauma (BAT). The objective of this study was to assess the cost impact of utilizing US in the evaluation of patients with BAT in a major trauma center. All patients sustaining BAT during a 6-month period before US was used at our institution (Jan-Jun 1993) were compared to BAT patients from a recent period in which US has been utilized (Jan-Jun 1995). The numbers of US, computed tomography (CT), and diagnostic peritoneal lavage (DPL) were tabulated for each group. Financial cost for each of these procedures as determined by our finance department were as follows: US $96, CT $494, DPL $137. These numbers are representative of actual hospital expenditures exclusive of physician fees as calculated in 1994 U.S. dollars. Cost analysis was performed with t test and chi squared test, and significance was defined as P < 0.05. There were 890 BAT admissions in the 1993 study period and 1033 admissions in the 1995 study period. During the 1993 period, 642 procedures were performed on the 890 patients to evaluate the abdomen: 0 US, 466 CT, and 176 DPL (see table) [table: see text]. This compares to 801 procedures on the 1,033 patients in 1995: 552 US, 228 CT, and 21 DPL. Total cost was $254,316 for the 1993 group and $168,501 for the 1995 group. Extrapolated to a 1-year period, a significant (P < 0.05) cost savings of $171,630 would be realized. Cost per patient evaluated was significantly reduced from $285.75 in 1993 to $163.12 in 1995 (P < 0.05). This represents a 43 per cent reduction in per patient expenditure for evaluating the abdomen. By effectively utilizing ultrasonography in the evaluation of patients with blunt abdominal trauma, a significant cost savings can be realized. This effect results chiefly from an eight-fold reduction in the use of DPL, and a two-fold reduction in the use of CT.

Prospective evidence of the superiority of a sonography-based algorithm in the assessment of blunt abdominal injury.

BACKGROUND: Although the routine use of FAST (focused assessment with sonography for trauma) in the evaluation of trauma victims is increasing, to our knowledge, a prospective comparison of contemporary adult trauma victims managed with and without FAST has not been reported in North America. METHODS: Adult victims of blunt trauma for whom there was a suspicion of abdominal injury were managed with one of two diagnostic algorithms, FAST or no-FAST. The two algorithms were compared for diagnostic accuracy, cost, time, and delayed diagnoses. RESULTS: Among 706 patients (mean Injury Severity Score, 23), 460 were managed with FAST and 246 with no-FAST. The two groups were similar with respect to age, Injury Severity Score, prehospital time, and mortality (p = not significant). There were 3 of 460 (0.7%) delayed diagnoses in the FAST group and 4 of 246 (1.6%) in the no-FAST group (p = not significant). The diagnostic accuracy for the FAST and no-FAST algorithms was 99% and 98%, respectfully. The FAST and no-FAST algorithms led to similar rates of laparotomy, 13% and 14%, respectfully, but nonoperative management was more common in the no-FAST group (p < 0.01). The mean diagnostic cost for the FAST algorithm was $156, compared with $540 with the no-FAST algorithm (p < 0.0001) and the mean time required for diagnostic work-up was 53 minutes with the FAST algorithm, compared with 151 minutes with the no-FAST algorithm (p < 0.0001). CONCLUSION: This study has provided prospective evidence that a FAST-based algorithm for blunt abdominal injury was more rapid, less expensive, and as accurate as an algorithm that used computed tomography or diagnostic peritoneal lavage only. Trauma centers are encouraged to incorporate a FAST-based algorithm into their initial management of blunt trauma victims.

Increased efficiency and cost-effectiveness in the evaluation of the blunt abdominal trauma patient with the use of ultrasound.

The efficacy and effectiveness of ultrasound (US) in evaluating patients suspected of having blunt abdominal trauma are near that of computed tomography (CT) and diagnostic peritoneal lavage (DPL). Because no cost-effectiveness study has been reported, the purpose of this study was to demonstrate that US is more efficient and cost-effective than CT/DPL in evaluating blunt abdominal trauma. Over a 9-month period, 331 patients suspected of sustaining blunt abdominal trauma were evaluated at a Level I trauma center by US, CT, and/or DPL. Cost data and time to disposition were determined for analysis. The sensitivity, specificity, and accuracy of US were similar to those reported in previous studies. There was a significant difference in time to disposition with the US group being significantly lower (P = 0.001). The total procedural cost was 2.8 times greater for the CT/DPL group than for the US group. US is not only effective in diagnosing blunt abdominal trauma, but it is also more efficient and cost-effective than is CT/DPL.

Safety and efficacy of diagnostic peritoneal lavage performed by supervised surgical and emergency medicine residents.

Diagnostic peritoneal lavage (DPL) remains an accurate diagnostic test for intra-abdominal injury. This study examined the safety and efficacy of DPL performed by supervised residents in an urban trauma centre. A retrospective chart review was carried out of a one year experience (July 1994-June 1995). Junior surgical and senior emergency medicine residents rotating on the Trauma Service performed an open DPL by protocol under the direct supervision of senior surgical residents. Standard criteria were used for diagnosis. During this study, 1349 injured patients were admitted to the Trauma Service. Of these 525 patients underwent DPL. Complete records were available on 516 patients. The average age of the patients was 33 years and injury was primarily blunt (95%). There were 72 true positives, 428 true negatives, two false positive and seven false negative DPLs; for a sensitivity of 91.1%, specificity of 99.5% and accuracy of 96.9%. Complications occurred in 12 patients (2.3%): non-diagnostic DPL-7 (1.3%); intraabdominal injury-4 (0.8%); wound complication-1 (0.2%). Seven patients underwent non-therapeutic laparotomy for a positive DPL. Thirty-four patients (6.6%) died, none from the DPL. DPL obviated the need for computed tomography scan of the abdomen and/or pelvis in 464 patients resulting in a cost saving of approximately $250,000. DPL performed by supervised junior surgical and senior emergency medicine residents is a safe and cost-effective method of evaluating patients with potential intra-abdominal injury.

Computed tomography vs clinical and multidisciplinary procedures for early evaluation of severe abdomen and chest trauma--a cost analysis approach.

OBJECTIVE: To compare contrast computed tomography (CT) for evaluating abdominal and vascular chest injuries after emergency room resuscitation with multidisciplinary management based on bedside procedure (BP), e.g., peritoneal lavage, abdomen ultrasonography urography and, if indicated, CT and/or aortography or transesophageal echocardiography. DESIGN: Randomized study. SETTING: Emergency, critical care and radiology departments in a trauma center. PATIENTS: The study was performed in 103 severe blunt trauma patients with a revised trauma index < 8, admitted over a 16 month period and divided into group (G1, n = 52, CT management) and group 2 (G2, n = 51, BP management). INTERVENTIONS: A relative direct cost scale used in our trauma center was applied, and cost units (U) were assigned to each diagnostic test for cost-minimization analysis (abdomen ultrasonograph = 7.5 U, peritoneal lavage = 8 U, urography = 9 U, computed tomography = 9 U, transesophageal echocardiography = 13.5 U, and aortography = 15 U). One unit is approximately equivalent to $43.7. RESULTS: Injury severity score (ISS) was 31.7 +/- 15.4 in G1 and 33.8 +/- 18.3 in G2. Sensitivity for CT was 90.4% (G1) vs 72.5% for BP (G2) in abdomen (P < 0.01) and 60% in chest for evaluating mediastinal hematoma etiology (G1). As Table 2 shows, G1 needed 59 tests for evaluating injuries (1.1 +/- 0.3 tests patient) while G2 required 81 tests (1.68 +/- 0.8 tests/patient) (P < 0.01). The total relative cost was 538 U for G1, 7.04 +/- 2.2 U cost/injury and 10.3 +/- 3.3 U/evaluation of trauma vs 698 U for G2, 9.84 +/- 5.03 U cost/injury and 13.68 +/- 8.5 U/evaluation (P < 0.05). CONCLUSIONS: This cost-minimization study suggests that CT is a more cost-effective method for the post-emergency room resuscitation evaluation of severe abdominal blunt trauma than the multidisciplinary BP. Chest CT is a screening method for mediastinal hematoma but not for etiology.

Randomized, prospective comparison of open and closed peritoneal lavage for abdominal trauma.

STUDY OBJECTIVE: The study was designed to determine if open peritoneal lavage is superior to closed peritoneal lavage. DESIGN AND PARTICIPANTS: Patients who were admitted to a trauma center and needed peritoneal lavage were assigned to alternate trauma teams. Team 1 performed only open lavages one month and then switched to closed lavages; team 2 did only closed lavages and then switched to open lavages. MEASUREMENTS: The incidences of positive lavages and lavage complication were noted. Also measured were the length of time for catheter insertion, length of time of fluid retrieval, volume of effluent, technical difficulty of lavage, training level of the operator, effluent RBC count, and material cost. RESULTS: Two hundred twenty patients were randomized. No differences were noted in complication rate, volume of effluent, or length of time for fluid retrieval. Significant differences were noted for catheter insertion time (3.6 minutes for closed lavage and 6.9 minutes for open), ease of catheter insertion (closed technique is favored), and material cost ($96.26 for open lavage and $69.70 for closed lavage). CONCLUSION: Closed peritoneal lavage is superior to open peritoneal lavage in abdominal trauma; it is faster, easier to use, cheaper, and as safe as open lavage.

Blunt trauma to the abdomen.

There is general agreement that physical examination alone is inadequate for abdominal evaluation in the multiply injured blunt trauma patient; but controversy exists regarding the preferred method of detecting intraabdominal injuries requiring celiotomy. Both peritoneal lavage and the newer computed tomography imaging techniques have advantages and disadvantages. Direct comparisons of the two techniques have not determined a preferred method. When used as complementary rather than competitive studies, diagnostic peritoneal lavage and computed tomography imaging provide more information than either test alone.

Open versus closed peritoneal lavage with particular attention to time, accuracy, and cost.

One hundred consecutive patients with blunt abdominal trauma, thoracoabdominal stab wounds, or anterior abdominal stab wounds with fascial penetration were prospectively randomized to either an open or closed technique for diagnostic peritoneal lavage. The closed or percutaneous technique of lavage was consistently faster to perform, of comparable cost, associated with fewer complications, and as accurate as the open technique.