RESUMO
BACKGROUND: Controversy exists over the timing of cholecystectomy for biliary pancreatitis in children. Some surgeons await normalization of serum lipase levels while others are guided by resolution of abdominal pain; however, there are minimal data to support either practice. We hypothesized that resolution of abdominal pain is equivalent in outcome to awaiting normalization of lipase levels in patients undergoing cholecystectomy for biliary pancreatitis. METHODS: After institutional review board (IRB) approval, the medical record was retrospectively queried for all cases of cholecystectomy for biliary pancreatitis at our institution from 2007 to 2017. Patients undergoing chemotherapy, admitted for another cause, or who had severe underlying comorbidities like ventilator dependence were excluded. Patients were stratified into two cohorts: those managed preoperatively by normalization of serum lipase levels versus resolution of abdominal pain. Demographics, serum lipase levels, postoperative complications, cost of stay, readmissions, and return to the emergency department were collected and analyzed using multivariate regression. RESULTS: Seventy-four patients met inclusion: 29 patients had lipase levels trended until normalization compared with 45 patients who had resolution of abdominal pain prior to cholecystectomy. Among the two cohorts there was no statistical difference in age, gender, race, ethnicity, or type of preoperative imaging used. Trended patients were found to have more serum lipase levels tested (8.5 ± 6.2 versus 3.4 ± 2.5, P < 0.0001). The trended lipase cohort was significantly more likely to require preoperative total parenteral nutrition (48% versus 11%, P = 0.007) and consequently a longer time before resuming a diet (10 ± 7.3 versus 4.6 ± 2.4 d, P < 0.0001). When comparing the two groups, we found no significant difference in the duration of surgery, postoperative complications, or readmissions. Lipase trended patients had a significantly longer length of stay compared with nontrended patients (11.5 ± 8.1 versus 4.2 ± 2.3 d, P < 0.0001) and had a higher total cost of stay ($38,094 ± 25,910 versus $20,205 ± 5918, P = 0.0007). CONCLUSIONS: Our data suggest that in children with biliary pancreatitis, proceeding with cholecystectomy after resolution of abdominal pain is equivalent in outcomes to trending serum lipase levels but is more cost-effective with a decreased length of stay and decreased need for preoperative total parenteral nutrition.
Assuntos
Dor Abdominal/diagnóstico , Colecistectomia Laparoscópica/normas , Cálculos Biliares/complicações , Lipase/sangue , Pancreatite/cirurgia , Tempo para o Tratamento/normas , Dor Abdominal/economia , Dor Abdominal/etiologia , Dor Abdominal/terapia , Adolescente , Criança , Colecistectomia Laparoscópica/efeitos adversos , Colecistectomia Laparoscópica/economia , Colecistectomia Laparoscópica/estatística & dados numéricos , Tomada de Decisão Clínica/métodos , Análise Custo-Benefício/estatística & dados numéricos , Feminino , Cálculos Biliares/sangue , Cálculos Biliares/economia , Cálculos Biliares/terapia , Humanos , Tempo de Internação/economia , Tempo de Internação/estatística & dados numéricos , Masculino , Duração da Cirurgia , Medição da Dor , Pancreatite/sangue , Pancreatite/economia , Pancreatite/etiologia , Nutrição Parenteral Total/estatística & dados numéricos , Readmissão do Paciente/estatística & dados numéricos , Complicações Pós-Operatórias/economia , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Guias de Prática Clínica como Assunto , Cuidados Pré-Operatórios/economia , Cuidados Pré-Operatórios/estatística & dados numéricos , Estudos Retrospectivos , Fatores de Tempo , Tempo para o Tratamento/economia , Tempo para o Tratamento/estatística & dados numéricos , Resultado do TratamentoRESUMO
BACKGROUND: Although, 33% to 40% of symptomatic gallstone patients reported persistent abdominal pain after laparoscopic cholecystectomy, there is no data on the burden of this pain to the healthcare system and society at large. This study determined healthcare consumption, sick leave, and costs in patients with persistent abdominal pain after laparoscopic cholecystectomy. Secondly, predictive factors for healthcare consumption were assessed. METHODS: This cross-sectional study included all 146 patients with persistent abdominal pain (patient-reported on Gastro-Intestinal Quality of Life Index (score 0-3) 24 weeks after laparoscopic cholecystectomy, derived from a previous prospective cohort. Healthcare consumption was assessed using Medical Consumption Questionnaire and medical records, and sick leave using Productivity Cost Questionnaire. Costs were calculated according "Guideline for performing economic evaluations in healthcare." Predictors of healthcare consumption were assessed using logistic regression analysis. RESULTS: In the study, 124/146 patients (85%) responded after mean follow-up of 31.0 months (standard deviation 6.5); 104 were female, mean age of responders was 52 years. Sixty-nine patients needed additional healthcare; 30.6% primary care; 37.1% secondary care; 16% emergency department admission; 8.9% hospital admission; 33.9% diagnostic procedures; 17.7% medication; 5.6% other interventions. Medical costs were $555 (BCa 95% confidence interval, $329-$852) and costs of sick leave were $361 (Bias-corrected and accelerated (BCa) 95% confidence interval, $189-$566) per year per patient. Younger age (odds ratio 0.95, 95% confidence interval, 0.92-0.98) and higher postoperative pain score (odds ratio 1.02, 95% confidence interval, 1.01-1.04) were associated with increased healthcare consumption. CONCLUSION: Persistent abdominal pain after laparoscopic cholecystectomy is associated with additional healthcare in 56% of patients. Yearly, medical costs and costs of sick leave are 20% of the initial costs of laparoscopic cholecystectomy.
Assuntos
Dor Abdominal/economia , Colecistectomia Laparoscópica/efeitos adversos , Atenção à Saúde/estatística & dados numéricos , Custos de Cuidados de Saúde , Dor Pós-Operatória/economia , Licença Médica , Dor Abdominal/etiologia , Adulto , Idoso , Estudos Transversais , Atenção à Saúde/economia , Feminino , Cálculos Biliares/complicações , Cálculos Biliares/economia , Cálculos Biliares/cirurgia , Humanos , Masculino , Pessoa de Meia-Idade , Dor Pós-Operatória/etiologiaRESUMO
BACKGROUND: Evidence from controlled trials and meta-analyses suggests that laparoendoscopic rendezvous (LERV) is preferable to sequential treatment in the management of common bile duct stones. MATERIALS AND METHODS: With this retrospective analysis of a prospective database that included consecutive patients treated for cholecystocholedocholithiasis at our institution between January 2007 and July 2015, we compared LERV with sequential treatment. The primary endpoint was global cost, defined as the cost/patient/hospital stay, and the secondary end points were efficacy and morbidity. Fisher's exact test or Mann-Whitney test was used. RESULTS: Of a total of 249 consecutive patients, 143 underwent LERV (group A) and 106 a two-stage procedure (group B). Based on an average cost of 613 for 1 day of hospital stay in the General Surgery Department, the overall median cost of treatment was 6403 for group A and 8194 for group B (p < 0.001). Operative time was significantly shorter (p < 0.001), and length of hospital stay was significantly longer for group B (p < 0.001). No mortality in either group was observed. The postoperative complications rate was significantly higher in group B than in group A (24.5 vs. 10.5%; p = 0.003). No significant difference in the postoperative pancreatitis rate or the number of patients with increased serum amylase at 24 h was observed in either group. CONCLUSION: Our study suggests that LERV is preferable to sequential treatment not only in terms of less morbidity, but also of lower costs accrued by a shorter hospital stay. However, the longer operative time raises multiple organizational issues in the coordination of surgery and endoscopy services.
Assuntos
Colangiopancreatografia Retrógrada Endoscópica/economia , Colecistectomia Laparoscópica/economia , Coledocolitíase/cirurgia , Cálculos Biliares/cirurgia , Custos de Cuidados de Saúde , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Colangiopancreatografia Retrógrada Endoscópica/métodos , Colecistectomia Laparoscópica/mortalidade , Colecistite/cirurgia , Custos e Análise de Custo , Feminino , Cálculos Biliares/economia , Humanos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Duração da Cirurgia , Complicações Pós-Operatórias/cirurgia , Estudos Retrospectivos , Adulto JovemRESUMO
BACKGROUND: Same-admission cholecystectomy is indicated after gallstone pancreatitis to reduce the risk of recurrent disease or other gallstone-related complications, but its impact on overall costs is unclear. This study analysed the cost-effectiveness of same-admission versus interval cholecystectomy after mild gallstone pancreatitis. METHODS: In a multicentre RCT (Pancreatitis of biliary Origin: optimal timiNg of CHOlecystectomy; PONCHO) patients with mild gallstone pancreatitis were randomized before discharge to either cholecystectomy within 72 h (same-admission cholecystectomy) or cholecystectomy after 25-30 days (interval cholecystectomy). Healthcare use of all patients was recorded prospectively using clinical report forms. Unit costs of resources used were determined, and patients completed multiple Health and Labour Questionnaires to record pancreatitis-related absence from work. Cost-effectiveness analyses were performed from societal and healthcare perspectives, with the costs per readmission prevented as primary outcome with a time horizon of 6 months. RESULTS: All 264 trial participants were included in the present analysis, 128 randomized to same-admission cholecystectomy and 136 to interval cholecystectomy. Same-admission cholecystectomy reduced the risk of acute readmission for recurrent gallstone-related complications from 16·9 to 4·7 per cent (P = 0·002). Mean total costs from a societal perspective were 234 (95 per cent c.i. -1249 to 738) less per patient in the same-admission cholecystectomy group. Same-admission cholecystectomy was superior to interval cholecystectomy, with a societal incremental cost-effectiveness ratio of -1918 to prevent one readmission for gallstone-related complications. CONCLUSION: In mild biliary pancreatitis, same-admission cholecystectomy was more effective and less costly than interval cholecystectomy.
Assuntos
Colecistectomia/economia , Cálculos Biliares/economia , Pancreatite/economia , Doença Aguda , Adulto , Idoso , Análise Custo-Benefício , Feminino , Cálculos Biliares/complicações , Cálculos Biliares/cirurgia , Custos de Cuidados de Saúde , Humanos , Tempo de Internação/economia , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Pancreatite/complicações , Pancreatite/cirurgia , Admissão do Paciente/economia , Inquéritos e Questionários , Resultado do TratamentoRESUMO
Predicting the presence of a persistent common bile duct (CBD) stone is a difficult and expensive task. The aim of this study is to determine if a previously described protocol-based scoring system is a cost-effective strategy. The protocol includes all patients with gallstone pancreatitis and stratifies them based on laboratory values and imaging to high, medium, and low likelihood of persistent stones. The patient's stratification then dictates the next course of management. A decision analytic model was developed to compare the costs for patients who followed the protocol versus those that did not. Clinical data model inputs were obtained from a prospective study conducted at The Mount Sinai Medical Center to validate the protocol from Oct 2009 to May 2013. The study included all patients presenting with gallstone pancreatitis regardless of disease severity. Seventy-three patients followed the proposed protocol and 32 did not. The protocol group cost an average of $14,962/patient and the non-protocol group cost $17,138/patient for procedural costs. Mean length of stay for protocol and non-protocol patients was 5.6 and 7.7 days, respectively. The proposed protocol is a cost-effective way to determine the course for patients with gallstone pancreatitis, reducing total procedural costs over 12 %.
Assuntos
Cálculos Biliares/complicações , Pancreatite/cirurgia , Protocolos Clínicos , Análise Custo-Benefício , Custos e Análise de Custo , Feminino , Cálculos Biliares/diagnóstico , Cálculos Biliares/economia , Cálculos Biliares/cirurgia , Indicadores Básicos de Saúde , Humanos , Masculino , Pessoa de Meia-Idade , Pancreatite/diagnóstico , Pancreatite/economia , Pancreatite/etiologia , Estudos ProspectivosRESUMO
This study uses a discrete choice experiment (DCE) to measure patients' preferences for public and private hospital care in New Zealand. A labeled DCE was administered to 583 members of the general public, with the choice between a public and private hospital for a non-urgent surgery. The results suggest that cost of surgery, waiting times for surgery, option to select a surgeon, convenience, and conditions of the hospital ward are important considerations for patients. The most important determinant of hospital choice was whether it was a public or private hospital, with respondents far more likely to choose a public hospital than a private hospital. The results have implications for government policy toward using private hospitals to clear waiting lists in public hospitals, with these results suggesting the public might not be indifferent to policies that treat private hospitals as substitutes for public hospitals.
Assuntos
Procedimentos Cirúrgicos Eletivos/normas , Hospitais Privados/estatística & dados numéricos , Hospitais Públicos/estatística & dados numéricos , Preferência do Paciente/psicologia , Adolescente , Adulto , Distribuição por Idade , Comportamento de Escolha , Custos e Análise de Custo , Procedimentos Cirúrgicos Eletivos/economia , Procedimentos Cirúrgicos Eletivos/estatística & dados numéricos , Feminino , Cálculos Biliares/economia , Cálculos Biliares/cirurgia , Pesquisas sobre Atenção à Saúde , Hospitais Privados/economia , Hospitais Privados/normas , Hospitais Públicos/economia , Hospitais Públicos/normas , Humanos , Masculino , Pessoa de Meia-Idade , Nova Zelândia , Preferência do Paciente/economia , Preferência do Paciente/estatística & dados numéricos , Distribuição por Sexo , Fatores de Tempo , Listas de Espera , Adulto JovemRESUMO
BACKGROUND: Laparoscopic common bile duct exploration (LCBDE) for stone can be carried out by either laparoscopic transcystic stone extraction (LTSE) or laparoscopic choledochotomy (LC). It remains unknown as to which approach is optimal for management of gallbladder stone with common bile duct stones (CBDS) in Chinese patients. METHODS: From May 2000 to February 2009, we prospective treated 346 consecutive patients with gallbladder stones and CBDS with laparoscopic cholecystectomy and LCBDE. Intraoperative findings, postoperative complications, postoperative hospital stay and costs were analyzed. RESULTS: Because of LCBDE failure,16 cases (4.6%) required open surgery. Of 330 successful LCBDE-treated patients, 237 underwent LTSE and 93 required LC. No mortality occurred in either group. The bile duct stone clearance rate was similar in both groups. Patients in the LTSE group were significantly younger and had fewer complications with smaller, fewer stones, shorter operative time and postoperative hospital stays, and lower costs, compared to those in the LC group. Compared with patients with T-tube insertion, patients in the LC group with primary closure had shorter operative time, shorter postoperative hospital stay, and lower costs. CONCLUSIONS: In cases requiring LCBDE, LTSE should be the first choice, whereas LC may be restricted to large, multiple stones. LC with primary closure without external drainage of the CBDS is as effective and safe as the T-tube insertion approach.
Assuntos
Colecistectomia Laparoscópica , Coledocolitíase/cirurgia , Cálculos Biliares/cirurgia , Adulto , Idoso , China , Colecistectomia Laparoscópica/economia , Coledocolitíase/diagnóstico , Coledocolitíase/economia , Feminino , Cálculos Biliares/diagnóstico , Cálculos Biliares/economia , Custos Hospitalares/estatística & dados numéricos , Humanos , Tempo de Internação/economia , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/economia , Estudos Prospectivos , Resultado do TratamentoRESUMO
BACKGROUND: Gallstone disease is a common gastrointestinal disorder in industrialised countries. Although symptoms can be severe, some people can be symptom free for many years after the original attack. Surgery is the current treatment of choice, but evidence suggests that observation is also feasible and safe. We reviewed the evidence on cholecystectomy versus observation for uncomplicated symptomatic gallstones and conducted a cost-effectiveness analysis. METHODS: We searched six electronic databases (last search April 2014). We included randomised controlled trials (RCTs) or non-randomised comparative studies where adults received either cholecystectomy or observation/conservative management for the first episode of symptomatic gallstone disease (biliary pain or cholecystitis) being considered for surgery in secondary care. Meta-analysis was used to combine results. A de novo Markov model was developed to assess the cost effectiveness of the interventions. RESULTS: Two RCTs (201 participants) were included. Eighty-eight percent of people randomised to surgery and 45 % of people randomised to observation underwent cholecystectomy during the 14-year follow-up period. Participants randomised to observation were significantly more likely to experience gallstone-related complications (RR = 6.69, 95 % CI = 1.57-28.51, p = 0.01), in particular acute cholecystitis (RR = 9.55, 95 % CI = 1.25-73.27, p = 0.03), and less likely to undergo surgery (RR = 0.50, 95 % CI = 0.34-0.73, p = 0.0004) or experience surgery-related complications (RR = 0.36, 95 % CI = 0.16-0.81, p = 0.01) than those randomised to surgery. Fifty-five percent of people randomised to observation did not require surgery, and 12 % of people randomised to cholecystectomy did not undergo surgery. On average, surgery costs £1,236 more per patient than conservative management, but was more effective. CONCLUSIONS: Cholecystectomy is the preferred treatment for symptomatic gallstones. However, approximately half the observation group did not require surgery or suffer complications indicating that it may be a valid alternative to surgery. A multicentre trial is needed to establish the effects, safety and cost effectiveness of observation/conservative management relative to cholecystectomy.
Assuntos
Colecistectomia/economia , Colecistite/terapia , Cálculos Biliares/terapia , Observação/métodos , Colecistite/economia , Análise Custo-Benefício , Cálculos Biliares/economia , HumanosRESUMO
BACKGROUND: Approximately 10-15% of the adult population suffer from gallstone disease, cholelithiasis, with more women than men being affected. Cholecystectomy is the treatment of choice for people who present with biliary pain or acute cholecystitis and evidence of gallstones. However, some people do not experience a recurrence after an initial episode of biliary pain or cholecystitis. As most of the current research focuses on the surgical management of the disease, less attention has been dedicated to the consequences of conservative management. OBJECTIVES: To determine the clinical effectiveness and cost-effectiveness of cholecystectomy compared with observation/conservative management in people presenting with uncomplicated symptomatic gallstones (biliary pain) or cholecystitis. DATA SOURCES: We searched all major electronic databases (e.g. MEDLINE, EMBASE, Science Citation Index, Bioscience Information Service, Cochrane Central Register of Controlled Trials) from 1980 to September 2012 and we contacted experts in the field. REVIEW METHODS: Evidence was considered from randomised controlled trials (RCTs) and non-randomised comparative studies that enrolled people with symptomatic gallstone disease (pain attacks only and/or acute cholecystitis). Two reviewers independently extracted data and assessed the risk of bias of included studies. Standard meta-analysis techniques were used to combine results from included studies. A de novo Markov model was developed to assess the cost-effectiveness of the interventions. RESULTS: Two Norwegian RCTs involving 201 participants were included. Eighty-eight per cent of people randomised to surgery and 45% of people randomised to observation underwent cholecystectomy during the 14-year follow-up period. Participants randomised to observation were significantly more likely to experience gallstone-related complications [risk ratio = 6.69; 95% confidence interval (CI) 1.57 to 28.51; p = 0.01], in particular acute cholecystitis (risk ratio = 9.55; 95% CI 1.25 to 73.27; p = 0.03), and less likely to undergo surgery (risk ratio = 0.50; 95% CI 0.34 to 0.73; p = 0.0004), experience surgery-related complications (risk ratio = 0.36; 95% CI 0.16 to 0.81; p = 0.01) or, more specifically, minor surgery-related complications (risk ratio = 0.11; 95% CI 0.02 to 0.56; p = 0.008) than those randomised to surgery. Fifty-five per cent of people randomised to observation did not require an operation during the 14-year follow-up period and 12% of people randomised to cholecystectomy did not undergo the scheduled operation. The results of the economic evaluation suggest that, on average, the surgery strategy costs £1236 more per patient than the conservative management strategy but was, on average, more effective. An increase in the number of people requiring surgery while treated conservatively corresponded to a reduction in the cost-effectiveness of the conservative strategy. There was uncertainty around some of the parameters used in the economic model. CONCLUSIONS: The results of this assessment indicate that cholecystectomy is still the treatment of choice for many symptomatic people. However, approximately half of the people in the observation group did not require surgery or suffer complications in the long term indicating that a conservative therapeutic approach may represent a valid alternative to surgery in this group of people. Owing to the dearth of current evidence in the UK setting a large, well-designed, multicentre trial is needed. STUDY REGISTRATION: The study was registered as PROSPERO CRD42012002817. FUNDING: The National Institute for Health Research Health Technology Assessment programme.
Assuntos
Colecistectomia , Colecistite/cirurgia , Cálculos Biliares/cirurgia , Conduta Expectante , Adulto , Colecistectomia/economia , Colecistite/economia , Colecistite/prevenção & controle , Colecistite/terapia , Análise Custo-Benefício , Feminino , Cálculos Biliares/economia , Cálculos Biliares/prevenção & controle , Cálculos Biliares/terapia , Humanos , Masculino , Recidiva , Resultado do TratamentoRESUMO
INTRODUCTION: Limited resources and organisational problems often result in significant waiting times for patients presenting with an indication for cholecystectomy. This study investigated the potential false economy of such practice. METHODS: Retrospective analysis of all patients on a waiting list for cholecystectomy between July 2007 and October 2010 was performed. The hospital computer document management system and patients' notes were used to collect data. RESULTS: A total of 1,021 patients were included in the study; 701 were listed from clinic and 320 were listed following an emergency admission. The median time on a waiting list before surgery was 96 days (range: 5-381 days). Eighty-seven patients (8.5%) had an emergency admission with a gallstone related problem while on a waiting list. This resulted in 488 cumulative inpatient days. There was a significant correlation between increased time spent on the waiting list and increased chance of an emergency admission (p=0.01). Patients added to the waiting list from emergency admissions were more likely to be admitted with complications than those listed from clinic (15.3% vs 5.4%, p<0.01). There was no association between age (p=0.53) or sex (p=0.23) and likelihood of emergency admission while on a waiting list. CONCLUSIONS: Prompt elective surgery and same-admission emergency laparoscopic cholecystectomy can reduce waiting list patient morbidity and is likely to save resources in the long term.
Assuntos
Colecistectomia Laparoscópica/economia , Cálculos Biliares/cirurgia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Colecistectomia Laparoscópica/estatística & dados numéricos , Procedimentos Cirúrgicos Eletivos/economia , Tratamento de Emergência/economia , Feminino , Cálculos Biliares/complicações , Cálculos Biliares/economia , Humanos , Tempo de Internação/economia , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Tempo para o Tratamento , Listas de Espera , Adulto JovemRESUMO
INTRODUCTION: Single-incision laparoscopic cholecystectomy (SILC) is considered to be less invasive and have less morbidity than conventional laparoscopic cholecystectomy (CLC). However, there is a relative paucity of data regarding postoperative pain scores in rural Indian populations following SILC. Also, data pertaining to the applicability of SILC in rural Indian population are scant. METHODS: In the present randomized control trial, pain scores after SILC and CLC were evaluated. Sixty patients with gallstone disease were randomly assigned to one of two groups with 30 patients each: the CLC group and the SILC group. Postoperative pain scores were recorded on the visual analog scale at 8 hours, 24 hours and 7 days after surgery. RESULTS: The patients were comparable with respect to age, sex and BMI. Operative time was longer for the SILC group (47.73 ± 5.57 min vs 69.53 ± 8.96 min; P < 0.0001).The pain scores were similar in both groups at 8 hours (3.61 ± 0.41 vs 3.50 ± 0.51; P = 0.36) and 24 hours (3.30 ± 0.59 vs 3.20 ± 0.40; P = 0.44) postoperatively. On day 7, the SILC group had lower pain scores than the CLC group (2.56 ± 0.56 vs 1.16 ± 0.37; P < 0.01). CONCLUSION: There was no distinct advantage to SILC with regard to immediate postoperative pain. Pain was significantly less (P < 0.01) in the SILC group on postoperative day 7.
Assuntos
Colecistectomia Laparoscópica/métodos , Cálculos Biliares/cirurgia , Dor Pós-Operatória/prevenção & controle , Adolescente , Adulto , Idoso , Colecistectomia Laparoscópica/economia , Análise Custo-Benefício , Feminino , Cálculos Biliares/economia , Humanos , Índia , Masculino , Pessoa de Meia-Idade , Medição da Dor , Dor Pós-Operatória/diagnóstico , Dor Pós-Operatória/etiologia , Estudos Prospectivos , Saúde da População Rural , Resultado do Tratamento , Adulto JovemRESUMO
BACKGROUND: Several randomized clinical trials have compared laparoscopic cholecystectomy (LC) and small-incision open cholecystectomy (SIOC). Most have had wide exclusion criteria and none was expertise-based. The aim of this expertise-based randomized trial was to compare healthcare costs, quality of life (QoL), pain and clinical outcomes after LC and SIOC. METHODS: Patients scheduled for cholecystectomy were randomized to treatment by one of two teams of surgeons with a preference for either LC or SIOC. Each team performed their specific method (SIOC or LC) as a first-choice operation, but converted to open cholecystectomy and common bile duct exploration when necessary. Intraoperative cholangiography was carried out routinely. The intention was to include all patients undergoing cholecystectomy, including emergency operations and procedures involving surgical training for residents. RESULTS: Some 74·9 per cent of all patients undergoing cholecystectomy were included. Of 355 patients randomized, 333 were analysed. Self-estimated QoL scores in 258 patients, analysed by the area under the curve method, were significantly lower in the SIOC group at 1 month after surgery: median 2326 (95 per cent confidence interval 2187 to 2391) compared with 2411 (2334 to 2502) for the LC group (P = 0·030). The mean(s.d.) duration of operation was shorter for SIOC: 97(41) versus 120(48) min (P < 0·001). There were no significant differences between the groups in conversion rate, pain, complications, length of hospital stay or readmissions. CONCLUSION: SIOC had comparable surgical results but slightly worse short-term QoL compared with LC. REGISTRATION NUMBER: NCT00370344 (http://www.clinicaltrials.gov).
Assuntos
Colecistectomia/métodos , Cálculos Biliares/cirurgia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Analgésicos/uso terapêutico , Colecistectomia/efeitos adversos , Colecistectomia/economia , Colecistectomia Laparoscópica/efeitos adversos , Colecistectomia Laparoscópica/economia , Colecistectomia Laparoscópica/métodos , Competência Clínica/normas , Feminino , Cálculos Biliares/economia , Cirurgia Geral/normas , Custos Hospitalares , Humanos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Duração da Cirurgia , Medição da Dor , Dor Pós-Operatória/etiologia , Qualidade de Vida , Resultado do Tratamento , Adulto JovemRESUMO
PURPOSE: The aim of this study was to establish enhanced recovery protocols for the management of mild gallstone pancreatitis. METHODS: Sixty consecutive patients were divided into enhanced recovery and traditional recovery (TR) groups in a randomized observational study. The basic enhanced recovery elements included early laparoscopic cholecystectomy, restrictive endoscopic intervention, and early oral nutrition. The incidence of complications, readmission, length of stay, and total medical cost were analyzed during the hospital course. RESULTS: The length of hospital stay and medical cost were significantly lower in the enhanced recovery group in comparison to the TR group: 5.9 days vs. 10.6 days (P < 0.01) and ¥10,023 vs. ¥15,035 (P < 0.01). The complications and readmission rates in the two groups were similar. CONCLUSIONS: The implementation of enhanced recovery protocols is feasible in the management of mild gallstone pancreatitis. The utilization of these protocols can achieve shorter hospital stays and reduced costs, with no increase in either the re-admission or peri-operative complication rates.
Assuntos
Custos e Análise de Custo , Cálculos Biliares/economia , Cálculos Biliares/terapia , Custos de Cuidados de Saúde/estatística & dados numéricos , Tempo de Internação/economia , Tempo de Internação/estatística & dados numéricos , Pancreatite/economia , Pancreatite/terapia , Doença Aguda , Adulto , Idoso , Idoso de 80 Anos ou mais , Colangiopancreatografia Retrógrada Endoscópica , Colecistectomia Laparoscópica , Estudos de Coortes , Feminino , Cálculos Biliares/complicações , Humanos , Masculino , Pessoa de Meia-Idade , Pancreatite/etiologia , Nutrição Parenteral , Readmissão do Paciente/estatística & dados numéricos , Complicações Pós-Operatórias/epidemiologia , Estudos Prospectivos , Índice de Gravidade de Doença , Resultado do TratamentoRESUMO
INTRODUCTION: The treatment of bile duct calculi associated with cholelithiasis is controversial. The hospital costs could be a decisive factor in choosing between the different therapeutic options. OBJECTIVES: To compare the effectiveness and costs of two options in the treatment of common bile duct calculi: 1) One-stage: Laparoscopic cholecystectomy and bile duct exploration, and 2) Two-stage: sequential endoscopic retrograde cholangiopancreatography and laparoscopic cholecystectomy. MATERIAL AND METHODS: A retrospective, observational study was performed on 49 consecutive patients with bile duct calculi and gallbladder in situ, treated consecutively and simultaneously over a two year period. The post-operate complication, hospital stay, number of procedures per patient, conversion to laparotomy, efficacy of removing the calculi, and hospital costs. RESULTS: There were no differences as regards the patient clinical features or morbidity. The mean post-surgical hospital stay for the One-stage group was less than that in the Two-stage group. Three patients of the Two-stage group required conversion to laparotomy. The median costs per patient were less for the One-stage strategy, representing an overall saving of 37,173 during the period studied. CONCLUSIONS: No significant differences were found between the two treatment options as regards efficacy or post-surgical morbidity and mortality, but there were differences in hospital stay and costs. The management of patients with gallstones in one-stage surgery represents a saving of 3 days hospital stay and 1,008 per patient.
Assuntos
Colangiopancreatografia Retrógrada Endoscópica/economia , Colecistectomia Laparoscópica/economia , Cálculos Biliares/economia , Cálculos Biliares/cirurgia , Custos Hospitalares/estatística & dados numéricos , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos RetrospectivosRESUMO
BACKGROUND: With respect to economic aspects it remains questionable if tertiary hospitals should focus on operations with high complexity or if surgery for benign diseases should be performed as well. MATERIAL AND METHODS: Data from the Institute for Reimbursement in hospitals (InEK) were analyzed for esophageal and pancreatic surgery and for appendectomy, cholezystectomy and thyroid surgery. RESULTS: Operations with a high complexity showed a slightly better revenue-cost relation. Earnings in esophageal and pancreatic surgery varied between 590 EUR and 1,977 EUR, while in operations for benign diseases it ranged from 492 EUR to 1,648 EUR. In patients with a longer hospital stay this advantage diminished. The cost-revenue ratio was much more stable for patients with appendectomy, cholezystectomy or thyroid resection. CONCLUSIONS: For economic reasons tertiary hospitals need to treat not only oncology patients but also patients with benign diseases. The focus on surgery for malignant diseases is economically not recommended because the revenues may be drained by the costs particularly in patients with a longer hospital stay due to complications.
Assuntos
Custos Hospitalares/estatística & dados numéricos , Programas Nacionais de Saúde/economia , Seleção de Pacientes , Mecanismo de Reembolso/economia , Procedimentos Cirúrgicos Operatórios/economia , Apendicectomia/economia , Apendicite/economia , Apendicite/cirurgia , Colecistectomia/economia , Comorbidade , Análise Custo-Benefício , Grupos Diagnósticos Relacionados/economia , Neoplasias Esofágicas/economia , Neoplasias Esofágicas/cirurgia , Cálculos Biliares/economia , Cálculos Biliares/cirurgia , Alemanha , Bócio/economia , Bócio/cirurgia , Humanos , Tempo de Internação/economia , Neoplasias Pancreáticas/economia , Neoplasias Pancreáticas/cirurgia , Paratireoidectomia/economia , Tireoidectomia/economiaRESUMO
INTRODUCTION: Gallstone related disease accounts for a large expenditure in the NHS. The aim of this study was to review the events and costs of the patient journey to treatment, and propose guidelines to provide an efficient streamlined service. PATIENTS AND METHODS: All cholecystectomies performed in one unit in 2009 were reviewed. The cost of all investigations and procedures performed was obtained from the Department of Health website. The individual cost was calculated for each patient. Results were expressed as mean (±SD) and compared using ANOVA. RESULTS: 132 patients (31 male) were reviewed with an overall age was 45.3 years (±15.1). Overall cost from referral to discharge was £4697 (±2007) per patient, ranging from £3406 to £12011. The largest proportion was contributed by surgery at £2849 (±414), followed by inpatient costs at £1527 (±1322). Pre-operative outpatient consultations were £174 (±144), supplemented by at least one ultrasound (£81±29). Additional imaging was required for only a minority. All blood tests involved in overall care contributed little to the total at £27 (±26). Patients who initially presented as an inpatient had an overall larger cost (£6112±1888 vs. £5097±1607; p=0.004). This difference was largely due to inpatient costs (£2611±1629 vs. £1194±1009; p<0.0001) and not the cost of surgery (p=0.29). Patients who were imaged in primary care prior to referral also had a lower overall cost (£4636±1343 vs. £5697±1804; p=0.0005). This was also due to inpatient costs (£1076±876 vs. £1740±1459; p=0.004) and not the actual surgery costs (p=0.36). Only 39 were reviewed post-operatively, adding £38±69 to the overall cohort costs. CONCLUSION: Emergency presentation and repeat admissions result in higher inpatient costs and should be avoided. Reduced delay to elective surgery through active participation by primary care needs to be encouraged.
Assuntos
Colecistectomia/economia , Cálculos Biliares/economia , Adulto , Feminino , Cálculos Biliares/diagnóstico , Cálculos Biliares/cirurgia , Hospitalização/economia , Humanos , Masculino , Pessoa de Meia-Idade , Irlanda do NorteRESUMO
BACKGROUND: Conventional laparoscopy with three or more ports remains the 'gold standard' for cholecystectomy, but a laparoendoscopic single-site (LESS) approach is emerging, designed to decrease parietal trauma and improve cosmesis. This study compared conventional laparoscopic (CL) with LESS cholecystectomy, with short-term clinical results as the main outcomes. METHODS: A randomized trial of CL and LESS cholecystectomies involving 150 patients was undertaken. Follow-up was for 1 month after surgery. The primary endpoint was body image results evaluated by means of validated scales. Secondary endpoints were: postoperative pain measured on a visual analogue scale, analgesia requirement, morbidity, quality of life (QoL) measured with Short Form 12, duration of operation, hospital stay, time to return to work and cost analysis. RESULTS: Operating times and complications were similar in the two groups. Two LESS procedures (3 per cent) were converted to two-port laparoscopy owing to difficulties with exposure, and one CL operation was achieved through a single port because extensive fibrous peritoneal adhesions prevented placement of other ports. There were three and four port-site seroma/haematomas in the LESS and CL groups respectively. Better pain profiles and lower analgesia requirements were recorded in the LESS group (P < 0·001). QoL, body image and scar scale results were also better (P < 0·001). Operative costs were higher for LESS procedures (P < 0·001), although median time to return to work was shorter (P = 0·003). CONCLUSION: LESS is an alternative to CL cholecystectomy associated with better cosmesis, body image, QoL and an improved postoperative pain profile.
Assuntos
Colecistectomia Laparoscópica/métodos , Colecistite/cirurgia , Cálculos Biliares/cirurgia , Pancreatite/cirurgia , Complicações Pós-Operatórias/etiologia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Imagem Corporal , Colecistectomia Laparoscópica/economia , Colecistectomia Laparoscópica/psicologia , Colecistite/economia , Colecistite/psicologia , Feminino , Cálculos Biliares/economia , Cálculos Biliares/psicologia , Humanos , Longevidade , Masculino , Pessoa de Meia-Idade , Pancreatite/economia , Complicações Pós-Operatórias/economia , Complicações Pós-Operatórias/psicologia , Qualidade de Vida , Adulto JovemRESUMO
BACKGROUND: Most patients with gallbladder and common bile duct stones are treated by preoperative endoscopic sphincterotomy (POES) followed by laparoscopic cholecystectomy. Recently, intraoperative endoscopic sphincterotomy (IOES) during laparoscopic cholecystectomy has been suggested as an alternative treatment. METHODS: Data from randomized clinical trials related to safety and effectiveness of IOES versus POES were extracted by two independent reviewers. Risk ratios (RRs) or mean differences were calculated with 95 per cent confidence intervals based on intention-to-treat analysis whenever possible. RESULTS: Four trials with 532 patients comparing IOES with POES were included. There were no deaths. There was no significant difference in rates of ampullary cannulation (RR 1·01, 0·97 to 1·04; P = 0·70) or stone clearance by ES (RR 0·99, 0·96 to 1·02; P = 0·58) between the groups. The proportion of patients with at least one post-ES complication, including pancreatitis, bleeding, perforation, cholangitis, cholecystitis or gastric ulcer, was significantly lower in the IOES group (RR 0·37, 0·18 to 0·78; P = 0·009). There was no significant difference in morbidity after laparoscopic cholecystectomy or requirement for open operation between the groups. Mean hospital stay was 3 days shorter in the IOES group: mean difference - 2·83 (-3·66 to - 2·00) days (P < 0·001). CONCLUSION: In patients with gallbladder and common bile duct stones, IOES is as effective and safe as POES and results in a significantly shorter hospital stay.
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Cálculos Biliares/cirurgia , Esfinterotomia Endoscópica/métodos , Viés , Colangiopancreatografia Retrógrada Endoscópica , Colecistectomia Laparoscópica , Análise Custo-Benefício , Cálculos Biliares/economia , Humanos , Cuidados Intraoperatórios , Tempo de Internação , Cuidados Pré-Operatórios , Qualidade de Vida , Ensaios Clínicos Controlados Aleatórios como Assunto , Esfinterotomia Endoscópica/economia , Resultado do TratamentoRESUMO
PURPOSE: Gallstone-related illnesses are one of the most common reasons for emergency hospital admissions, often with serious complications. Standard treatment of uncomplicated gallstone-disease is by laparoscopic cholecystectomy, which can be safely and cost-effectively performed during a short hospital stay or as day-case. This paper aims to evaluate the referral pattern of patients with gallstones, which treatment is given and whether patients admitted as emergency could have benefited from earlier elective referral. The management of these patients is examined in the context of payment by results to determine cost and potential savings. DESIGN/METHODOLOGY/APPROACH: The approach takens was prospective clinical audit and patient questionnaire in a district general hospital. Cost comparisons were made using secondary care income (NHS tariff) and estimated cost of hospitalisation, investigations and treatment. FINDINGS: Between May and July 2007, 114 patients were admitted with symptomatic gallstones, 62 (54.4 per cent) were emergencies. Cholecystectomy was performed in all 52 elective patients and performed or planned for 59/62 (95.2 per cent) emergencies. A total 17/62 emergencies (27.4 per cent) presented with complications of gallstones. 38/62 (61.3 per cent) had similar symptoms before, with 21/38 (55.3 per cent) diagnosed in primary care or by another hospital department. 11 (52.4 per cent) of these had not been referred for a surgical opinion; taking account of age, co-morbidity and data acquired for elective admissions, the cost of their treatment could have been reduced by at least pounds 16,194. ORIGINALITY/VALUE: A large proportion of patients admitted with symptomatic biliary disease could have been referred earlier and electively. Such referral practice could improve the quality of care and reduce cost for the NHS both in primary and secondary care.
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Colecistectomia/economia , Serviço Hospitalar de Emergência/economia , Cálculos Biliares/economia , Programas Nacionais de Saúde/economia , Encaminhamento e Consulta/economia , Idoso , Colecistectomia/estatística & dados numéricos , Auditoria Clínica , Custos e Análise de Custo , Feminino , Cálculos Biliares/cirurgia , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Encaminhamento e Consulta/normas , Inquéritos e Questionários , Reino UnidoRESUMO
BACKGROUND: The British Society of Gastroenterology recommends that all patients with gallstone pancreatitis should undergo cholecystectomy within 2 weeks. This study assessed whether these guidelines are feasible and cost-effective. METHODS: Admissions for gallstone pancreatitis between January 2006 and January 2008 were reviewed. Readmissions for subsequent pancreatitis or biliary pathology were noted together with additional investigations, severity scores, hospital stay and time to cholecystectomy. The costs of readmission and theoretical costs of developing a dedicated operating list were provided by independent accountants. RESULTS: During the 2 years, 153 patients were admitted. Twenty-one patients (13.7 per cent) had further attacks requiring 40 readmissions. There were no deaths. Additional hospital costs related to readmissions were 172,170 pound sterling, including bed occupancy (67,860 pound sterling), investigations (12,510 pound sterling) and 153 cholecystectomies on an existing theatre list (91,800 pound sterling). The estimated cost of staffing a half-day theatre list every fortnight, performing 153 cholecystectomies, was 170,391 pound sterling. CONCLUSION: Instigating a dedicated theatre for cholecystectomy after biliary pancreatitis has many potential benefits. The costs of readmissions and ad hoc operating are balanced by those of a dedicated theatre list in the long term. Implementation of the guidelines would save approximately 900 pound sterling annually and be cost neutral.