Three-arm robotic cholecystectomy: a novel, cost-effective method of delivering and learning robotic surgery in upper GI surgery.

Cholecystectomy is one of the commonest performed surgeries worldwide. With the introduction of robotic surgery, the numbers of robot-assisted cholecystectomies has risen over the past decade. Despite the proven use of this procedure as a training operation for those surgeons adopting robotics, the consumable cost of routine robotic cholecystectomy can be difficult to justify in the absence of evidence favouring or disputing this approach. Here, we describe a novel method for performing a robot-assisted cholecystectomy using a "three-arm" technique on the newer, 4th generation, da Vinci system. Whilst maintaining the ability to perform precision dissection, this method reduces the consumable cost by 46%. The initial series of 109 procedures proves this procedure to be safe, feasible, trainable and time efficient.

Cost-effectiveness of Restrictive Strategy Versus Usual Care for Cholecystectomy in Patients With Gallstones and Abdominal Pain (SECURE-trial).

OBJECTIVE: To perform a cost-effectiveness analysis of restrictive strategy versus usual care in patients with gallstones and abdominal pain. SUMMARY OF BACKGROUND DATA: A restrictive selection strategy for surgery in patients with gallstones reduces cholecystectomies, but the impact on overall costs and cost-effectiveness is unknown. METHODS: Data of a multicentre, randomized-controlled trial (SECURE-trial) were used. Adult patients with gallstones and abdominal pain were included. Restrictive strategy was economically evaluated against usual care from a societal perspective. Hospital-use of resources was gathered with case-report forms and out-of-hospital consultations, out-of-pocket expenses, and productivity loss were collected with questionnaires. National unit costing was applied. The primary outcome was the cost per pain-free patient after 12 months. RESULTS: All 1067 randomized patients (49.0 years, 73.7% females) were included. After 12 months, 56.2% of patients were pain-free in restrictive strategy versus 59.8% after usual care. The restrictive strategy significantly reduced the cholecystectomy rate with 7.7% and reduced surgical costs with €160 per patient, €162 was saved from a societal perspective. The cost-effectiveness plane showed that restrictive strategy was cost saving in 89.1%, but resulted in less pain-free patients in 88.5%. Overall, the restrictive strategy saved €4563 from a societal perspective per pain-free patient lost. CONCLUSIONS: A restrictive selection strategy for cholecystectomy saves €162 compared to usual care, but results in fewer pain-free patients. The incremental cost per pain-free patient are savings of €4563 per pain-free patient lost. The higher societal willingness to pay for 1 extra pain-free patient, the lower the probability that the restrictive strategy will be cost-effective. TRIAL REGISTRATION: The Netherlands National Trial Register NTR4022. Registered on 5 June 2013.

Emergency General Surgery Procedures and Cost of Care for Older Adults in the State of Maryland.

BACKGROUND: Older adults (OAs) ≥ 65 years of age, representing the fastest growing segment in the United States, are anticipated to require a greater percentage of emergency general surgery procedures (EGSPs) with an associated increase in health care costs. The aims of this study were to identify the frequency of EGSP and charges incurred by OA compared to their younger counterparts in the state of Maryland. METHODS: A retrospective review of the Maryland Health Services Cost Review Commission from 2009 to 2018 was undertaken. Patients undergoing urgent or emergent ESGP were divided into 2 groups (18-64 years and ≥65 years). Data collected included demographics, APR-severity of illness (SOI), APR-risk of mortality (ROM), the EGSP (partial colectomy [PC], small bowel resection [SBR], cholecystectomy, operative management of peptic ulcer disease, lysis of adhesions, appendectomy, and laparotomy), length of stay (LOS), and hospital charges. P-values (P < .05) were significant. RESULTS: Of the 181,283 patients included in the study, 55,401 (38.1%) were ≥65 years of age. Older adults presented with greater APR-SOI (major 37.7% vs 21.3%, extreme 5.2% vs 9.3%), greater APR-ROM (major 25.3% vs 8.7%, extreme 22.3% vs 5.3%), underwent PC (24.5% vs 10.9%) and SBR (12.8% vs 7.0%) more frequently, and incurred significantly higher median hospital charges for every EGSP, consistently between 2009 and 2018 due to increased LOS and complications when compared to those ≤65 years of age. CONCLUSION: These findings stress the need for validated frailty indices and quality improvement initiatives focused on the care of OAs in emergency general surgery to maximize outcomes and optimize cost.

The Impact of FASTPASS: A Collaboration With Emergency Department to Improve Management of Patients With Gallbladder Disease and Acute Appendicitis.

BACKGROUND: Efficient Emergency Department (ED) throughput depends on several factors, including collaboration and consultation with surgical services. The acute care surgery service (ACS) collaborated with ED to implement a new process termed "FASTPASS" (FP), which might improve patient-care for those with acute appendicitis and gallbladder disease. The aim of this study was to evaluate the 1-year outcome of FP. METHODS: FASTPASS is a joint collaboration between ACS and ED. ED physicians were provided with a simple check-list for diagnosing young males (<50-year old) with acute appendicitis (AA) and young males or females (<50-year old) with gallbladder disease (GBD). Once ED deemed patients fit our FP check-list, patients were directly admitted (FASTPASSed) to the observation unit. The ACS then came to evaluate the patients for possible surgical intervention. We performed outcome analysis before and after the institution of the FP. Outcomes of interest were ED length of stay (LOS), time from ED to the operating room (OR) (door-to-knife), hospital LOS (HLOS), and cost. RESULTS: During our 1-year study period, for those patients who underwent GBD/AA surgery, 56 (26%) GBD and 27 (26%) AA patients met FP criteria. Compared to the non-FP patients during FP period, FP halved ED LOS for GBD (7.4 ± 3.0 versus 3.5 ± 1.7 h, P < 0.001) and AA (6.7 ± 3.3 versus. 1.8 ± 1.6 h, P < 0.001). Similar outcome benefits were observed for door-to-knife time, HLOS, and costs. CONCLUSIONS: In this study, the FP process improved ED throughput in a single, highly-trained ER leading to an overall improved patient care process. A future study involving multiple EDs and different disease processes may help decrease ED overcrowding and improve healthcare system efficiency.

Disparities in Emergency Versus Elective Surgery: Comparing Measures of Neighborhood Social Vulnerability.

BACKGROUND: Several composite measures of neighborhood social vulnerability exist and are used in the health disparity literature. This study assesses the performance of the Social Vulnerability Index (SVI) compared with three similar measures used in the surgical literature: Area Deprivation Index (ADI), Community Needs Index (CNI), and Distressed Communities Index (DCI). There are advantages of the SVI over these other scales, and we hypothesize that it performs equivalently. METHODS: We identified all cholecystectomies at a single, urban, academic hospital over a 9-month period. Cases were considered emergency if the patient presented and underwent surgery during that admission. We geocoded patient's addresses and assigned estimated SVI, ADI, CNI, and DCI. Cutoffs for high versus low social vulnerability were generated using Youden's index, and the scales were compared using multivariable modeling. RESULTS: Overall, 366 patients met inclusion criteria, and the majority (n = 266, 73%) had surgery in the emergency setting. On multivariable modeling, patients with high social vulnerability were more likely to undergo emergency surgery compared with those with low social vulnerability in accordance with all four scales: SVI (OR 3.24, P < 0.001), ADI (OR 3.2, P < 0.001), CNI (OR 1.90, P = 0.04), and DCI (OR 2.01, P = 0.03). The scales all had comparable predictive value. CONCLUSIONS: The SVI performs similarly to other indices of neighborhood vulnerability in demonstrating disparities between emergency and elective surgery and is readily available and updated. Because the SVI has multiple subcategories in addition to the overall measure, it can be used to stratify by modifiable factors such as housing or transportation to inform interventions.

Patient Factors Lead to Extensive Variation in Outcomes and Cost From Cholecystectomy.

BACKGROUND: Cholecystectomy is a common procedure with significantly varied outcomes. We analyzed differences in comorbidities, outcomes, and cost of cholecystectomy by acute care surgery (ACS) versus hepatopancreaticobiliary (HPB) surgery. STUDY DESIGN: Patients were retrospectively identified between 2008 and 2015. Exclusion criteria included the following: (1) part of another procedure; (2) abdominal trauma; (3) ICU admission; vasopressors. RESULTS: One hundred and twenty-six ACS and 122 HPB patients were analyzed. The HPB subset had higher burden of comorbid disease and significantly lower projected 10-year survival (87.4% ACS vs 68.5% HPB, P < .0001). Median lengths of stay were longer in HPB patients (2 vs 5 days, P < .0001) as were readmission rates (30-day 5.6% vs 13.1%, P = .040; 90-day 7.9% vs 20.5%, P = .005). Median cost was higher including operative supply cost ($969.42 vs $1920.66, P < .0001) and total cost of care ($7340.66 vs $19 338.05, P < .0001). A predictive scoring system for difficult gallbladders was constructed and a phone application was created. CONCLUSION: Cholecystectomy in a complicated patient can be difficult with longer hospital stays and higher costs. The utilization of procedure codes to explain disparities is not sufficient. Incorporation of comorbidities needs to be addressed for planning and reimbursement.

Cost containment: an experience with surgeon education and universal preference cards at two institutions.

BACKGROUND: As the cost of health care increases in the US, focus has been placed upon efficiency, cost reduction, and containment of spending. Operating room costs play a significant role in this spending. We investigated whether surgeon education and universal preference cards can have an impact on reducing the disposable supply costs for common laparoscopic general surgery procedures. METHODS: General surgeons at two institutions participated in an educational session about the costs of the operative supplies used to perform laparoscopic appendectomies and cholecystectomies. All the surgeons at one institution agreed upon a universal preference card, with other supplies opened only by request. At the other, no universal preference cards were created, and surgeons were free to modify their own existing preference cards. Case cost data for these procedures were collected for each institution pre- (July 2014-December 2014) and post-intervention (February 2015-November 2017). RESULTS: At the institution with an education only program, there was no statistically significant change in supply costs after the intervention. At the institution that intervened with the combined education and universal preference card program, there was a statistically significant supply cost decrease for these common laparoscopic procedures combined. This significant cost decrease persisted for each appendectomies and cholecystectomies when analyzed independently as well (p = 0.001 and p < 0.001 respectively). CONCLUSIONS: In this study, surgeon education alone was not effective in reducing operating room disposable supply costs. Surgeon education, combined with the implementation of universal preference cards, significantly maintains reductions in operating room supply costs. As health care costs continue to increase in the US and internationally, universal preference cards can be an effective tool to contain cost for common laparoscopic general surgery procedures.

Robot-assisted cholecystectomy is a safe but costly approach: A national database review.

BACKGROUND: This study sought to evaluate surgical outcomes, cost, and opiate utilization of patients who underwent laparoscopic (LC) or robotic cholecystectomy (RC). METHODS: The Vizient database was queried for patients admitted with mild to moderate severity of illness (SOI) scores who underwent LC or RC from January 2015 through December 2017. Rates of overall complications, postoperative infection, mortality, LOS, cost, and opiate utilization were compared between groups using IBM SPSS v.25.0, α = 0.05. RESULTS: 91,849 patients (LC:N = 89,878; RC:N = 1,971) met the inclusion criteria. Robotic approach was associated with more complications (LC:0.9%, RC:1.7%; p < 0.001), postoperative infections (LC:0.2%, RC:0.4%; p = 0.033) and a higher direct cost (LC:$6782 ±â€¯3421, RC:$9354 ±â€¯5497; p < 0.001). Opiates were prescribed more frequently in the laparoscopic group (LC:98.3%, RC:97.2%; p = 0.002). CONCLUSION: The direct cost of RC is significantly higher than LC with no added benefit. Routine use of the robotic platform for cholecystectomy should be discouraged until costs are reduced.

The heavy price of conversion from laparoscopic to open procedures for emergent cholecystectomies.

BACKGROUND: Laparoscopic cholecystectomy (LC) is the standard operative intervention for gallbladder disease. Complications may necessitate conversion to an open cholecystectomy (OC). This study aims to determine the cost-consequences of laparoscopic-to-open conversion using a nationally-representative sample. METHODS: Using the National Inpatient Sample (2007-2011), adult patients undergoing emergent LC were identified. Patients undergoing secondary-conversion to OC were subsequently identified. Multivariable regression analyses, accounting for differences in propensity-quintile, mortality, length of stay, and hospital-level factors were then performed to assess for differences in the odds of conversion and total predicted mean costs per index-hospitalization. RESULTS: Of 225,805 observations, conversion to open occurred in 1.86% (n = 4203) of cases. Increased age, African-American ethnicity, public-insurance and teaching-hospital status were associated with a higher likelihood of conversion (p < 0.05) after risk-adjustment. Risk-adjusted odds of conversion increased by 34% (95%CI:1.33-1.36) for each day surgery was delayed. Risk-adjusted costs, were 259% higher (absolute-difference $23,358,p < 0.05) with conversion. Mortality was higher amongst patients undergoing conversion to open (4.98% vs 0.34%,p < 0.001). CONCLUSION: Patients undergoing conversion from laparoscopic to open cholecystectomy are at an increased risk of receiving disparate care and increased mortality.

Combined robot assisted right partial nephrectomy and cholecystectomy with single docking.

ΑBSTRACT: We report the first case of robot-assisted partial nephrectomy (RARN) and Robot assisted cholecystectomy in a 66 years old female overweight patient with organ-confined right kidney tumor identified on the investigation of gastrointestinal symptoms with a single docking. A modified position of the patient and a slight altered placement of the trocars made feasible the concomitant performance of the two operations. Total blood loss was 80 ml, operation time was 253 min and console time 187 min. The drain was removed on second post-operative day and the patient was discharged at the 3rd post-operative day. Using a single docking of the da Vinci S system, intraoperative time and cost are minimized in patients with both organ-confined kidney tumors and gall bladder stones.

Operative complications and economic outcomes of cholecystectomy for acute cholecystitis.

BACKGROUND: Recent management of acute cholecystitis favors same admission (SA) or emergent cholecystectomy based on overall shorter hospital stay and therefore cost savings. We adopted the practice of SA cholecystectomy for the treatment of acute cholecystitis at our tertiary care center and wanted to evaluate the economic benefit of this practice. We hypothesized that the existence of complications, particularly among patients with a higher degree of disease severity, during SA cholecystectomy could negate the cost savings. AIM: To compare complication rates and hospital costs between SA vs delayed cholecystectomy among patients admitted emergently for acute cholecystitis. METHODS: Under an IRB-approved protocol, complications and charges for were obtained for SA, later after conservative management (Delayed), or elective cholecystectomies over an 8.5-year period. Patients were identified using the acute care surgery registry and billing database. Data was retrieved via EMR, operative logs, and Revenue Cycle Operations. The severity of acute cholecystitis was graded according to the Tokyo Guidelines. TG18 categorizes acute cholecystitis by Grades 1, 2, and 3 representing mild, moderate, and severe, respectively. Comparisons were analyzed with χ 2, Fisher's exact test, ANOVA, t-tests, and logistic regression; significance was set at P < 0.05. RESULTS: Four hundred eighty-six (87.7%) underwent a SA while 68 patients (12.3%) received Delayed cholecystectomy. Complication rates were increased after SA compared to Delayed cholecystectomy (18.5% vs 4.4%, P = 0.004). The complication rates of patients undergoing delayed cholecystectomy was similar to the rate for elective cholecystectomy (7.4%, P = 0.35). Mortality rates were 0.6% vs 0% for SA vs Delayed. Patients with moderate disease (Tokyo 2) suffered more complications among SA while none who were delayed experienced a complication (16.1% vs 0.0%, P < 0.001). Total hospital charges for SA cholecystectomy were increased compared to a Delayed approach ($44500 ± $59000 vs $35300 ± $16700, P = 0.019). The relative risk of developing a complication was 4.2x [95% confidence interval (CI): 1.4-12.9] in the SA vs Delayed groups. Among eight patients (95%CI: 5.0-12.3) with acute cholecystitis undergoing SA cholecystectomy, one patient will suffer a complication. CONCLUSION: Patients with Tokyo Grade 2 acute cholecystitis had more complications and increased hospital charges when undergoing SA cholecystectomy. This data supports a selective approach to SA cholecystectomy for acute cholecystitis.

Outcomes and Costs of Common Surgical Procedures at Children's and Nonchildren's Hospitals.

BACKGROUND: Variations in the management of pediatric patients at children's hospitals (CHs) and non-CHs (NCHs) have been well described, especially within the trauma literature. However, little is known about the outcomes and costs of common general surgical procedures at NCHs. The purpose of this study was to evaluate the effect of CH designation on the outcomes and costs of appendectomy and cholecystectomy. METHODS: The Kids' Inpatient Database (2003-2012) was queried for patients aged under 18 y who underwent appendectomy or cholecystectomy at CHs and NCHs. Outcomes analyzed included disease severity, complications, laparoscopy, length of stay (LOS), and cost. RESULTS: Most of appendectomies and cholecystectomies were performed at NCHs. Overall, CHs cared for younger children were more likely to be teaching hospitals, had higher costs, and longer LOS. On multivariate analysis for appendectomies, CHs were associated with higher rates of perforated appendicitis (OR = 1.53, 95% CI = 1.42-1.66, P < 0.001), less complications (OR = 0.68, 95% CI = 0.61-0.75, P < 0.001), increased laparoscopy (OR = 2.93, 95% CI = 2.36-3.64, P < 0.001), longer LOS (RR = 1.13, 95% CI = 1.09-1.17, P < 0.001), and higher costs (exponentiated log $ = 1.19, 95% CI = 1.13-1.24, P < 0.001). Multivariate analysis for cholecystectomies revealed that CHs were associated with less laparoscopy (OR = 0.58, 95% CI = 0.50-0.67, P < 0.001), longer LOS (RR = 1.26, 95% CI = 1.19-1.34, P < 0.001), and higher costs (exponentiated log $ = 1.29, 95% CI = 1.22-1.37, P < 0.001) with similar complications. Independent predictors of LOS and cost included CH designation, negative appendectomy, perforated appendicitis, complications, younger age, black patients, and public insurance. CONCLUSIONS: Variations in surgical management, outcomes, and costs after appendectomy and cholecystectomy exist between CHs and NCHs. CHs excelled in treating complicated appendicitis. NCHs effectively performed cholecystectomies. These differences in outcomes require further investigation to identify modifiable factors to optimize care across all hospitals for these common surgical diseases.

Single-incision robotic cholecystectomy versus single-incision laparoscopic cholecystectomy: A systematic review and meta-analysis.

BACKGROUND: Single-incision laparoscopic cholecystectomy (SILC) is the result of the ongoing trend to minimally invasive of laparoscopy, but some surgeons thought that the SILC can increase the risk of bile duct injure or bile spillage, and the single-incision robotic cholecystectomy (SIRC) can overcome the drawbacks of SILC. Some articles described that the SIRC had longer operative time and more cost than SILC. The advantages and disadvantages of SIRC have still not been extensively studied. We aimed to investigate the outcomes of SIRC compared to SILC and evaluate the safety and feasibility of SIRC. METHODS: To find relevant studies, the electronic databases PubMed, MEDLINE, The Cochrane Library, and EMBASE were searched to seek information in English literature from 2011 to 2017. Studies comparing SIRC to SILC, for any indication, were included in the analysis. This systematic review and meta-analysis were performed with RevMan Version 5.3. RESULTS: Six comparative studies (n = 633 patients) were included in our analysis. The data showed that the SIRC and SILC had equivalent outcomes for operative time [mean difference (MD) = 17.32, 95% confidence interval (CI): -8.93-43.57, P = .20], intraoperative complications [odd ratio (OR) = 0.48, 95% CI: 0.17-1.39, P = .18], postoperative complications (OR = 0.62, 95% CI: 0.21-1.86, P = .39), hospital stay (MD = -0.01, 95% CI: -0.21-0.19, P = .90), readmissions rate (OR = 0.70, 95% CI: 0.09-5.63, P = .74), and conversion rate (OR = 0.52, 95% CI: 0.14-1.96, P = .33), but total cost was statistically significant (MD = 3.7, 95% CI: 3.61-3.79, P < .00001). CONCLUSION: SIRC is a safe and feasible procedure for cholecystectomy, and the operative time is same as SILC, but the total cost of SIRC is significantly higher than SILC.

Long-term results of cholecystectomy for biliary dyskinesia: outcomes and resource utilization.

BACKGROUND: The purpose of this study is to describe a cohort of pediatric patients undergoing cholecystectomy for biliary dyskinesia (BD) and characterize postoperative resource utilization. METHODS: Single-institution, retrospective chart review of pediatric patients after cholecystectomy for BD was done. Patient demographics and clinical characteristics as well as operative details and postoperative interventions were abstracted. Telephone follow-up was performed to identify persistent symptoms, characterize the patient experience, and quantify postoperative resource utilization. RESULTS: Forty-nine patients were included. Twenty-two patients (45%) were seen postoperatively by a gastroenterologist, of which, only 32% were known to the gastroenterologist before surgery. Postoperative studies included 13 abdominal ultrasounds for persistent pain, 13 esophagogastroduodenoscopies, five endoscopic retrograde cholangiopancreatographies (ERCPs), one endoscopic ultrasound, one magnetic resonance cholangiopancreaticogram, and five colonoscopies. Of the patients with additional diagnostic testing postoperatively, one had mild esophagitis, three had sphincter of Oddi dysfunction, and one was suspected to have inflammatory bowel disease. Telephone survey response rate was 47%. Among respondents, 65.2% reported ongoing abdominal pain, nausea, or vomiting at an average of 26 mo after operation. Of note, all patients who underwent postoperative ERCP with sphincterotomy reported symptom relief following this procedure. CONCLUSIONS: Relief of symptoms postoperatively in pediatric patients with BD is inconsistent. Postoperative studies, though numerous, are of low diagnostic yield and generate high costs. These findings suggest that the initial diagnostic criteria and treatment algorithm may require revision to better predict symptom improvement after surgery. Improvement seen after ERCP/sphincterotomy is anecdotal but appears to merit further investigation.

Complications, length of stay, and cost of cholecystectomy in kidney transplant recipients.

We hypothesized that cholecystectomy may be riskier for kidney transplant recipients (KTR) given their lifelong immunosuppression, physiologic impact of renal failure, and increased risk of gallstone and biliary disease. Using NIS, we compared mortality, morbidity, length of stay and cost in KTR vs non-KTR following cholecystectomy in the US from 2000 to 2011, adjusting for patient and hospital level factors, including transplant center status. Mortality was higher (OR 2.4), morbidity was higher (OR 1.3), LOS was longer (ratio 1.2), and costs were greater (ratio 1.1) for KTR compared to non-KTR following cholecystectomy. While it is clear that KTR are a high risk group following cholecystectomy, the cause of this increased risk requires further investigation.

An evaluation of mini-laparotomy cholecystectomy in the laparoscopic era: a rural experience.

BACKGROUND: Laparoscopic cholecystectomy (LC) is the gold standard for the management of symptomatic cholelithiasis and complications of gallstone disease. Mini laparotomy cholecystectomy (MOC) may be a more appropriate option in the resource constrained rural setting due to its widespread applicability and comparable outcome with LC. The study aimed to provide an epidemiological analysis of gallstone disease in the rural population and to evaluate the outcome of MOC in a rural hospital. METHOD: A retrospective chart analysis of 248 patients undergoing cholecystectomy in a rural regional referral hospital in KwaZulu-Natal from January 2009 to December 2013 was undertaken. RESULTS: Of the 248 patients, the majority were females (n = 211, [85%]). The most frequent indications for cholecystectomy included: biliary colic (n = 115, [46.3%]); acute cholecystitis (n = 80, [32.3%]); gallstone pancreatitis (n = 27, [10.8%]). Forty cases (16.1%) were converted to open cholecystectomy (OC). The median operative time was 40 minutes (range18-57). Twenty-three morbidities (9.3%) occurred including: bile leaks (n = 6, [2.4%]); bleeding from drain site (n = 1, [0.4%]), incisional hernia (n = 8 [3.2%]) and wound sepsis (n = 8 [3.2%]). The median length of hospital stay in patients who underwent MOC was 48 hours (range: 24-72 hours) and the median time to return to work was 10 days (range: 4-14 days). There was one mortality in the entire cohort. CONCLUSION: MOC is a safe and feasible operation for symptomatic cholelithiasis when cholecystectomy is indicated. The low operative morbidity and mortality in the context of a high risk patient profile and complicated gallstone disease makes this procedure an alternative to LC where LC is inaccessible.

Cost analysis and risk factors for interval cholecystectomy after bariatric surgery: a national study.

BACKGROUND: Besides rate and extent of weight loss, little is known regarding demographic factors predicting interval cholecystectomy (IC) after bariatric surgery and its incremental costs. OBJECTIVES: We aim to identify risk factors predicting IC after bariatric surgery and quantify its associated costs. SETTING: Nationally representative sampling of acute care hospitals across the United States. METHODS: A retrospective cohort study was performed using the National Readmission Database 2010 to 2014. Cox proportional hazard analyses were used to identify risk factors for IC. Linear regression models were constructed to examine associations between cholecystectomy timing and cumulative hospitalization costs. RESULTS: An estimated national total of 553,658 patients received bariatric surgery during the study period. Of these, 3.3% received concomitant cholecystectomy (CC). After adjusting for bariatric procedure type, age, sex, complication, and length of stay, CC was independently associated with a US$1589 increase in hospitalization cost (95% confidence interval US$1021-2158, P<.01). Of patients that received no CC, only .6% underwent IC during the up to 1-year follow-up. Age<35 (P<.01), female sex (P<.01), and high preoperative body mass index (P = .03) were all risk factors for IC. IC was independently associated with a US$1499 higher cumulative hospitalization cost than CC (P<.01, 95% confidence interval US$844-2154). CONCLUSIONS: Despite the higher absolute cost of IC, its low incidence does not financially justify a routine prophylactic CC approach. In addition, no significant reduction in cholecystectomy-related complications was achieved by performing CC. An individualized approach taking identified risk factors for IC into consideration is recommended when deciding whether to perform prophylactic CC.

Effect of socioeconomic inequalities on cholecystectomy outcomes: a 10-year population-based analysis.

BACKGROUND: Although numerous epidemiological studies on cholecystectomy have been conducted worldwide, only a few have considered the effect of socioeconomic inequalities on cholecystectomy outcomes. Specifically, few studies have focused on the low-income population (LIP). METHODS: A nationwide prospective study based on the Taiwan National Health Insurance dataset was conducted during 2003-2012. The International Classification of ICD-9-CM procedure codes 51.2 and 51.21-51.24 were identified as the inclusion criteria for cholecystectomy. Temporal trends were analyzed using a joinpoint regression, and the hierarchical linear modeling (HLM) method was used as an analytical strategy to evaluate the group-level and individual-level factors. Interactions between age, gender and SES were also tested in HLM model. RESULTS: Analyses were conducted on 225,558 patients. The incidence rates were 167.81 (95% CI: 159.78-175.83) per 100,000 individuals per year for the LIP and 123.24 (95% CI: 116.37-130.12) per 100,000 individuals per year for the general population (GP). After cholecystectomy, LIP patients showed higher rates of 30-day mortality, in-hospital complications, and readmission for complications, but a lower rate of routine discharge than GP patients. The hospital costs and length of stay for LIP patients were higher than those for GP patients. The multilevel analysis using HLM revealed that adverse socioeconomic status significantly negatively affects the outcomes of patients undergoing cholecystectomy. Additionally, male sex, advanced age, and high Charlson Comorbidity Index (CCI) scores were associated with higher rates of in-hospital complications and 30-day mortality. We also observed that the 30-day mortality rates for patients who underwent cholecystectomy in regional hospitals and district hospitals were significantly higher than those of patients receiving care in a medical center. CONCLUSION: Patients with a disadvantaged finance status appeared to be more vulnerable to cholecystectomy surgery. This result suggested that further interventions in the health care system are necessary to reduce this disparity.

Addressing the quality and cost of cholecystectomy at a safety net hospital.

BACKGROUND: The aim of this study was to evaluate the effects of safety-net burden on outcomes of a common, urgent operation like cholecystectomy. METHODS: We identified all cholecystectomies performed from 2005 to 2011 in the California State Inpatient Database and separated them into three cohorts based on the performing hospital's safety-net burden. Hierarchical multivariable regression analyses were performed with outcomes including laparoscopy, advanced disease, morbidity, length of hospitalization, and cost. RESULTS: Safety-net hospitals had similar rates of laparoscopy, overall advanced disease, and post-operative morbidity. Yet, they were able to maintain lower overall costs (cost difference -5592, 95% CI -8928, -2256, p < 0.01), despite having similar lengths of stay. CONCLUSION: Safety-net hospitals performed cholecystectomy with similar rates of laparoscopy and morbidity, while achieving lower costs. Safety-net hospitals may be well equipped to perform common, urgent operations like cholecystectomy.

Adoption of robotics in a general surgery residency program: at what cost?

BACKGROUND: Robotic technology is increasingly being utilized by general surgeons. However, the impact of introducing robotics to surgical residency has not been examined. This study aims to assess the financial costs and training impact of introducing robotics at an academic general surgery residency program. METHODS: All patients who underwent laparoscopic or robotic cholecystectomy, ventral hernia repair (VHR), and inguinal hernia repair (IHR) at our institution from 2011-2015 were identified. The effect of robotic surgery on laparoscopic case volume was assessed with linear regression analysis. Resident participation, operative time, hospital costs, and patient charges were also evaluated. RESULTS: We identified 2260 laparoscopic and 139 robotic operations. As the volume of robotic cases increased, the number of laparoscopic cases steadily decreased. Residents participated in all laparoscopic cases and 70% of robotic cases but operated from the robot console in only 21% of cases. Mean operative time was increased for robotic cholecystectomy (+22%), IHR (+55%), and VHR (+61%). Financial analysis revealed higher median hospital costs per case for robotic cholecystectomy (+$411), IHR (+$887), and VHR (+$1124) as well as substantial associated fixed costs. CONCLUSIONS: Introduction of robotic surgery had considerable negative impact on laparoscopic case volume and significantly decreased resident participation. Increased operative time and hospital costs are substantial. An institution must be cognizant of these effects when considering implementing robotics in departments with a general surgery residency program.