Complications nearly double the cost of care after pancreaticoduodenectomy.

BACKGROUND: Despite considerable data focused on the morbidity of pancreaticoduodenectomy (PD), the financial impact of complications has been infrequently analyzed. This study evaluates the impact of the most common complications associated with PD on the cost of care. Additionally, we identified cost centers that were significantly affected by complications. METHODS: A retrospective analysis of a prospective database in a network of community-based teaching hospitals was performed. All patients (n = 145) who underwent PD were included for years 2005 to 2009. Of these, 144 had complete in-hospital cost data. Complications were assessed and classified into major and minor categories according to Dindo et al. Forty-nine cost centers were analyzed for their association with the cost of complications. Univariate and multivariate linear regression analyses were performed. Significance was reported for P < .05. RESULTS: The median cost for PD was $30,937. Patients with major complications had significantly higher median cost compared with those without ($56,224 vs $29,038; P < .001). Independent predictors of increased cost included reoperation; sepsis; pancreatic fistula; bile leak; delayed gastric emptying; and pulmonary, renal, and thromboembolic complications. Cost center analysis showed significant added charges for patients with major complications for blood bank ($1,018), clinical laboratory ($3,731), a computed tomography scan ($4,742), diagnostic imaging ($697), intensive care unit ($4,986), pharmacy ($33,850) and respiratory therapy ($1,090) (P < .05, all). CONCLUSIONS: This study identified the major complications of PD, which are significantly associated with a higher cost. Substantial cost center increases were associated with major complications, particularly in pharmacy ($33,850). Measures aimed at limiting complications through centralization of care or care pathways may reduce the overall cost of care for patients after pancreatic resection.

Computed tomography (CT)-guided versus laparoscopic radiofrequency ablation: a single-institution comparison of morbidity rates and hospital costs.

BACKGROUND: Computed tomography (CT)-guided radiofrequency ablation (RFA) is presumed to be less morbid and less costly than laparoscopic RFA. This analysis investigates the 30-day morbidity, hospital cost, and reimbursement for CT-guided RFA versus laparoscopic RFA used to manage hepatocellular carcinoma (HCC) and colorectal liver metastases (CRLM). METHODS: A retrospective review was performed for all patients with CRLM or HCC who underwent CT-guided RFA or laparoscopic RFA between January 2002 and August 2008. Demographics, risk stratification, and procedural data were analyzed. Hospital financial data were queried for total cost, reimbursement, and itemized departmental charges. The CRLM and HCC patients were evaluated separately. RESULTS: The study analyzed 18 RFA procedures for the treatment of HCC (8 CT-guided RFA; 10 laparoscopic RFA) and 25 RFA procedures for the treatment of CRLM (6 CT-guided RFA; 19 laparoscopic RFA). Immediate local failures were reported for 33.3% and 12.5% of the CT-guided RFA procedures for CRLM and HCC and for 5.2% and 0.0% of the laparoscopic RFA procedures for CRLM and HCC, respectively. The mean hospital cost was higher for the patients who underwent laparoscopic RFA ($11,808.70 ± $7,238.90 for HCC vs $9,882.40 ± $1,926.90 for CRLM) than for those who underwent CT-guided RFA ($7,186.10 ± $3,899.60 for HCC vs $5,767.50 ± $2,869.00 for CRLM). The mean reimbursement was lower than the mean hospital cost for the patients who underwent CT-guided RFA for CRLM ($4,329.10 vs $5,767.50). CONCLUSION: Although CT-guided RFA is less expensive, it is poorly reimbursed. Also, CT-guided RFA is associated with a higher immediate local failure rate for both CRLM and HCC and a higher complication rate for patients with CRLM. For patients with HCC, CT-guided RFA is associated with a lower complication rate. Our data suggest that laparoscopic RFA should be used for most patients with CRLM and only selectively for patients with HCC.

Hepatic resection vs minimally invasive radiofrequency ablation for the treatment of colorectal liver metastases: a Markov analysis.

HYPOTHESIS: Current literature evaluating radiofrequency ablation (RFA) for treatment of colorectal liver metastases describes high-risk surgical candidates or patients with unresectable disease. This creates bias when comparing RFA and hepatic resection. A Markov analysis would define theoretical outcomes necessary for RFA to demonstrate equivalence to resection. DESIGN: A multistate Markov decision analytic model was constructed. Second-order Monte Carlo analysis was used to simulate a randomized controlled trial. Sensitivity analyses were performed to determine the projected outcomes necessary for RFA to achieve equivalence with resection. SETTING: Tertiary care teaching hospital. PATIENTS: A systematic review of published literature was performed, identifying studies involving patients with colorectal liver metastases treated with RFA or resection. Data were also included from a prospective database of patients undergoing laparoscopic RFA at our institution. INTERVENTIONS: Percutaneous or laparoscopic RFA and hepatic resection. MAIN OUTCOME MEASURES: Quality-adjusted life expectancy and quality of life-adjusted survival. RESULTS: The base-case analysis (60-year-old man) demonstrated a mean ± SD quality-adjusted life expectancy of 5.67 ± 0.71 years and a 5-year survival of 38.2% following resection. Based on current literature, the mean ± SD quality-adjusted life expectancy for RFA was 3.61 ± 0.49 years, with a 5-year survival of 27.2%. Sensitivity analyses demonstrated that RFA becomes the preferred strategy if the median disease-free survival reaches 1.42 years. When limited to patients from our institution with resectable lesions, the quality-adjusted life expectancy for RFA improved to a mean ± SD of 5.72 ± 0.50 years. CONCLUSIONS: Classical Markov analysis demonstrates that based on current literature, resection is superior to RFA in the treatment of colorectal liver metastases. When input is limited to laparoscopic RFA in patients with resectable lesions, projected 5-year survival is superior to that of hepatic resection.

Surgeon volume versus morbidity and cost in patients undergoing pancreaticoduodenectomy in an academic community medical center.

BACKGROUND: Despite trends toward regionalization of care, the majority of pancreaticoduodenectomies (PD) are performed in community hospitals by surgeons with varying degrees of experience. We analyzed the impact of several variables, including surgeon volume, on outcomes following PD within a high-volume community-based teaching hospital system. METHODS: Patients who underwent PD from 2005 to 2008 were reviewed retrospectively. Perioperative data, complications, and hospital financial data was queried. A high-volume (HV) surgeon was defined as an average of 10 or more PD per year. RESULTS: Ninety-four patients underwent PD with an overall operative mortality rate of 9.6% (HV 2.2%, LV 16.0%), major complication rate of 32% (HV 18%, LV 44%), and median cost of $30,860 (HV $27,185, LV $33,007). Factors predictive of death were age (p < 0.02), body mass index (p < 0.01), and surgeon volume (p < 0.05). Factors predictive of major complication were surgeon volume (p < 0.01) and body mass index (p < 0.01). Factors predictive for increased length of stay for patients discharged from the hospital were surgeon volume (p < 0.02) and preoperative ASA classification (p < 0.05). CONCLUSIONS: Surgeon volume and patient body mass index have a significant impact on perioperative morbidity following PD in a community teaching hospital.

Measuring mental workload during the performance of advanced laparoscopic tasks.

INTRODUCTION: Mental workload is a finite resource and is increased while learning new tasks and performing complex tasks. Measurement of a surgeon's mental workload may therefore be an indication of expertise. We hypothesized that surgeons who were expert at laparoscopic suturing would have more spare mental resources to perform a secondary task, compared with surgeons who had just started to learn suturing. METHODS: Standardized suturing tasks were performed on a bench-top model. Twelve junior residents (novices) and nine fellows and attending surgeons (experts) were instructed to perform as many sutures as possible in 6 min. An adjacent monitor was placed 15 degrees off axis to the first and randomly displayed 30 true visual signals among 90 false ones. Participants were required to identify the true signals while continuing to suture. Laparoscopic sutures were evaluated using the Fundamentals of Laparoscopic Surgery (FLS) scoring system. The secondary (visual detection) task was evaluated by calculating the rate of missed true signals or detection of false signals. RESULTS: Experts completed significantly more secure sutures (6 +/- 2) than novices (3 +/- 1; p = 0.001). The suture performance score was 50 +/- 20 for experts, significantly higher than for novices (29 +/- 10; p = 0.005). The rate for detecting visual signals was higher for experts (98%) compared with for novices (93%; p = 0.041). CONCLUSION: Practice develops automaticity, which reduces the mental workload and allows surgeons to have sufficient spare mental resources to attend to a secondary task. Visual detection provides a simple and reliable way to assess mental workload and situation awareness abilities of surgeons during skills training, and may be an indirect measure of expertise.