Cost-benefit analysis of an enhanced recovery protocol for pancreaticoduodenectomy.

BACKGROUND: Enhanced recovery after surgery (ERAS) programmes have been shown to decrease complications and hospital stay. The cost-effectiveness of such programmes has been demonstrated for colorectal surgery. This study aimed to assess the economic outcomes of a standard ERAS programme for pancreaticoduodenectomy. METHODS: ERAS for pancreaticoduodenectomy was implemented in October 2012. All consecutive patients who underwent pancreaticoduodenectomy until October 2014 were recorded. This group was compared in terms of costs with a cohort of consecutive patients who underwent pancreaticoduodenectomy between January 2010 and October 2012, before ERAS implementation. Preoperative, intraoperative and postoperative real costs were collected for each patient via the hospital administration. A bootstrap independent t test was used for comparison. ERAS-specific costs were integrated into the model. RESULTS: The groups were well matched in terms of demographic and surgical details. The overall complication rate was 68 per cent (50 of 74 patients) and 82 per cent (71 of 87 patients) in the ERAS and pre-ERAS groups respectively (P = 0·046). Median hospital stay was lower in the ERAS group (15 versus 19 days; P = 0·029). ERAS-specific costs were €922 per patient. Mean total costs were €56 083 per patient in the ERAS group and €63 821 per patient in the pre-ERAS group (P = 0·273). The mean intensive care unit (ICU) and intermediate care costs were €9139 and €13 793 per patient for the ERAS and pre-ERAS groups respectively (P = 0·151). CONCLUSION: ERAS implementation for pancreaticoduodenectomy did not increase the costs in this cohort. Savings were noted in anaesthesia/operating room, medication and laboratory costs. Fewer patients in the ERAS group required an ICU stay.

[Enhanced Recovery After Surgery--optimal management of the surgical patient]. / Réhabilitation améliorée après chirurgie--L'ere de la prise en charge optimale du patient chirurgical.

Enhanced Recovery After Surgery (ERAS) is a multimodal, standardized and evidence-based perioperative care pathway. With ERAS, postoperative complications are significantly lowered, and, as a secondary effect, length of hospital stay and health cost are reduced. The patient recovers better and faster allowing to reduce in addition the workload of healthcare providers. Despite the hospital discharge occurs sooner, there is no increased charge of the outpatient care. ERAS can be safely applied to any patient by a tailored approach. The general practitioner plays an essential role in ERAS by assuring the continuity of the information and the follow-up of the patient.

Laparoscopy in the era of enhanced recovery.

Laparoscopy is one of the cornerstones in the surgical revolution and transformed outcome and recovery for various surgical procedures. Even if these changes were widely accepted for basic interventions, like appendectomies and cholecystectomies, laparoscopy still remains challenged for more advanced operations in many aspects. Despite these discussion, there is an overwhelming acceptance in the surgical community that laparoscopy did transform the recovery for several abdominal procedures. The importance of improved peri-operative patient management and its influence on outcome started to become a focus of attention 20 years ago and is now increasingly spreading, as shown by the incoming volume of data on this topic. The enhanced recovery after surgery (ERAS) concept incorporates simple measures of general management, and requires multidisciplinary collaboration from hospital staff as well as the patient and the relatives. Several studies have demonstrated a significant decrease in postoperative complication rate, length of hospital stay and reduced overall cost. The key elements of success are fluid restriction, a functioning epidural and preoperative carbohydrate intake. With the expansion of laparoscopic techniques, ERAS increasingly incorporates laparoscopic patients, especially in colorectal surgery. However, the precise impact of laparoscopy on ERAS is still not clearly defined. Increasing evidence suggests that laparoscopy itself is an additional ERAS item that should be considered as routine where feasible in order to obtain the best surgical outcomes.

Cost-effectiveness of the implementation of an enhanced recovery protocol for colorectal surgery.

BACKGROUND: Enhanced recovery protocols may reduce postoperative complications and length of hospital stay. However, the implementation of these protocols requires time and financial investment. This study evaluated the cost-effectiveness of enhanced recovery implementation. METHODS: The first 50 consecutive patients treated during implementation of an enhanced recovery programme were compared with 50 consecutive patients treated in the year before its introduction. The enhanced recovery protocol principally implemented preoperative counselling, reduced preoperative fasting, preoperative carbohydrate loading, avoidance of premedication, optimized fluid balance, standardized postoperative analgesia, use of a no-drain policy, as well as early nutrition and mobilization. Length of stay, readmissions and complications within 30 days were compared. A cost-minimization analysis was performed. RESULTS: Hospital stay was significantly shorter in the enhanced recovery group: median 7 (interquartile range 5-12) versus 10 (7-18) days (P = 0·003); two patients were readmitted in each group. The rate of severe complications was lower in the enhanced recovery group (12 versus 20 per cent), but there was no difference in overall morbidity. The mean saving per patient in the enhanced recovery group was €1651. CONCLUSION: Enhanced recovery is cost-effective, with savings evident even in the initial implementation period.

Critical appraisal of single port access cholecystectomy.

BACKGROUND: Single port access (SPA) cholecystectomy is a new concept in laparoscopic surgery. A review of existing results was performed to evaluate critically the current state of SPA with specific reference to feasibility, safety, learning curve, indications and cost-effectiveness. METHODS: All papers identified in MEDLINE until 15 February 2010 and all other relevant papers obtained from cited references were reviewed, without any language restriction. Case reports and series of fewer than three patients were excluded. RESULTS: After selection, 24 studies including 895 patients were analysed. None was randomized. Feasibility seems to be established, with a conversion rate of 2 per cent. SPA was not standardized and there was much technical variation. The learning curve could not be determined. Median follow-up time was 3 (range 0.25-12) months. The overall published complication rate was 5.4 per cent and the biliary complication rate 0.7 per cent. The rate of umbilical complications ranged from 2 to 10 per cent. CONCLUSION: SPA cholecystectomy seems feasible, but standardization, safety and the real benefits for patients need further assessment. Uncontrolled wide adoption of this approach may be responsible for a rise in biliary complications.

Prospective randomized study of monopolar scissors, bipolar vessel sealer and ultrasonic shears in laparoscopic colorectal surgery.

BACKGROUND: Many instruments are used for laparoscopic dissection, including monopolar electrosurgery scissors (MES), electrothermal bipolar vessel sealers (BVS) and ultrasonically coagulating shears (UCS). These three devices were compared with regard to dissection time, blood loss, safety and costs. METHODS: Sixty-one consecutive patients undergoing laparoscopic left-sided colectomy were randomized to MES, BVS or UCS. The primary endpoint was dissection time. RESULTS: Patient and operation characteristics did not differ between the groups. Median dissection time was significantly shorter with BVS (105 min) and UCS (90 min) than with MES (137 min) (P < 0.001). With BVS and UCS, significantly fewer additional clips were required (MES 9 versus BVS 0 versus UCS 3; P < 0.001) and there was a trend towards lower blood loss (125 versus 50 versus 50 ml respectively; P = 0.223) and a reduced volume of suction fluid (425 versus 80 versus 110 ml; P = 0.058). Overall satisfaction was similar for the three instruments. Dissection with BVS and UCS was significantly cheaper than with MES, assuming a centre volume of 200 cases per year (P = 0.009). CONCLUSION: BVS and UCS shorten dissection time in laparoscopic left-sided colectomy and are cost-effective compared with MES.

[Preoperative assessment in visceral surgery]. / Bilan préopératoire en chirurgie viscérale.

The purpose of preoperative assessment is to evaluate the patient's health status, to address known or unidentified co-morbidities and to perform adequate complementary exams if necessary. On the other hand, it allows to prepare and protect the patient in order to reduce perioperative risk. The assessment consists of patient's history and physical examination, both focusing on cardiovascular and respiratory assessment. Complementary exams have to be chosen selectively depending on the patient's risk factors and the type of surgery. They are indicated if their result leads to a potential patient's benefit only, either by a modification in anesthetic and/or surgical management or by introduction of a pharmacological strategy, adequate and maximal if necessary, especially for cardioprotection.

Outcome and cost analysis of sacral nerve stimulation for faecal incontinence.

BACKGROUND: Sacral nerve stimulation (SNS) may be successful in treating incapacitating faecal incontinence. The technique is expensive, and no cost analysis is currently available. The aim of this study was to assess clinical outcome and analyse cost-effectiveness. METHODS: Thirty-six consecutive patients underwent a two-stage SNS procedure. Outcome parameters and real costs were assessed prospectively. RESULTS: SNS was tested successfully in 33 of 36 patients, and 31 patients were stimulated permanently. In the first stage, eight of 36 patients reported minor complications (pain, infection or electrode dislocation), resulting in a cost of euro 4053 (range euro 2838-7273) per patient. For the second stage (permanent stimulation), eight of 33 patients had an infection, pain or loss of effectiveness, resulting in a cost of euro 11,292 (range euro 7406-20,274) per patient. Estimated costs for further follow-up were euro 997 per year. The 5-year cumulative cost for SNS was euro 22,150 per patient, compared with euro 33,996 for colostomy, euro 31,590 for dynamic graciloplasty and euro 3234 for conservative treatment. CONCLUSION: SNS is a highly cost-effective treatment for faecal incontinence. Options for further reduction of SNS costs include strict patient selection, treatment in an outpatient setting and using cheaper devices.

Laparoscopic donor nephrectomy.

BACKGROUND: Living kidney donation represents an important source of organs for patients with end-stage renal failure. Over the past decade, laparoscopic donor nephrectomy has replaced the conventional open procedure in many transplant centres. Using evidence-based methods, this study examines the current status of laparoscopic donor nephrectomy. METHOD: A Medline literature search (PubMed database, 1999-2002) and manual cross-referencing were performed to identify all articles relating to laparoscopic donor nephrectomy. Safety and efficacy criteria were analysed systematically for each study. Studies included were categorized using an evidence-based level grading system. RESULTS: Of 687 publications, 20 studies with level I-II evidence and 12 with level III evidence were analysed. Only one level I study could be identified. Level I and level II evidence suggests superiority of the laparoscopic approach in regard to postoperative analgesic consumption, hospital stay and return to work. Other safety and efficacy criteria, including donor and recipient outcomes, were similar between the two techniques. CONCLUSION: Laparoscopic donor nephrectomy has gained community acceptance by physicians and patients over the past decade. Despite a lack of strong evidence, such as large prospective randomized studies, laparoscopic donor nephrectomy is likely to become the 'gold standard' for donor nephrectomy in the near future.

[Prospective assessment of the learning curve and safety of stapler hemorrhoidectomy]. / Prospektive Erfassung von Lernkurve und Sicherheit der Stapler-Hämorrhoidektomie.

INTRODUCTION: Stapled haemorrhoidectomy (SH) is a recently introduced procedure for the surgical excision of haemorrhoids. Actually, there is only limited information concerning the impact of the learning curve, complication rates and long-term results. Therefore, a prospective single-center study was performed with special regard to the learning curve and clinical safety of SH. METHODS: The data of 61 SH performed between March 1999 and May 2001 were analyzed. Operating times, complication rates and outcome results were prospectively recorded and then correlated to the surgical experience of the operating team. Postoperative pain was measured using the visual analogue scale (VAS). Sphincter lesions represented by the patient's incontinence and muscle defects were analyzed by using Williams incontinence score and histological examination of the resected specimen. Clinical follow-up studies were performed three and twelve weeks postoperatively. RESULTS: There were 18 patients with grade II haemorrhoids, 38 patients with grade III haemorrhoids, and five patients with grade IV haemorrhoids. Both, operating times and complication rates decreased with more surgical experience. The mean pain score during the first four postoperative days was 1.9 (range 0-8). Mean hospital stay and mean convalescence time were 1.7 days (range 1-5 days) and 10 days (range 1-31 days), respectively. Incontinence scores revealed only minor differences between pre- and postoperative values. CONCLUSIONS: SH represents a safe and effective new treatment modality for symptomatic haemorrhoids. Meticulous surgical technique and experience are mandatory to achieve excellent clinical results, e.g., reduced postoperative pain, shortened hospital stay and convalescence. We adopted SH to our surgical armamentarium for the treatment of haemorrhoids grade III and recurrent haemorrhoids.

Assessment of telemedicine in surgical education and patient care.

OBJECTIVE: To analyze the value of teleconferencing for patient care and surgical education by assessing the activity of an international academic network. SUMMARY BACKGROUND DATA: The uses of telemedicine include teleeducation, training, and consulting, and surgical teams are now involved, sharing diagnostic information and opinions without the need for travel. However, the value of telematics in surgery remains to be assessed. METHODS: During a 2-year period, weekly surgical teleconferences were held among six university hospitals in four European countries. To assess the accuracy of telediagnosis for surgical cases, 60 randomly selected cases were analyzed by a panel of surgeons. Participants' opinions were analyzed by questionnaire. RESULTS: Seventy teleconferences (50 lectures and 271 case presentations) were held. Ninety-five of the 114 participants (83.3%) completed the final questionnaire. Eighty-six percent rated the surgical activity as good or excellent, 75.7% rated the scientific level as good or excellent, 55.8% rated the daily clinical activity as good or excellent, and 28.4% rated the manual surgical technique as good or excellent. The target organ was identified in all the cases; the organ structure and pathology were considered well defined in 93.3%, and the fine structure was considered well defined in 58.3%. Diagnosis was accurate in 17 cases (28.3%), probable in 25 (41.7%), possible but uncertain in 16 (26.7%), and not possible in 2 cases (3.3%). Discussion among the remote sites increased the rate of valuable therapeutic advice from 55% of cases before the discussion to 95% after the discussion. Eighty-six percent of the surgeons expressed satisfaction with telematics for medical education and patient care. CONCLUSIONS: Participant satisfaction was high, transmission of clinical documents was accurate, and the opportunity to discuss case documentation and management significantly improved diagnostic potential, resulting in an accuracy rate of up to 95%. Teleeducation and teleconsultation in surgery appear to be beneficial.