Direct medical costs of robotic sleeve gastrectomy compared to laparoscopic approach in a single academic center.

BACKGROUND: The use of the robotic platform in bariatric surgery remains controversial because of lack of level I evidence to support its superiority compared to the laparoscopic approach and because of cost concerns. Recently, an extended use program (EUP) for robotic instruments was also introduced at our institution to help reduce the associated direct medical costs of robotic surgery. OBJECTIVES:  To evaluate the direct medical costs of a robotic sleeve gastrectomy (R-SG) and compare it to a standard laparoscopic approach (L-SG). SETTING:  Academic, tertiary care center. METHODS:  The analysis included the last 50 R-SG performed at our institution between June 1st 2019 and October 31st 2020. Those cases were compared to the L-SG cases (29 cases) performed in the same time period. All revisions or conversions were then excluded which resulted in a total of 74 primary SG (R-SG = 45 and L-SG = 29). Direct medical costs included operating room cost, instrument cost, miscellaneous cost, and cost of hospital stay. Direct cost data was generated using the StrataJazz reporting module, which is fed daily from EPIC, our electronic health record system. Patients who underwent a primary SG or a primary SG with a concomitant Paraesophageal Hernia Repair (PEH) were analyzed separately using Mann-Whitney rank sum tests and Student's t tests. An additional analysis and subanalysis of the groups was also performed after applying the potential savings of the Extended Use Program (EUP). RESULTS:  Overall, the direct medical cost of R-SG was comparable to L-SG ($6330.77 vs $6804.12 respectively, p = 0.07). The direct medical cost of patients undergoing SG alone without PEH was significantly lower in the R-group compared to the L-group ($5927.08 vs $6508.01, respectively, p = 0.04). When applying the EUP savings to our data, the predicted direct medical cost of R-SG becomes significantly lower than L-SG ($6145.77 vs $6804.12 respectively, p = 0.01). CONCLUSION:  At our academic medical center, we found no difference in direct medical costs between R-SG and L-SG. With the application of the EUP, direct medical costs of R-SG can be significantly lowered compared to L-SG. It is important to consider that cost data are largely dependent upon the academic medical center of interest, and surgeons need to collect their own cost data to evaluate whether robotic surgery is feasible at their institution.

Assessment and management of gastroesophageal reflux disease following bariatric surgery.

Gastroesophageal reflux disease (GERD) is a common disease in patients with obesity. The incidence of de novo GERD and the effect of bariatric surgery on patients with pre-existing GERD remain controversial. Management of GERD following bariatric surgery is complicated and can range from medical therapy to non-invasive endoscopic options to invasive surgical options. To address these issues, we performed a systematic review of the literature on the incidence of GERD and the various modalities of managing GERD in patients following bariatric surgery. Given the increased number of laparoscopic sleeve gastrectomy (LSG) procedures being performed and the high incidence of GERD following LSG, bariatric surgeons should be familiar with the options available to manage GERD following LSG as well as other bariatric procedures.

Cost Analysis of Robotic Roux-en-Y Gastric Bypass in a Single Academic Center: How Expensive Is Expensive?

BACKGROUND: Although the use of da Vinci robotic platforms in bariatric surgery is gaining momentum, it is still controversial because of financial concerns. OBJECTIVES: The objective of our study is to evaluate the cost of robotically assisted Roux-en-Y gastric bypass (R-RYGB) versus conventional laparoscopic Roux-en-Y gastric bypass (L-RYGB). METHODS: We analyzed consecutive primary bariatric patients who underwent R-RYGB and compared them with patients who underwent L-RYGB during the same time period. Primary outcomes were overall cost for length of stay, operating time, and supplies. Direct cost data was generated using the StrataJazz reporting module, which is fed daily from EPIC, our electronic health record system, and contains hospital-based data only. Secondary outcomes were 30-day rates of complications, reoperations, and readmissions. RESULTS: We found no difference in primary or secondary outcomes following R-RYGB and L-RYGB. The overall cost for R-RYGB and L-RYGB was not statistically different (median total cost for R-RYGB and L-RYBG was $6431.34 and $6349.09, P > 0.05, respectively). Operating time cost was significantly higher for R-RYGB compared with L-RYGB ($2248.51 versus $19,836.29, respectively, P < 0.0001, respectively). R-RYGB had lower cost of supplies as well as a shorter length of stay compared with L-RYGB (mean 1.5 versus 1.7 days, respectively). CONCLUSIONS: Our study revealed no cost difference between R-RYGB and L-RYGB, with a decreased cost of supplies and trend toward lower hospital stay favoring R-RYGB. Further studies are needed to evaluate the outcomes of R-RYGB compared with L-RYGB; however, the cost of robotic surgery may not be a prohibitive factor.

Cost analysis of robotic sleeve gastrectomy (R-SG) compared with laparoscopic sleeve gastrectomy (L-SG) in a single academic center: debunking a myth!

BACKGROUND: Although use of the da Vinci robotic platform in bariatric surgery is gaining momentum, there are financial concerns. OBJECTIVES: Our retrospective study evaluated the cost of robotically assisted sleeve gastrectomy (R-SG) versus conventional laparoscopic sleeve gastrectomy (L-SG). SETTING: Center of Excellence bariatric surgery center in Allentown, Pennsylvania. METHODS: We analyzed consecutive patients who underwent primary R-SG and compared them with L-SG patients. Primary outcomes were overall cost for length of stay, operating time, and supplies. Secondary outcomes were 30-day complications, reoperations, and readmissions. RESULTS: We had no adverse events in either group. The overall cost for R-SG and L-SG was not statistically different (mean total cost for R-SG and L-SG was $5308.99 and $4918.88, respectively). Operating time cost was significantly higher for R-SG compared with L-SG ($1340 versus $112 for R-SG and L-SG, respectively). R-SG had a shorter length of stay compared with L-SG (1.4 versus 1.5 d, respectively). CONCLUSIONS: Our study revealed no difference in cost R-SG and L-SG, with a trend toward shorter length of stay for R-SG over time.

Assessment of Sleeve Gastrectomy Surgical Technique: First Look at 30-Day Outcomes Based on the MBSAQIP Database.

BACKGROUND: Obesity rates in the US have reached epidemic proportions, and sleeve gastrectomy (SG) is the procedure performed most commonly. Controversies exist about the most appropriate surgical technique. STUDY DESIGN: Using the 2016 MBSAQIP database, we selected all primary SG procedures and compared 4 surgical techniques (staple line reinforcement [SLR] alone; SLR and oversewing [OS]; no SLR or OS; and OS alone). Primary outcomes were bleeding and organ space infection (OSI), including leakage. Secondary outcomes were 30-day severe adverse events (SAEs) and readmissions. We conducted separate chi-square tests of association, followed by 4 separate exploratory multivariable logistic regression models. RESULTS: There were significant differences in bleeding (p = 0.002) and SAE rates (p = 0.003) among the 4 SG techniques; both SLR and OS yielded lower bleeding and SAE rates compared with the other techniques (0.3% and 1.9%, respectively). The associations between SG technique and OSI (p = 0.93) and readmission (p = 0.24) were not significant. The following SG techniques independently predicted less likelihood of bleeding: SLR alone (adjusted odds ratio [AOR] 0.70; 95% CI 0.54 to 0.90; p = 0.006) and both SLR and OS (AOR 0.50; 95% CI 0.33 to 0.77; p = 0.002). In addition, SLR and OS independently predicted less likelihood of SAEs (AOR 0.76; 95% CI 0.64 to 0.91; p = 0.003). CONCLUSIONS: Our study demonstrated that SLR resulted in lower postoperative bleeding rates, but not lower leak rates. When combined with OS, SLR yielded lower 30-day SAE rates. Future studies must clarify and confirm these results.

IV Acetaminophen Results in Lower Hospital Costs and Emergency Room Visits Following Bariatric Surgery: a Double-Blind, Prospective, Randomized Trial in a Single Accredited Bariatric Center.

BACKGROUND: Postoperative pain control in bariatric surgery is challenging, despite use of intravenous (IV) narcotics. IV acetaminophen is one pain control alternative. OBJECTIVE: The aim of this study was to investigate the economic impact of IV acetaminophen in bariatric surgery and its effect on patients' pain, satisfaction, and hospital length of stay. METHODS: In a randomized controlled trial, Group 1 (treatment) received IV acetaminophen plus IV narcotics 30 min before surgery, then medication plus IV narcotics/PO narcotics for the remaining 18 h. Group 2 (control) received IV normal saline plus IV/PO narcotics. Patients underwent laparoscopic Roux-en-Y gastric bypass (LRYGB) or laparoscopic sleeve gastrectomy (SG). Primary outcomes included direct hospital costs, length of stay, postoperative pain, and patient satisfaction. Secondary outcomes included indirect costs, rescue narcotics dosage, and 30-day outcomes. RESULTS: Mean direct hospital cost in the treatment group (n = 50) was $3089.18 versus $2991.62 for the control group (n = 50) (p > 0.05). Pain scores did not differ significantly (p = 0.61). After adjusting for surgery type, there was no significant difference in length of stay (p = 0.95). Significantly more control group patients incurred surgery-related indirect costs (10 versus 2%, p < 0.05), with greater presentation to the emergency department (ED) for abdominal pain (5/50 versus 1/50), yielding higher total indirect costs ($39,293 versus $13,185). CONCLUSIONS: Using IV acetaminophen for postoperative pain management produced notable indirect cost savings and reduced ED visits in the first 30 days postoperatively, with good safety and tolerance. Decreased statistical power may have accounted for certain non-significant findings.

Improving outcome of bariatric surgery: best practices in an accredited surgical center.

The number of laparoscopic bariatric procedures being performed in the USA has increased dramatically in the past decade. Because of limited health-care resources, hospital administrators and insurance carriers are placing emphasis on length of stay and patient outcomes. The goal of this study was to evaluate the feasibility and safety of a clinical pathway in managing patients undergoing bariatric surgery in a Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) accredited center. The setting was a university hospital in USA. A retrospective analysis of data collected prospectively on patients undergoing bariatric surgery at St Luke's University was performed. Patients included underwent either a laparoscopic Roux-en-Y gastric Bypass (LRYGB) or laparoscopic sleeve gastrectomy (LSG). Patients were subjected to a clinical protocol and discharged when discharge criteria were met. The primary outcomes were length of stay, 30 day readmission, complication, and reoperation rates. A cost analysis of the savings accrued was also performed. Two hundred twenty-nine patients were included in our analysis (80.4% females and 19.6% males). Seventy-one patients (31%) underwent LSG, and 158 patients (69%) underwent LRYGB. The average length of stay was 32.45 h (range 24-72 h). The 30-day readmission rate was 3.0% (7/229 patients). The 30 day complication rate (including intervention, reintubation, and reoperation) was 2.6% (6/229). The 30 day mortality rate was 0. The average prospective cost savings were $2,016 and $1,209 per LRYGB and LSG patient, respectively. Our bariatric surgery clinical protocol is feasible and safe with substantial prospective cost savings at St Luke's University and Health Network. Patients subjected to our protocol have low readmission and complication rates. Further studies are needed to fully elucidate the benefit of this innovative new protocol in bariatric surgery.

Insurance-mandated medical programs before bariatric surgery: do good things come to those who wait?

BACKGROUND: Insurance companies often require a mandated medical program (MMP) before bariatric surgery. It is unknown whether MMPs improve weight loss before and after surgery. The purpose of our study was to determine whether MMPs improve pre- and postoperative weight loss at a tertiary care, U.S. academic teaching hospital. METHODS: After institutional review board approval, data were collected prospectively from consecutive patients undergoing nonrevisional laparoscopic gastric bypass or adjustable gastric banding from August 2006 to 2010 by a single surgeon (T.S.K.). The patients were divided into 2 groups: those undergoing a MMP and those who did not. The MMP patients underwent a standardized program of ≥6 months' duration under the direction of our medical bariatricians and nutritionists. The data from the laparoscopic gastric bypass and laparoscopic adjustable gastric banding patients were analyzed separately. The primary outcome data included the interval to surgery and the percentage of excess weight loss before surgery and at 6 and 12 months after surgery. RESULTS: A total of 440 patients (327 laparoscopic gastric bypass and 113 laparoscopic adjustable gastric banding) were included in the present study. No significant difference was found in the preoperative percentage of excess weight loss or the percentage of excess weight loss at 6 and 12 months after surgery between the MMP and non-MMP patients. The MMP patients had a significantly longer wait time to surgery. CONCLUSION: Patients who underwent a standardized MMP had a significant delay in their time to surgery and did not experience significant benefit in their preoperative or postoperative weight loss. Insurance companies should abandon the policy of mandating preoperative medical weight loss programs.