Acute cholecystitis: early versus delayed cholecystectomy, a multicenter randomized trial (ACDC study, NCT00447304).

OBJECTIVE: Acute cholecystitis is a common disease, and laparoscopic surgery is the standard of care. BACKGROUND: Optimal timing of surgery for acute cholecystitis remains controversial: either early surgery shortly after hospital admission or delayed elective surgery after a conservative treatment with antibiotics. METHODS: The ACDC ("Acute Cholecystitis-early laparoscopic surgery versus antibiotic therapy and Delayed elective Cholecystectomy") study is a randomized, prospective, open-label, parallel group trial. Patients were randomly assigned to receive immediate surgery within 24 hours of hospital admission (group ILC) or initial antibiotic treatment, followed by delayed laparoscopic cholecystectomy at days 7 to 45 (group DLC). For infection, all patients were treated with moxifloxacin for at least 48 hours. Primary endpoint was occurrence of predefined relevant morbidity within 75 days. Secondary endpoints were as follows: (1) 75-day morbidity using a scoring system; (2) conversion rate; (3) change of antibiotic therapy; (4) mortality; (5) costs; and (6) length of hospital stay. RESULTS: Morbidity rate was significantly lower in group ILC (304 patients) than in group DLC (314 patients): 11.8% versus 34.4%. Conversion rate to open surgery and mortality did not differ significantly between groups. Mean length of hospital stay (5.4 days vs 10.0 days; P < 0.001) and total hospital costs (€2919 vs €4262; P < 0.001) were significantly lower in group ILC. CONCLUSIONS: In this large, randomized trial, laparoscopic cholecystectomy within 24 hours of hospital admission was shown to be superior to the conservative approach concerning morbidity and costs. Therefore, we believe that immediate laparoscopic cholecystectomy should become therapy of choice for acute cholecystitis in operable patients. (NCT00447304).

Cost distribution of orthotopic liver transplantation: single-center analysis under DRG-based reimbursement.

Costs of orthotopic liver transplantation (OLT) are influenced by multiple factors. Surgeons must be interested in determining the probability of meeting the projected cost averages. Costs of procedures, labor, drugs and pharmaceuticals, materials, and overhead costs of infrastructure were calculated during the primary stay in 38 consecutive patients undergoing OLT at a single center. Endpoint of cost aggregation was discharge from acute care. Costs per patient were grouped to plot the cost density distribution function. Mean cost of OLT was 49,000. Costs showed a large variation, ranging from 18,000 to 189,000 per case. Most patients were grouped in the G-DRG-A01C split (n=31), which characterizes the least resource consumptive split. Costs of OLT were not normally distributed. There was a left-skewed beta-distribution of costs. Labor-related costs were responsible for the largest cost fraction (mean 42.9%), whereas drugs and medication accounted for 24.9% on average. Most patients could be transplanted within cost groups below 50,000. The marked cost heterogeneity after OLT suggests that primarily medical comorbidities are of relevance for extraordinary resource consumption. A minimum number of transplants should be performed in single institutions to improve chances to financially counterbalance higher costs of individual cases under DRG-based reimbursement. Small programs have to bear increased risks of financial distortion. The asymmetry of cost distribution after OLT should be taken into account in future reimbursement regulations.