Cost-Effectiveness of Robotic vs. Laparoscopic Surgery for Different Surgical Procedures: Protocol for a Prospective, Multicentric Study (ROBOCOSTES).

Background: The studies which address the impact of costs of robotic vs. laparoscopic approach on quality of life (cost-effectiveness studies) are scares in general surgery. Methods: The Spanish national study on cost-effectiveness differences among robotic and laparoscopic surgery (ROBOCOSTES) is designed as a prospective, multicentre, national, observational study. The aim is to determine in which procedures robotic surgery is more cost-effective than laparoscopic surgery. Several surgical operations and patient populations will be evaluated (distal pancreatectomy, gastrectomy, sleeve gastrectomy, inguinal hernioplasty, rectal resection for cancer, Heller cardiomiotomy and Nissen procedure). Discussion: The results of this study will demonstrate which treatment (laparoscopic or robotic) and in which population is more cost-effective. This study will also assess the impact of previous surgical experience on main outcomes.

KRAS Assessment Following ESMO Recommendations for Colorectal Liver Metastases. Is It Always Worth It?

BACKGROUND: Genetic evaluation is essential in assessing colorectal cancer (CRC) and colorectal liver metastasis (CRLM). The aim of this study was to determine the pragmatic value of KRAS on oncological outcomes after CRLM according to the ESMO recommendations and to query whether it is necessary to request KRAS testing in each situation. METHODS: A retrospective cohort of 126 patients who underwent surgery for hepatic resection for CRLM between 2009 and 2020 were reviewed. The patients were divided into three categories: wild-type KRAS, mutated KRAS and impractical KRAS according to their oncological variables. The impractical (not tested) KRAS group included patients with metachronous tumours and negative lymph nodes harvested. Disease-free survival (DFS), overall survival (OS) and hepatic recurrence-free survival (HRFS) were calculated by the Kaplan-Meier method, and a multivariable analysis was conducted using the Cox proportional hazards regression model. RESULTS: Of the 108 patients identified, 35 cases had KRAS wild-type, 50 cases had a KRAS mutation and the remaining 23 were classified as impractical KRAS. Significantly longer medians for OS, HRFS and DFS were found in the impractical KRAS group. In the multivariable analyses, the KRAS mutational gene was the only variable that was maintained through OS, HRFS and DFS. For HRFS (HR: 13.63; 95% confidence interval (CI): 1.35-100.62; p = 0.010 for KRAS), for DFS (HR: 10.06; 95% CI: 2.40-42.17; p = 0.002 for KRAS) and for OS (HR: 4.55%; 95% CI: 1.37-15.10; p = 0.013). CONCLUSION: Our study considers the possibility of unnecessary KRAS testing in patients with metachronous tumours and negative lymph nodes harvested. Combining the genetic mutational profile (i.e., KRAS in specific cases) with tumour characteristics helps patient selection and achieves the best prognosis after CRLM resection.

Watch-and-Wait policy versus robotic surgery for locally advanced rectal cancer: A cost-effectiveness study (RECCOSTE).

INTRODUCTION: Complete surgical resection for locally advanced rectal cancer is the standard treatment after a clinical complete response following chemoradiotherapy. However, some novel clinical approaches could achieve better functional results, such as Robotic Resection, or avoiding surgical procedure and incrementing surveillance intensity, called Watch-and-Wait policy. We use computational techniques to compare these clinical approaches using quality adjusted life years (QALYs). METHODS: A Markov decision analytic model was used in order to perform a cost-utility analysis, comparing standard resection (SR), Robotic Rectal Resection (RRR) and Watch-and-Wait (WW) strategies, estimating the incremental cost-effectiveness ratio per QALY to be gained from patients reaching a clinical complete response to chemoradiotherapy. Model parameter estimates were informed by previously published studies comparing WW to SR and from our database of RRR versus SR. Lifetime incremental cost-utility ratio was calculated among approaches, and a sensitivity analysis were performed in order to estimate the model uncertainty. A willingness-to-pay of per one additional QALY gained was measured to determine which strategies would be most cost-effective. RESULTS: WW is a dominating option over SR ( -75,486. 75 € and +2.04 QALYs) and RRR ( -75,486. 75 € and +0.41 QALYs). The cost-effectiveness plane shows that WW does not always dominate over RRR or SR. WW saves costs in 99.98% of the simulations when compared with either SR or RRR but only 86.9% and 55.38% (respectively) of these fall within the SR quadrant. WW is only more effective than SR 55% of the time which implies a significant uncertainty due to the high utility value assigned to cCR after chemoradiotherapy in the RRR alternative. CONCLUSION: This study provides data of cost-effectiveness differences among Standard Surgery, Watch-and-Wait and Robotic Resection approaches in clinical complete response in locally advanced rectal cancer patients after neoadjuvant chemoradiotherapy, showing a benefit for Watch-and-Wait policy.

National survey on the treatment of acute appendicitis in Spain during the initial period of the COVID-19 pandemic.

INTRODUCTION: The COVID-19 pandemic has had a significant impact on Spanish hospitals, which have had to allocate all available resources to treat these patients, reducing the ability to attend other common pathologies. The aim of this study is to analyze how the treatment of acute appendicitis has been affected. METHOD: A national descriptive study was carried out by an online voluntary specific questionnaire with Google Drive™ distributed by email by the Spanish Association of Surgeons (AEC) to all affiliated surgeons currently working in Spain (5203), opened from April 14th to April 24th. RESULTS: We received 337 responses from 170 centers. During the first month of the pandemic, the incidence of acute appendicitis decreased. Although conservative management increased, the surgical option has been the most used in both simple and complicated appendicitis. Despite the fact that the laparoscopic approach continues to be the most widely used in our services, the open approach has increased during this pandemic period. CONCLUSION: Highlight the contribution of this study in terms of knowledge of the status of the treatment of acute appendicitis during this first month of the pandemic, being able to serve for a better possible organization in future waves of the pandemic and a reorganization of current protocols and management of acute appendicitis in a pandemic situation.

Robotic versus laparoscopic distal pancreatectomies: A systematic review and meta-analysis on costs and perioperative outcome.

AIM: The aim of this meta-analysis is to compare perioperative outcomes and costs of robotic and laparoscopic distal pancreatectomy (RDP and LDP). MATERIAL AND METHODS: In accordance with the PRISMA guidelines, we searched Medline, EMBASE, Cochrane and Web of Science for reports published before December 2020. RESULTS: The literature search identified 11 papers (1 187 patients). RDP showed a lower conversion rate (odds ratio: 2.56, 95% confidence intervals [CI]: 1.31 to 5.00) with no significant differences in bleeding and operative time, complications ≥ Clavien-Dindo grade III, pancreatic fistulas and length of stay. Despite RDP presenting higher costs in all included studies, none of these differences were significant. However, RDP showed higher total costs than LDP (standardized mean differences [SMD]: -1.18, 95% CI: -1.97 to -0.39). A subgroup analysis according to the continent of origin showed that studies coming from Asian research groups kept showing significant differences (SMD: -2.62, 95% CI: -3.38 to -1.85), while Western groups did not confirm these findings. CONCLUSION: Based on low-quality evidence, despite some potential technical advantages, RDP still seems to be costlier than LDP.

Laparoscopic inguinal hernia repair: cost-effectiveness analysis of trend modifications of the technique.

The aim of this study is to evaluate the cost-effectiveness of different modifications of the trans-abdominal pre-peritoneal (TAPP) repair of groin hernia. Data were collected prospectively for all consecutive patients who underwent TAPP unilateral inguinal hernia repair between November 2017 and March 2019, and who completed a minimum of 1 year of follow-up. Costs and quality adjusted life year (QALY) gained were collected. Three TAPP variations were assessed: mesh fixation and peritoneal closure with staples (group 1); mesh fixation with fibrin glue and peritoneal closure with sutures (group 2); and mesh fixation and peritoneal closure with fibrin glue (group 3). A matched group of open repairs was established. The incremental cost-effectiveness ratio (ICER) and main intra-operative and post-operative outcomes were assessed. Overall 120 patients were included (group 1 n = 31; group 2 n = 27; group 3 n = 33; open group: 29). Operative time was shorter for groups 2 and 3, and the main post-operative outcomes were similar. The overall mean total cost of the open group (1185.95€) was lower compared with the laparoscopic group (group 1: 1682.39; group 2: 1538.54€; group 3: 1510.1€) (p = 0.026). However, the mean ICERs of groups 2 and 3 were significantly higher compared with group 1 (p = 0.021) and the open group (p = 0.032). At simulations analysis, the probability of cost-effectiveness was 33.32%, 36.26%, and 36.7% in TAPP groups 1, 2, and 3. In the long term, laparoscopic repair of groin hernia is cost-effective compared with open surgery. The use of fibrin glue for mesh fixation and/or for closing the peritoneum is the most cost-effective option and shortens operative times.

A cost-effectiveness analysis of robotic versus laparoscopic distal pancreatectomy.

AIM: There is no study in the literature that evaluates the cost-effectiveness of robotic distal pancreatectomy (RDP) over laparoscopic distal pancreatectomy (LDP). We performed a comparative study of RDP and LDP with the aim of evaluating clinical and cost-effective outcomes. MATERIAL AND METHODS: This is an observational, comparative prospective nonrandomized study. The primary end point was to compare the cost-effectiveness differences between both groups. A willingness to pay of €20 000 and €30 000 per quality-adjusted life year (QALY) was used as a threshold to recognize which treatment was most cost-effective. RESULTS: A total of 31 RDP and 28 LDP have been included. The overall mean total cost was similar in both groups (RDP: €9712.15 versus LDP: €9424.68; P > .5). Mean QALYs for RDP (0.652) was higher than that associated with LDP (0.59) (P > .5). CONCLUSION: This study seems to provide data of cost-effectiveness between RDP and LDP approaches, showing some benefits for RDP.

Cost-effectiveness of Randomized Study of Laparoscopic Versus Open Bilateral Inguinal Hernia Repair.

OBJECTIVE: The aim of this study is to compare the clinical and cost-effective outcomes of the open Lichtenstein repair (OL) and laparoscopic trans-abdominal preperitoneal (TAPP) repair for bilateral inguinal hernias. SUMMARY BACKGROUND DATA: A cost-effective analysis of laparoscopic versus open inguinal hernia repair is still not well addressed, especially regarding bilateral hernia. METHODS: This is a clinical and cost-effectiveness analysis within a randomized prospective study conducted at Sanchinarro University Hospital.Cases of primary, reducible bilateral inguinal hernia were included and randomized using a simple randomization program.The outcome parameters included surgical and postoperative costs, quality adjusted life years (QALY), and incremental cost per QALY gained or the incremental cost effectiveness ratio. RESULTS: Between March 2013 and January 2017, 165 patients were enrolled in this study (81 of them underwent TAPP and 84 OL).The TAPP procedure had less early postoperative pain (P = 0.037), a shorter length of stay (P = 0.001), and fewer postoperative complications (P = 0.002) when compared with the OL approach. The overall cost of TAPP procedure was higher compared with the OL cost (1,683.93&OV0556; vs 1192.83&OV0556;, P = 0.027). The mean QALYs at 1 year for TAPP (0.8094) was higher than that associated with OL (0.6765) (P = 0.018). At a willingness-to-pay threshold of 20,000 &OV0556; and 30,000 &OV0556;, there was a 95.38% and 97.96% probability that TAPP was more cost-effective relative to OL. CONCLUSIONS: The TAPP procedure for bilateral inguinal hernia appears to be more cost-effective compared with OL.

Robotic versus laparoscopic distal pancreatectomy: A comparative study of clinical outcomes and costs analysis.

BACKGROUND: The robotic surgery cost presents a critical issue which has not been well addressed yet. This study aims to compare the clinical outcomes and cost differences of robotic distal pancreatectomy (RDP) versus laparoscopic distal pancreatectomy (LDP). METHODS: Data were abstracted prospectively from 2011 to 2017. An independent company performed the financial analysis. RESULTS: A total of 28 RDP and 26 LDP were included. The mean operative time was significantly lower in the LDP (294 vs 241 min; p = 0.02). The main intra and post-operative data were similar, except for the conversion rate (RDP: 3.6% vs LDP: 19.2%; p = 0.04) and hospital stay (RDP: 8.9 vs LDP 13.1 days; p = 0.04). The mean total costs were similar in both groups (RDP: 9198.64 € vs LDP: 9399.74 €; p > 0.5). CONCLUSIONS: RDP showed lower conversion rate and shorter hospital stay than LDP at the price of longer operative time. RDP is financially comparable to LDP.

Robotic versus laparoscopic surgery for rectal cancer: a comparative study of clinical outcomes and costs.

PURPOSE: The costs involved in performing robotic surgery present a critical issue which has not been well addressed yet. The aims of this study are to compare the clinical outcomes and cost differences of robotic versus laparoscopic surgery in the treatment of rectal cancer and to conduct a literature review of the cost analysis. METHODS: This is an observational, comparative study whereby data were abstracted from a retrospective database of patients who underwent laparoscopic and robotic rectal resection from October 2010 to March 2017, at Sanchinarro University Hospital, Madrid. An independent company performed the financial analysis, and fixed costs were excluded. RESULTS: A total of 86 robotic and 112 laparoscopic rectal resections were included. The mean operative time was significantly lower in the laparoscopic approach (336 versus 283 min; p = 0.001). The main pre-operative data, overall morbidity, hospital stay and oncological outcomes were similar in both groups, except for the readmission rate (robotic: 5.8%, laparoscopic: 11.6%; p = 0.001). The mean operative costs were higher for robotic surgery (4285.16 versus 3506.11€; p = 0.04); however, the mean overall costs were similar (7279.31€ for robotic and 6879.8€ for the laparoscopic approach; p = 0.44). We found four studies reporting costs, three comparing robotic versus laparoscopy costs, with all of them reporting a higher overall cost for the robotic rectal resection. CONCLUSION: Robotic rectal resection has similar clinical outcomes to that of the conventional laparoscopic approach. Despite the higher operative costs of robotic rectal resection, overall mean costs were similar in our series.