Visualization versus neuromonitoring of recurrent laryngeal nerves during thyroidectomy: what about the costs?

BACKGROUND: The objective of the present study was to evaluate costs for thyroidectomy performed with the aid of intraoperative neural monitoring (IONM), which has gained widespread acceptance during thyroid surgery as an adjunct to the gold standard of visual nerve identification. METHODS: Through a micro-costing approach, the thyroidectomy patient-care process (with and without IONM) was analyzed by considering direct costs (staff time, consumables, equipment, drugs, operating room, and general expenses). Unit costs were collected from hospital accounting and standard tariff lists. To assess the impact of the IONM technology on hospital management, three macro-scenarios were considered: (1) traditional thyroidectomy; (2) thyroidectomy with IONM in a high-volume setting (5 procedures per week); and (3) thyroidectomy with IONM in a low-volume setting (1 procedure per week). Energy-based devices (EBD) for hemostasis and dissection in thyroidectomy were also evaluated, as well as the reimbursement made by the Italian Healthcare System on the basis of diagnosis related groups (DRGs), about €2,600. RESULTS: Comparison between costs and the DRG fee shows an underfunding of total hospitalization costs for all thyroidectomies, regardless of IONM use (scenario 1: €3,471). The main cost drivers are consumables and technologies (25%), operating room (16%), and staff (14%). Hospitalization costs for a thyroidectomy with IONM range from €3,713 to €3,770 (scenarios 2 and 3), 5­7% higher than those for traditional thyroidectomy. Major economic differences emerge when an EBD is used (€3,969). CONCLUSIONS: The regional DRG tariff for thyroid surgery is barely sufficient to cover conventional surgery costs. Intraoperative neural monitoring accounts for 5­7% of the hospitalization costs for a thyroidectomy.

Preoperative assessment of rectal cancer stage: state of the art.

Rectal cancer is one of the most common tumors worldwide; it accounts for approximately 25-30% of cancers arising in the large bowel. Owing to greater distribution of screening programs and better attention from both patients and General Practitioners to this disease, in recent years we have observed an increasing number of cases diagnosed in the early stages, with a consequent better prognosis. The improved 5-year survival is also partially due to better, and more accurate, diagnostic techniques and to more curative treatments. In this review, the authors analyze and discuss the more recent diagnostic techniques for an accurate preoperative staging of rectal cancer, highlighting each method's advantages and limits for their routine use in clinical practice.

Cancer of the esophagus: the value of preoperative patient assessment.

In the past few years, major improvements and new technologies have been proposed and applied in esophageal surgery. Its evolution depended not only on a thorough knowledge of surgical anatomy and technique, but also on important developments in pre- and postoperative care. Esophageal resection for cancer is still associated with high morbidity and mortality. Postoperative complications may be either patient or surgeon related. Patient-related factors include age, malnutrition, immunodepression and associated diseases. The surgeon-related factors are surgical experience, hospital volume and multidisciplinary approach. Preoperative evaluation is defined as the process of clinical assessment that precedes the delivery of anesthesia. The principle is to gain information concerning patients that leads to modification of their management, and improves the outcome from surgery.

Technological advances in minimally invasive surgery.

Advances in technology continue at a rapid pace affecting several aspects of life; medicine is no exception. Minimally invasive surgery is, by its nature, a highly technological specialty of surgical practice. The development of new instruments and new technologies during the last few years have allowed complex procedures that were previously considered unsuitable for minimally invasive surgery. The aim of this article is to review some of these advances and the impact they are having on the managements of different surgical problems.

Influence of new technologies on thyroid surgery: state of the art.

The history of thyroid surgery starts with Billroth, Kocher and Halsted, who developed the technique for thyroidectomy between 1873 and 1910. In general, the essential objectives for thyroidectomy are conservation of the parathyroid glands, avoidance of injury to the recurrent laryngeal nerve, an accurate hemostasis and an excellent cosmesis. In the last 20 years, major improvements and new technologies have been proposed and applied in thyroid surgery; among these are mini-invasive thyroidectomy, new devices for achieving hemostasis and dissection, regional anesthesia and intraoperative neuro-monitoring.