The price is right: Routine fluorescent cholangiography during laparoscopic cholecystectomy.

BACKGROUND: Early experience with indocyanine green-based fluorescent cholangiography during laparoscopic cholecystectomy suggests the potential to improve outcomes. However, the cost-effectiveness of routine use has not been studied. Our objective was to evaluate the cost-effectiveness of fluorescent cholangiography versus standard bright light laparoscopic cholecystectomy for noncancerous gallbladder disease. METHODS: A Markov model decision analysis was performed comparing fluorescent cholangiography versus standard bright light laparoscopic cholecystectomy alone. Probabilities of outcomes, survival, toxicities, quality-adjusted life-years, and associated costs were determined from literature review and pooled analysis of currently available studies on fluorescent cholangiography (n = 37). Uncertainty in the model parameters was evaluated with 1-way and probabilistic sensitivity analyses, varying parameters up to 40% of their means. Cost-effectiveness was measured with an incremental cost-effectiveness ratio expressed as the dollar amount per quality-adjusted life-year. RESULTS: The model predicted that fluorescent cholangiography reduces lifetime costs by $1,235 per patient and improves effectiveness by 0.09 quality-adjusted life-years compared to standard bright light laparoscopic cholecystectomy. Reduced costs were due to a decreased operative duration (21.20 minutes, P < .0001) and rate of conversion to open (1.62% vs 6.70%, P < .0001) associated with fluorescent cholangiography. The model was not influenced by the rate of bile duct injury. Probabilistic sensitivity analysis found that fluorescent cholangiography was both more effective and less costly in 98.83% of model iterations at a willingness-to-pay threshold of $100,000/quality-adjusted life year. CONCLUSION: The current evidence favors routine use of fluorescent cholangiography during laparoscopic cholecystectomy as a cost-effective surgical strategy. Our model predicts that fluorescent cholangiography reduces costs while improving health outcomes, suggesting fluorescence imaging may be considered standard surgical management for noncancerous gallbladder disease. Further study with prospective trials should be considered to verify findings of this predictive model.

An ERAS protocol for bariatric surgery: is it safe to discharge on post-operative day 1?

BACKGROUND: Laparoscopic sleeve gastrectomy is the most commonly performed bariatric surgery in the world. Enhanced recovery after surgery (ERAS) protocols have been shown to reduce complications and decrease length of stay for various types of surgeries. In this study, we propose an ERAS protocol for laparoscopic sleeve gastrectomy and compare the clinical outcomes with patients who received standard care. METHODS: We performed a single-institution retrospective analysis in patients who underwent laparoscopic sleeve gastrectomy from February 2015 to December 2017. Patients were stratified into standard care and ERAS protocol groups. The ERAS protocol consisted of goal-directed patient education, specific pre- and post-op multi-modal medication regimen, early ambulation, and early oral intake. Patients were discharged on their first post-operative day if they met appropriate post-surgical milestones. The primary outcomes were length of stay, 7- and 30-day readmission rates, and complication rates. Secondary outcomes included anti-emetic and pain medication utilization, post-operative emesis episodes per day, post-operative pain scores, and mortality. RESULTS: We included 214 consecutive patients who underwent sleeve gastrectomy, 130 were in the ERAS group and 84 were in the standard care group. Median hospital stay was significantly shorter in the ERAS group compared to the standard care group (1 vs. 2 days; p < 0.001). There were no differences in 7- or 30-day readmission rates (1.5 vs. 1.2%; p = 0.838, 2.3 vs. 2.4%; p = 0.966) or post-operative complications (6.2 vs. 3.6%; p = 0.410). The ERAS group also had decreased median intra-operative opioid consumption and self-reported pain scores on post-operative day 1 (27.5 MME vs. 27.4 MME; p = 0.044, 3.3 vs. 3.9; p = 0.046). Mortality rate was 0% overall. CONCLUSION: A cost-effective ERAS protocol for laparoscopic sleeve gastrectomy results in shorter length of stay, without increase in peri-operative morbidity or readmission rates.

Increasing the Value of Healthcare: Improving Mortality While Reducing Cost in Bariatric Surgery.

BACKGROUND: Healthcare costs in the United States (U.S.) are rising. As outcomes improve, such as decreased length of stay and decreased mortality, it is expected that costs should go down. The aim of this study is to analyze hospital charges, cost of care, and mortality in bariatric surgery over time. METHODS: A retrospective analysis of the Nationwide Inpatient Sample (NIS) database was performed. Adults with morbid obesity who underwent gastric bypass or sleeve gastrectomy were identified by ICD-9 codes. Multivariate analyses identified independent predictors of changes in hospital charges and in-hospital mortality. Results were adjusted for age, race, gender, Charlson comorbidity index, surgical approach (open versus laparoscopic), hospital volume, and insurance status. In order to estimate baseline surgical inflation, changes in hospital charges over time were also calculated for appendectomy. RESULTS: From 1998 to 2011, 209,106 patients were identified who underwent bariatric surgery. Adjusted in-hospital mortality for bariatric surgery decreased significantly by 2003 compared to 1998 (p < 0.001, OR 0.47, 95 % CI 0.22-0.92) and remained significantly decreased for the remainder of the study period. As such, a 60-80 % decrease in mortality was maintained from 2003 to 2010 compared to 1998. After adjusting for inflation, the cumulative increase in hospital charges per day of a bariatric surgery admission was 130 % from 1998 to 2011. Charges per stay increased by 2.1 % annually for bariatric surgery compared to 5.5 % for appendectomy. CONCLUSION: In-hospital mortality rate following bariatric surgery underwent a ninefold decrease since 1998 while maintaining surgical inflation costs less than appendectomy. Innovation in bariatric surgical technique and technology has resulted in improvement of outcomes while providing overall cost savings.