Cost of open and laparoscopic distal gastrectomy: surgeon perceptions versus the reality of hospital spending.

BACKGROUND: Rising health care costs have led to increasing focus on cost containment and accountability from health care providers. We sought to explore surgeon awareness of supply costs for open and laparoscopic distal gastrectomy. METHODS: Surveys were sent in 2015 to surgeons at 8 academic hospitals in Toronto who performed distal gastrectomy for gastric adenocarcinoma. Respondents were asked to estimate the total cost, type and number of disposable equipment pieces required to perform open and laparoscopic distal gastrectomy. We determined the accuracy of estimates through comparisons with procedural invoices for distal gastrectomy performed between Jan. 1, 2011, and Dec. 31, 2015. All values are in 2015 Canadian dollars. RESULTS: Of the 53 surveys sent out, 12 were completed (response rate 23%). Surgeon estimates of total supply costs ranged from $500 to $3000 and from $1500 to $5000 for open and laparoscopic cases, respectively. Estimated supply costs for requested equipment ranged from $464 to $2055 for open cases and from $1870 to $2960 for laparoscopic cases. Invoices for actual equipment yielded a mean of $821 (standard deviation $543) (range $89-$2613) for open cases and $2678 (standard deviation $958) (range $835-$4102) for laparoscopic cases. Estimates of total cost were within 25% of the median invoice total in 1 response (9%) for open cases and 3 (27%) of those for laparoscopic cases. CONCLUSION: Respondents failed to accurately estimate equipment costs. The variation in true total costs and estimates of supply costs represents an opportunity for intraoperative cost minimization, efficient equipment selection and value-based purchasing arrangements.

CONTEXTE: En raison de l'augmentation des coûts des soins de santé on attend des professionnels qu'ils mettent davantage l'accent sur les restrictions budgétaires et l'imputabilité. Nous avons voulu vérifier à quel point les chirurgiens sont conscients du coût des fournitures utilisés dans les cas de gastrectomie distale ouverte et laparoscopique. MÉTHODES: Des questionnaires ont été envoyés en 2015 aux chirurgiens de 8 hôpitaux universitaires de Toronto qui pratiquent la gastrectomie distale pour l'adénocarcinome de l'estomac. On demandait aux participants d'estimé le coût total, le type et le nombre de fournitures jetables requises pour une gastrectomie distale ouverte et laparoscopique. Nous avons déterminé l'exactitude des estimations en comparant les factures pour les interventions de gastrectomie distale effectuées entre le 1er janvier 2011 et le 31 décembre 2015. Toutes les valeurs sont présentées en dollars canadiens. RÉSULTATS: Parmi les 53 questionnaires envoyés, 12 sont revenus complétés (taux de réponse 23 %). Les estimations des chirurgiens pour le coût total des fournitures allaient de 500 $ à 3000 $ et de 1500 $ à 5000 $ pour les interventions ouvertes et laparoscopiques, respectivement. Le coût estimé des fournitures pour l'équipement nécessaire variait de 464 $ à 2055 $ pour les interventions ouvertes et de 1870 $ à 2960 $ pour les interventions laparoscopiques. Les factures soumises pour les équipements réellement utilisés ont été en moyenne de 821 $ (écart-type 543 $) (éventail 89 $-2613 $) pour les interventions ouvertes et de 2678 $ (écart-type 958 $) (éventail 835 $-4102 $) pour les interventions laparoscopiques. Les estimations des coûts totaux se situaient à plus ou moins 25 % du montant total médian des factures dans 1 réponse (9 %) pour les interventions ouvertes et dans 3 réponses (27 %) pour les interventions laparoscopiques. CONCLUSION: Les participants n'ont pas été en mesure d'estimer avec exactitude le coût des fournitures. Cet écart entre les coûts totaux réels et estimés représente une occasion de réduire les coûts peropératoires, de sélectionner les équipements de façon efficiente et de conclure des contrats d'achat en fonction de la valeur.

Reusable single-port access device shortens operative time and reduces operative costs.

BACKGROUND: In recent years, single-port laparoscopy (SPL) has become an attractive approach for performing surgical procedures. The pitfalls of this approach are technical and financial. Financial concerns are due to the increased cost of dedicated devices and prolonged operating room time. Our aim was to calculate the cost of SPL using a reusable port and instruments in order to evaluate the cost difference between this approach to SPL using the available disposable ports and standard laparoscopy. METHODS: We performed 22 laparoscopic procedures via the SPL approach using a reusable single-port access system and reusable laparoscopic instruments. These included 17 cholecystectomies and five other procedures. Operative time, postoperative length of stay (LOS) and complications were prospectively recorded and were compared with similar data from our SPL database. Student's t test was used for statistical analysis. RESULTS: SPL was successfully performed in all cases. Mean operative time for cholecystectomy was 72 min (range 40-116). Postoperative LOS was not changed from our standard protocols and was 1.1 days for cholecystectomy. The postoperative course was within normal limits for all patients and perioperative morbidity was recorded. Both operative time and length of hospital stay were shorter for the 17 patients who underwent cholecystectomy using a reusable port than for the matched previous 17 SPL cholecystectomies we performed (p < 0.001). Prices of disposable SPL instruments and multiport access devices as well as extraction bags from different manufacturers were used to calculate the cost difference. Operating with a reusable port ended up with an average cost savings of US$388 compared with using disposable ports, and US$240 compared with standard laparoscopy. CONCLUSION: Single-port laparoscopic surgery is a technically challenging and expensive surgical approach. Financial concerns among others have been advocated against this approach; however, we demonstrate herein that using a reusable port and instruments reduces operative time and overall operative costs, even beyond the cost of standard laparoscopy.

[Benefits of mechanical suture in our experience]. / Beneficiile utilizarii suturii mecanice în experienta noastrta.

UNLABELLED: The evolution of mechanical suture technology experienced a continuous improvement but the implementation of these devices in current practice of Romanian surgery encountered difficulties related mostly to increased costs. PURPOSE: Review of casuistic related to the use of mechanical suture devices. METHODS: We studied the casuistic between 2008 and July 2011. More parameters were analyzed compared to cases in which manual suture was used. RESULTS: 74 patients benefited from using mechanical suture. Circular staplers EAEC type were used in 53 cases, TA staplers in 48 cases and Endo GIA in 19 cases. Operations performed were: 44 colo-rectal anastomoses (2 laparoscopic), 9 eso-jejunal anastomoses, 17 gastric resections, 2 duodenal stump closures and 2 rectal stump closures. One (2.56%) colorectal anastomotic fistula was found which led to death. There was a single anastomotic imperfection where we performed ileostomy with favorable evolution. Duration of Dixon's operation was shortened by 36 minutes average. The anastomosis could be lowered to 3 cm from the anal verge. There were 3 late local rectal cancer recurrences, 1 recto-vaginal fistula and 1 rectovesical fistula. There were no anastomotic stenoses. CONCLUSIONS: There were two main advantages of using mechanical anastomosis: (1) the opportunity of palette broadening of laparoscopic operations, (2) the possibility of making safe anastomosis in difficult to access areas (rectum, esophagus). The use of mechanical staplers offers advantages especially in patients with rectal tumors, especially in obese male patients with narrow basin, where we can save many cases from rectal amputation. Staplers bring more comfort to the surgeon offering physical and psychological feeling of a perfect anastomosis. Although staplers cost is high, in selected cases, this disadvantage is offset by reducing the duration of operations, hospitalization and subsequent cost of stomas maintenance.

Ultrasonic scalpel for gastric cancer surgery: a prospective randomized study.

BACKGROUND: The aim of the study was to evaluate the potential advantages of the ultrasonic scalpel compared with the conventional technique in gastric cancer surgery. METHODS: Patients with resectable adenocarcinoma of the stomach were randomly assigned to ultrasonic scalpel or conventional technique. We used the HARMONIC FOCUS (Ethicon Endo-Surgery, Inc.) as ultrasonic scalpel. RESULTS: Between February 2010 and December 2010, 60 patients with resectable gastric cancer were enrolled into the study. Operative time was significantly shorter with the ultrasonic arm than with the conventional arm (median 238.5 vs. 300.5 min; P = 0.0004). Blood loss was also significantly lower in the ultrasonic arm than in the conventional arm (median 351.0 vs. 569.5 ml; P = 0.016). Clavien-Dindo grades of postoperative complications were similar in the two groups. From a questionnaire survey of operators, the ultrasonic scalpel significantly reduced the stress of lymph node dissection (3.67 vs. 2.87; P = 0.0006). However, in assisting surgeons, the contributions to surgery, study, and technical improvement of the ultrasonic group were lower than in the conventional group. CONCLUSIONS: This study shows that the ultrasonic scalpel is a reliable and safe tool for open gastric cancer surgery.

[Operative techniques and outcomes in metabolic surgery: sleeve gastrectomy]. / Operative Techniken und deren Outcome in der metabolischen Chirurgie: Sleeve-Gastrektomie.

Laparoscopic sleeve gastrectomy (LSG) was initially introduced for super-obese patients in a two-step concept in order to reduce the perioperative risk. Many years before a very similar technique - the Magenstrasse and Mill (M & M) operation - was developed by Johnston in Leeds / UK as a "more physiological" bariatric procedure with acceptable weight loss, while preserving gastric emptying mechanisms and thus minimising possible side-effects such as vomiting, dumping and diarrhoea, which are common complications of gastric bypass procedures. The following manuscript analyses the current literature and our own preliminary results and parallels publications of the M & M procedure. Until now numerous modifications (e. g., bougie size and residual volume, stapler technique, use of buttress mate-rial) have been reported. However, reported -morbidity and mortality rates were equal to those of gastric banding and gastric bypass (RYGB). In conclusion, laparoscopic sleeve gastrectomy (LSG) has now proven to be as effective as the RYGB for weight loss over a three-year period. Control of hunger and feeling of fullness are -reported to be superior compared to gastric band-ing. Laparoscopic sleeve gastrectomy is no longer an experimental procedure. It should be accepted as one of the effective standard procedures for surgical treatment of morbid obesity.

[The role of the ultracision technique in visceral surgery. Ligature-free operation--an illusion?]. / Ein Erfahrungsbericht mit Ultrazision in der offenen Chirurgie.Die ligaturfreie Operation--eine Illusion?

We report on 431 operations in conventional visceral surgery with the general use of the ultracision technique for preparation (thyroid resections n = 356, colonic resections n = 28, local excisions of the gastric wall n = 3, gastrectomy n = 14, anterior resections of the rectum n = 19, abdominoperineal resection of the rectum [Miles' operation] n = 11). Ligatures were only used for truncal blood vessel ligation. A thorough study of the technical possibilities is a prerequisite for the use of the ultracision technique. The general use of the ultracision technique leads to a revolutionary change of the surgical technique and saves a considerable amount of suture material. In combination with the use of bipolar electrocoagulation the ultracision technique makes the operation fast and leads to a major reduction of bleeding. The biggest disadvantage of the ultracision technique in comparison to the conventional surgical technique is the high cost of the device at present. Despite of savings of suture material, swabs and blood transfusions, the costs for the ultracision scissors are still higher due to its single use.

Different techniques for creating oesophageal anastomoses. A historical review and personal experience.

UNLABELLED: Among the surgical techniques used to create a reliable oesophageal anastomosis, mention should be made of the handmade (in one or two layers, wire or Vicryl) and the different stapler anastomoses. 41 oesophageal anastomoses were performed by stapler technique between 4 March 1985 and 4 March 1991. The EEA stapler was used in 15, and the SPTU stapler in 26 patients. The average age was 56.8 years overall, 53.6 in the female (7 patients) and 57.4 years in the 34 male patients. Tumours in the middle and lower third of the oesophagus and on the cardia were the indications for resection in 30 instances. Total gastrectomy was performed in 9 patients and oesophageal resection for peptic stricture in 2 cases. Replacement with stomach was carried out after oesophageal resection (17 patients), and with Roux-loop in 24 cases. The EEA anastomoses were not covered by a hand-made layer of interrupted sutures as is compulsory in the case of the SPTU gun. The intraoperative complication rate was 12.2%--two severe complications with the SPTU and 3 mild ones with the EEA (2 cases) and SPTU (1 case) machines. The postoperative complication rate was 17%--the severe ones with the SPTU gun. The only fatal anastomosis insufficiency was observed in this group. 3 of the 41 patients died--a mortality rate of 7.3%--but only one of them was due to technical failure in the SPTU group: 2.4%. CONSEQUENCES: Both the intra- and postoperative complications were more severe with the SPTU technique. The early postoperative complications are closely related to the intraoperative ones. Mortality due to technical failure was only observed in the SPTU group. The EEA stapler gun is superior in every respect to the SPTU sewing-machine. The future belongs to the even more sophisticated bent and modifiable devices. These were used in our Department Between 1992 and 1997, with practically no morbidity and no mortality. Although they are the most expensive of all the possibilities, the low morbidity and mortality rates pay off from the aspects of the short hospital stay and the savings in human life.