Cost-effectiveness of Surgical Treatment Pathways for Prolapse.

OBJECTIVE: To evaluate the cost-effectiveness of surgical treatment pathways for apical prolapse. STUDY DESIGN: We constructed a stochastic Markov model to assess the cost-effectiveness of vaginal apical suspension, laparoscopic sacrocolpopexy, and robotic sacrocolpopexy. We modeled over 5 and 10 years, with 9 pathways accounting for up to 2 separate surgical repairs, recurrence of symptomatic apical prolapse, reoperation, and complications, including mesh excision. We calculated costs from the health care system's perspective. RESULTS: Over 5 years, compared with expectant management, all surgical treatment pathways cost less than the willingness-to-pay threshold of US $50,000 per quality adjusted life-years. However, among surgical treatments, all but 2 pathways were dominated. Of the remaining 2, laparoscopic sacrocolpopexy followed by vaginal repair for apical recurrence was not cost-effective compared with the vaginal-only approach (incremental cost-effectiveness ratio [ICER], >$500,000). Over 10 years, all but the same 2 pathways were dominated. However, starting with the laparoscopic approach in this case was more cost-effective with an ICER of US $6,176. If the laparoscopic approach was not available, starting with the robotic approach similarly became more cost-effective at 10 years (ICER, US $35,479). CONCLUSIONS: All minimally invasive surgical approaches for apical prolapse repair are cost-effective when compared with expectant management. Among surgical treatments, the vaginal-only approach is the only cost-effective option over 5 years. However, over a longer period, starting with a laparoscopic (or robotic) approach becomes cost-effective. These results help inform discussions regarding the surgical approach for prolapse.

Gastrostomía por minilaparotomía / PERCUTANEOUS GASTROSTOMY WITHOUT LAPAROTOMY

Introducción: la cirugía percutánea constituye sin lugar a dudas la técnica de elección para la realización de la gastrostomía para alimentación enteral. No obstante sus ventajas, requiere de costosos sets y una complejidad para su realización, que no siempre tenemos al alcance en nuestro medio. Todo esto nos llevó a buscar una alternativa que fuese segura, de fácil manejo domiciliario y económicamente factible en todos los casos que se presentan en nuestro medio. Material y Método: se trata de un estudio retrospectivo de 18 pacientes tratados entre 2005 y 2008 por medio de esta técnica: laparotomía mínima (3 Cm), para mediana izquierda por debajo del reborde costal identificación de la porción ascendente del estómago, colocación de una sonda Foley N° 18 y fijación del estómago a la pared durante el cierre de la laparotomía. Resultados: en los pacientes de la serie estudiada no se observaron complicaciones graves, salvo alguna dermatitis por reflujo peri tubo y un prolapso de mucosa. Se observó también un fácil manejo domiciliario y una buena aceptación por parte de los pacientes. Discusión: se trata de una técnica segura y de bajo costo, que si bien no constituye el procedimiento de primera elección, permite en medios económicamente limitados como el nuestro, la realización de una vía de alimentación enteral segura, de bajo costo y con resultados similares. Introducción: la cirugía percutánea constituye sin lugar a dudas la técnica de elección para la realización de la gastrostomía para alimentación enteral. No obstante sus ventajas, requiere de costosos sets y una complejidad para su realización, que no siempre tenemos al alcance en nuestro medio. Todo esto nos llevó a buscar una alternativa que fuese segura, de fácil manejo domiciliario y económicamente factible en todos los casos que se presentan en nuestro medio. Material y Método: se trata de un estudio retrospectivo de 18 pacientes tratados entre 2005 y 2008 por medio de esta técnica: laparotomía mínima (3 Cm), para mediana izquierda por debajo del reborde costal identificación de la porción ascendente del estómago, colocación de una sonda Foley N° 18 y fijación del estómago a la pared durante el cierre de la laparotomía. Resultados: en los pacientes de la serie estudiada no se observaron complicaciones graves, salvo alguna dermatitis por reflujo peri tubo y un prolapso de mucosa. Se observó también un fácil manejo domiciliario y una buena aceptación por parte de los pacientes. Discusión: se trata de una técnica segura y de bajo costo, que si bien no constituye el procedimiento de primera elección, permite en medios económicamente limitados como el nuestro, la realización de una vía de alimentación enteral segura, de bajo costo y con resultados similares.

Introduction: Percutaneous surgery is undoubtedly the preferred technique to perform a gastrostomy for enteral feeding. Despite its advantages, it requires expensive sets and a complex procedure, which are not always available in our locations. All this led us to look for a safe alternative, easy to manage at home, and economically viable in all cases that occur in our locations. Material and Method: This is a retrospective study that includes 18 patients treated between 2005 and 2008 using the technique of minimal laparotomy (3 cm) for left median below the costal ridge, detection of the ascending portion of the stomach, placement of a Foley tube No. 18 and fixation of the stomach to the wall during the closure of the incision. Results: No serious complications were observed in the patients included in this study, except for some peri-tube reflux dermatitis and a mucous membrane prolapse. Easy home management and good patient tolerance were also observed. Discussion: Although this procedure is not the first-line treatment of choice, it is a safe and low-cost technique, which allows the placement of a safe, low-cost enteral feeding route with similar results in areas with scarce economic means like ours.

Cost-effectiveness analysis of medical management versus conservative surgery for early tubal pregnancy.

STUDY QUESTION: Is conservative surgery (laparoscopic salpingotomy) cost-effective, using fertility as the endpoint compared with medical management (Methotrexate) in women with an early tubal pregnancy? SUMMARY ANSWER: Conservative surgery appeared slightly, but not statistically significantly, more effective than medical management but also more costly. WHAT IS KNOWN ALREADY: Women with an early tubal pregnancy treated with medical therapy (Methotrexate) or conservative surgery (laparoscopic salpingotomy) have comparable future intrauterine pregnancy rates by natural conception. Also, cost-minimisation studies have shown that medical therapy was less expensive than conservative surgery, but there is no cost-effectiveness study comparing these two treatments with fertility as the endpoint. STUDY DESIGN, SIZE, DURATION: A multicentre randomised controlled trial-based (DEMETER study) cost-effectiveness analysis of conservative surgery compared with medical therapy in women with an early tubal pregnancy was performed. PARTICIPANTS/MATERIALS, SETTINGS, METHODS: Included women had an ultrasound that confirmed an early tubal pregnancy. They were randomly allocated to conservative surgery or to medical therapy. The study clinical outcome was the intrauterine pregnancy rate. The payer's perspective was considered. Costs of conservative surgery and medical therapy were compared. The analysis was performed according to the intention-to-treat principle. Missing variables were imputed using the fully conditional method. To characterise uncertainty and to provide a summary of it, a non-parametric bootstrap resampling was executed and cost-effectiveness accessibility curves were constructed. MAIN RESULTS AND THE ROLE OF CHANCE: At baseline, costs per woman in the conservative surgery group and in the medical therapy group were 2627€ and 2463€, respectively, with a statistically significant difference of +164€. Conservative surgery resulted in a marginally, but non-significant (P = 0.46), higher future intrauterine pregnancy rate compared to medical therapy (0.700 vs. 0.649); leading, after bootstrap, to an incremental cost-effectiveness ratio of 1299€ (95% CI = -29 252; +29 919). Acceptability curves showed that conservative surgery could be considered a cost-effective treatment at a threshold of 3201€ for one additional future intrauterine pregnancy. LIMITATIONS, REASONS FOR CAUTION: A limitation was that monetary valuation was carried out using 2016 euros while the DEMETER study took place from 2005 to 2009. Anyway, the results would not have been very different given the marginal changes in the health insurance reimbursement tariffs during this period. WIDER IMPLICATIONS OF THE FINDINGS: Conservative surgery can be considered a cost-effective treatment, if the additional cost of 3201€ per additional future intrauterine pregnancy is an acceptable financial effort for the payer. STUDY FUNDING/COMPETING INTEREST(S): None. TRIAL REGISTRATION NUMBER: NCT 00137982.

[Experience in transumbilical endoscopic surgery diagnosis for 3 cases of pseudomyxoma peritonei].

Three patients of pseudomyxoma peritonei who were diagnozed by transumbilical endoscopic surgery (TUES) were reviewed retrospectively from September 2014 to November 2014. Three cases of ascites patients underwent TUES were diagnozed as pseudomyxoma peritonei. All operations were successful. No open surgery or laparoscopic surgery was required. The mean operative time was (45±16) min; the mean intraoperative blood loss was 510 mL; the mean hospital stay time was 3 days. During the follow up of 911 months, no obvious scar was observed. Cosmetic results appear to be excellent. All patients were treated with intraperitoneal hyperthermia and chemotherapy. The survival rate was 100%. As a novel scarless endoscopic invasive abdominal surgery, TUES has high clinical value with the advantages such as small trauma, no scars, small risk and low cost in the diagnosis of unexplained ascites.

A Multidimensional Analysis of Prostate Surgery Costs in the United States: Robotic-Assisted versus Retropubic Radical Prostatectomy.

BACKGROUND: The economic value of robotic-assisted laparoscopic prostatectomy (RALP) in the United States is still not well understood because of limited view analyses. OBJECTIVES: The objective of this study was to examine the costs and benefits of RALP versus retropubic radical prostatectomy from an expanded view, including hospital, payer, and societal perspectives. METHODS: We performed a model-based cost comparison using clinical outcomes obtained from a systematic review of the published literature. Equipment costs were obtained from the manufacturer of the robotic system; other economic model parameters were obtained from government agencies, online resources, commercially available databases, an advisory expert panel, and the literature. Clinical point estimates and care pathways based on National Comprehensive Cancer Network guidelines were used to model costs out to 3 years. Hospital costs and costs incurred for the patients' postdischarge complications, adjuvant and salvage radiation treatment, incontinence and potency treatment, and lost wages during recovery were considered. Robotic system costs were modeled in two ways: as hospital overhead (hospital overhead calculation: RALP-H) and as a function of robotic case volume (robotic amortization calculation: RALP-R). All costs were adjusted to year 2014 US dollars. RESULTS: Because of more favorable clinical outcomes over 3 years, RALP provided hospital ($1094 savings with RALP-H, $341 deficit with RALP-R), payer ($1451), and societal ($1202) economic benefits relative to retropubic radical prostatectomy. CONCLUSIONS: Monte-Carlo probabilistic sensitivity analysis demonstrated a 38% to 99% probability that RALP provides cost savings (depending on the perspective). Higher surgical consumable costs are offset by a decreased hospital stay, lower complication rate, and faster return to work.

[APPLICATION OF MINIINVASIVE INTERVENTIONS UNDER ULTRASONOGRAPHIC CONTROL FOR NONPARASITIC HEPATIC CYSTS].

The results of treatment of 21 patients, suffering nonparasitic hepatic cysts, using laparoscopic draining and puncture under ultrasonographic control, were analyzed. Minimal traumaticity of the intervention, absence of necessity to apply general anesthesia, low rate of postoperative morbidity (7.1%), reduction of duration of the patients stationary treatment down to (3.3 ± 0.61) days, reduction of economic wastes on the treatment constitute the advantages of such method.

Electroacupuncture for postoperative pain and gastrointestinal motility after laparoscopic appendectomy (AcuLap): study protocol for a randomized controlled trial.

BACKGROUND: Acupuncture is a widely serviced complementary medicine. Although acupuncture is suggested for managing postoperative ileus and pain, supporting evidence is weak. The AcuLap trial is designed to provide high-level evidence regarding whether or not electroacupuncture is effective in promoting gastrointestinal motility and controlling pain after laparoscopic surgery. METHODS/DESIGN: This study is a prospective randomized controlled trial with a three-arm, parallel-group structure evaluating the efficacy of electroacupuncture for gastrointestinal motility and postoperative pain after laparoscopic appendectomy. Patients with appendicitis undergoing laparoscopic surgery are included and randomized into three groups: 1) electroacupuncture group, 2) sham acupuncture group, and 3) control group. Patients receive 1) acupuncture with electrostimulation or 2) fake electroacupuncture with sham device twice a day or 3) no acupuncture after laparoscopic appendectomy. The primary outcome is time to first passing flatus after operation. Secondary outcomes include postoperative pain, analgesics, nausea/vomiting, bowel motility, time to tolerable diet, complications, hospital stay, readmission rates, time to recovery, quality of life, medical costs, and protocol failure rate. Patients and hospital staff (physicians and nurses) are blinded to which group the patient is assigned, electroacupuncture or sham acupuncture. Data analysis personnel are blinded to group assignment among all three groups. Estimated sample size to detect a minimum difference of time to first flatus with 80 % power, 5 % significance, and 10 % drop rate is 29 × 3 groups = 87 patients. Analysis will be performed according to the intention-to-treat principle. DISCUSSION: The AcuLap trial will provide evidence on the merits and/or demerits of electroacupuncture for bowel motility recovery and pain relief after laparoscopic appendectomy. TRIAL REGISTRATION: The trial was registered in Clinical Research Information Service (CRiS), Republic of Korea ( KCT0001486 ) on 14 May 2015.

Cost-effectiveness of robotic surgery in gynecologic oncology.

PURPOSE OF REVIEW: Robotically assisted surgeries have flourished in the United States, especially in gynecological procedures. Current robotic systems have high upfront and procedure costs that have led many in the medical community to question the new technology's cost-effectiveness. RECENT FINDINGS: Recent research continues to find that robotically assisted gynecological cancer treatments have comparable outcomes to traditional laparoscopy and similar or better outcomes than that of laparotomy in the cases studied. However, robotic surgery costs remain higher than that of traditional laparoscopy. SUMMARY: Under the current reimbursement climate, practicing physicians and hospitals should collaborate on identifying cost-effective uses of robotic systems and pushing manufacturers to lower purchase and procedure costs to a level that may be accepted by all stakeholders.

Cost-effectiveness of laparoscopic fundoplication versus continued medical management for the treatment of gastro-oesophageal reflux disease based on long-term follow-up of the REFLUX trial.

BACKGROUND: Laparoscopic fundoplication surgery has been shown to be a cost-effective alternative to continued medical management over 1 year for patients with gastro-oesophageal reflux disease (GORD). The longer-term cost-effectiveness is, however, uncertain. This study evaluated the long-term health benefits, costs and cost-effectiveness of laparoscopic fundoplication compared with continued medical management in patients with GORD. METHODS: Individual patient data were used from the 5-year follow-up of the REFLUX trial, a large multicentre, pragmatic, randomized trial in which 357 patients with GORD for at least 12 months at trial entry were allocated randomly to early laparoscopic fundoplication or continued medical management. Health outcomes were expressed in quality-adjusted life-years (QALYs). A UK National Health Service perspective was used for costs. RESULTS: The group randomized to surgery experienced better health outcomes in each year of follow-up, but the difference narrowed over time. At 5 years, the surgery group had experienced 0.216 (95 per cent confidence interval 0.021 to 0.412) more QALYs but also accrued €1832 (1214 to 2448) more costs. The incremental cost-effectiveness ratio was €8481 per QALY gained. The probability that surgery is the most cost-effective intervention was 0.932 at a threshold of €24,134/QALY (£20,000/QALY). Results were robust to most sensitivity analyses, except where patients with missing data randomized to surgery were assumed to have worse health outcomes. CONCLUSION: Laparoscopic fundoplication is a cost-effective alternative to continued medical management over 5 years. No evidence was found to suggest that the cost-effectiveness of laparoscopic fundoplication diminishes over time.

Fast-track pathway for minimally invasive colorectal surgery with and without alvimopan (Entereg)™: which is more cost-effective?

Multimodal fast-track (FT) pathways for both open and laparoscopic colorectal surgery have been shown to improve gastrointestinal recovery, shorten length of stay, and decrease morbidity. The aim of our study was to determine if using alvimopan (Entereg)™ in the setting of a FT minimally invasive colorectal pathway is beneficial and cost-effective. All minimally invasive colorectal surgeries performed by one surgeon using a multimodal FT pathway with and without alvimopan were reviewed. Ninety total patients were identified, 64 patients treated without and 26 with alvimopan. Main outcomes included postoperative day tolerating a soft diet, return of gastrointestinal function, length of stay, 30-day readmission rate, and patient care, anesthesia, pharmacy, and combined cost. Tolerance of a soft diet, return of gastrointestinal function, and length of stay were all shorter and showed significance in the alvimopan group (mean 2.1 vs 2.8 days, mean 1.5 vs 2.4 days, and mean 3.5 vs 4.5 days, respectively) (P = 0.0197, P = 0.0029, and 0.0158, respectively). Patient care and combined hospital costs were both increased in the nonalvimopan group; however, combined hospital costs was not significant (P = 0.0216 and P = 0.0875, respectively). The 30-day readmission rate of 6.3 per cent was also not significant in this group (P = 0.0941). Patients undergoing minimally invasive colorectal surgery treated with a multimodal FT pathway tolerated a soft diet sooner, had earlier return of bowel function, a shorter length of stay, and lower patient care and combined costs when alvimopan was used.

Comparative cost-effectiveness of robot-assisted and standard laparoscopic prostatectomy as alternatives to open radical prostatectomy for treatment of men with localised prostate cancer: a health technology assessment from the perspective of the UK National Health Service.

BACKGROUND: Robot-assisted laparoscopic prostatectomy is increasingly used compared with a standard laparoscopic technique, but it remains uncertain whether potential benefits offset higher costs. OBJECTIVE: To determine the cost-effectiveness of robotic prostatectomy. DESIGN, SETTING, AND PARTICIPANTS: We conducted a care pathway description and model-based cost-utility analysis. We studied men with localised prostate cancer able to undergo either robotic or laparoscopic prostatectomy for cure. We used data from a meta-analysis, other published literature, and costs from the UK National Health Service and commercial sources. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Care received by men for 10 yr following radical prostatectomy was modelled. Clinical events, their effect on quality of life, and associated costs were synthesised assuming 200 procedures were performed annually. RESULTS AND LIMITATIONS: Over 10 yr, robotic prostatectomy was on average (95% confidence interval [CI]) £1412 (€1595) (£1304 [€1473] to £1516 [€1713]) more costly than laparoscopic prostatectomy but more effective with mean (95% CI) gain in quality-adjusted life-years (QALYs) of 0.08 (0.01-0.15). The incremental cost-effectiveness ratio (ICER) was £18 329 (€20 708) with an 80% probability that robotic prostatectomy was cost effective at a threshold of £30 000 (€33 894)/QALY. The ICER was sensitive to the throughput of cases and the relative positive margin rate favouring robotic prostatectomy. CONCLUSIONS: Higher costs of robotic prostatectomy may be offset by modest health gain resulting from lower risk of early harms and positive margin, provided >150 cases are performed each year. Considerable uncertainty persists in the absence of directly comparative randomised data.

Pharmaceutical utilisation and costs before and after bariatric surgery.

OBJECTIVE: To determine whether pharmaceutical utilisation and costs change after bariatric surgery. SUBJECTS: Total population of Australians receiving Medicare-subsidised laparoscopic adjustable gastric banding (LAGB) in 2007 (n=9542). DESIGN: Computerised data linkage with Medicare, Australia's universal tax-funded health insurance scheme. Pharmaceuticals relating to obesity-related disease and postsurgical management were assigned to therapeutic categories and analysed. The mean annual numbers of pharmaceutical prescriptions for each category were compared over the 4-year period from the year before LAGB (2006) to 2 years after LAGB (2009) using utilisation incidence rate ratios (IRRs). RESULTS: The population was mainly female (77.7%) and age was normally distributed with the majority (60.7%) of subjects aged between 35-54 years. Utilisation rates decreased significantly after LAGB in the following therapeutic categories: diabetes (IRR 0.51, IRR 95% CI 0.50-0.53, mean annual cost differences per person $30), cardiovascular (0.81, 0.80-0.82, $29), psychiatric (0.95, 0.93-0.97, $13), rheumatic and inflammatory disorders (0.51, 0.49-0.53, $10) and asthma (0.78, 0.75-0.81, $9). In contrast, significantly greater utilisation was observed in the pain (1.28, 1.23-1.32, $12), gastrointestinal tract disorder (1.04, 1.02-1.07, $5) and anaemia/vitamins (2.34, 2.01-2.73, $4) therapeutic categories. When the defined categories were combined, a net reduction in pharmaceutical utilisation was observed, from 10.5 to 9.6 pharmaceuticals prescribed per person/year, and costs decreased from $AUD517 to $AUD435 per year in 2009 prices. CONCLUSION: Relative to the year before LAGB, overall pharmaceutical utilisation was reduced in the 2 years after the year of LAGB surgery, demonstrating that bariatric surgery can lead to reductions in pharmaceutical utilisation in the 'real world' setting. The greatest absolute cost reductions were observed in the therapies to treat diabetes and cardiovascular disease.

Comparisons of perioperative outcomes and costs between open and laparoscopic radical prostatectomy: a propensity-score matching analysis based on the Japanese Diagnosis Procedure Combination database.

We compared perioperative outcomes and costs between open and laparoscopic radical prostatectomy for prostate cancer. The Japanese Diagnosis Procedure Combination database, including cases from 2007 to 2010, was used by one-to-one propensity-score matching. The following items were compared: complication rate; homologous and autologous transfusion rate; first cystography day and cystography repeat rate; anesthesia time; postoperative length of stay; and costs. Multivariate analyses were carried out by including age, Charlson Comorbidity Index, T stage, hospital volume and hospital academic status as variables. As a result, among 15 616 open and 1997 laparoscopic radical prostatectomies, 1627 propensity-score matched pairs were generated. The laparoscopic approach showed a better overall complication rate (3.4% vs 5.0%), homologous transfusion rate (3.3% vs 9.2%), autologous transfusion rate (44.9% vs 79.3%), first cystography day (mean 6th vs 7th day), mean postoperative length of stay (mean 11 vs 13 days), and cost without surgery and anesthesia (mean $7965 vs $9235; all P < 0.001). Anesthesia time was longer (mean 345 vs 285 min) and total cost was higher (mean $14 980 vs $12 356) for the laparoscopic approach (both P < 0.001). The secondary cystography rates were comparable between the groups (18.3% vs 15.7%, P = 0.144). The multivariate analyses showed similar trends. In conclusion, these findings confirm several benefits of laparoscopy over open approach for radical prostatectomy.

Robot-assisted minimally invasive thoraco-laparoscopic esophagectomy versus open transthoracic esophagectomy for resectable esophageal cancer, a randomized controlled trial (ROBOT trial).

BACKGROUND: For esophageal cancer patients, radical esophagolymphadenectomy is the cornerstone of multimodality treatment with curative intent. Transthoracic esophagectomy is the preferred surgical approach worldwide allowing for en-bloc resection of the tumor with the surrounding lymph nodes. However, the percentage of cardiopulmonary complications associated with the transthoracic approach is high (50 to 70%).Recent studies have shown that robot-assisted minimally invasive thoraco-laparoscopic esophagectomy (RATE) is at least equivalent to the open transthoracic approach for esophageal cancer in terms of short-term oncological outcomes. RATE was accompanied with reduced blood loss, shorter ICU stay and improved lymph node retrieval compared with open esophagectomy, and the pulmonary complication rate, hospital stay and perioperative mortality were comparable. The objective is to evaluate the efficacy, risks, quality of life and cost-effectiveness of RATE as an alternative to open transthoracic esophagectomy for treatment of esophageal cancer. METHODS/DESIGN: This is an investigator-initiated and investigator-driven monocenter randomized controlled parallel-group, superiority trial. All adult patients (age ≥ 18 and ≤ 80 years) with histologically proven, surgically resectable (cT1-4a, N0-3, M0) esophageal carcinoma of the intrathoracic esophagus and with European Clinical Oncology Group performance status 0, 1 or 2 will be assessed for eligibility and included after obtaining informed consent. Patients (n = 112) with resectable esophageal cancer are randomized in the outpatient department to either RATE (n = 56) or open three-stage transthoracic esophageal resection (n = 56). The primary outcome of this study is the percentage of overall complications (grade 2 and higher) as stated by the modified Clavien-Dindo classification of surgical complications. DISCUSSION: This is the first randomized controlled trial designed to compare RATE with open transthoracic esophagectomy as surgical treatment for resectable esophageal cancer. If our hypothesis is proven correct, RATE will result in a lower percentage of postoperative complications, lower blood loss, and shorter hospital stay, but with at least similar oncologic outcomes and better postoperative quality of life compared with open transthoracic esophagectomy. The study started in January 2012. Follow-up will be 5 years. Short-term results will be analyzed and published after discharge of the last randomized patient. TRIAL REGISTRATION: Dutch trial register: NTR3291 ClinicalTrial.gov: NCT01544790.

[Introduction of interdisciplinary prostate cancer centers based on the recommendations of the German Cancer Society. A cost-benefit analysis 3 years after accreditation]. / Etablierung von interdisziplinären Prostatakrebszentren nach den Empfehlungen der DKG. Eine Kosten-Nutzen-Analyse 3 Jahre nach Zertifizierung.

The introduction of prostate cancer treatment centers according to the criteria of the German Cancer Society ("Deutsche Krebsgesellschaft", DKG) aims at improving the quality of care for patients with prostate cancer. Systematic analyses of the effects and costs are lacking as yet. Three years after certification of the Interdisciplinary Prostate Cancer Center at the Charité Hospital Berlin we observed a decrease in the rate of positive surgical margins (tumor stage pT2), but other parameters of treatment quality including patient satisfaction remained unchanged. A survey among urologists of the region showed a high acceptance of prostate cancer centers in general. The majority of participating urologists appreciated the work of the Charité center, in particular the treatment recommendations given by the center were mostly followed and the majority of urologists regularly use educational activities of the center. However, only 30% of the participating urologists confirmed short-term improvements in the quality of patient care. Yearly additional costs for the Charité prostate cancer center are estimated at 205,000 euro (precertification phase and certification) and 138,000 euro (monitoring phase), despite the initial drop in mean treatment costs per case (radical prostatectomy). The introduction of prostate cancer treatment centers certified by the DKG is cost intensive, increases in treatment efficiency notwithstanding. Short-term improvements in quality of care cannot be unequivocally demonstrated. Prostate cancer centers serve an important role in counseling and medical education and may thus help disseminate evidence-based treatment strategies.

[Diagnosis of acute appendicitis over two decades - effects of increasing number of imaging procedures on costs, preoperative reliability and patient outcome]. / Diagnostik der akuten Appendizitis im Verlauf von 2 Jahrzehnten - Auswirkungen der bildgebenden Verfahren auf präoperative Diagnosesicherung, Kosten und Patientenoutcome.

BACKGROUND: An increasing number of modern imaging procedures are being applied for the diagnosis of appendicitis. We compared one hundred consecutive appendectomies of the years 1988, 1998 and 2008 concerning reliability of preoperative diagnosis and resulting costs. METHODS: We analysed the first one hundred consecutive patients undergoing appendectomy during the years 1988, 1998 and 2008, 59 % were female and 41 % male. The average age was 26 years, the average BMI 21.09. The costs and results of radiological investigations (US, CT, MRI, X-ray) have been compared in all patients. The sensitivity of ultrasound and CT scan in preoperative diagnosis has been analysed. RESULTS: The number of preoperative imaging procedures for the diagnosis of appendicitis has increased over the last two decades. Simultaneously increased the costs (total costs and costs per partient) for imaging procedures. 2008 the costs were 10 times higher than 1988. CT had a higher sensitivity (77 %) in the diagnosis of appendicitis than ultrasound (33 %). The number of operations because of subacute and chronic appendicitis was lower in 2008 (34 of 100) compared with 1988 (80 of 100) and 1998 (60 of 100). In 2008 (14) we found a higher number of gangrenous and perforated appendicitis compared to 1988 (2) and 1998 (5). The majority (50 of 100) of patients in the group with acute and phlegmonous appendicitis was found in 2008. CONCLUSION: There has been an increase in the use of preoperative imaging procedures in the diagnosis of appendicitis during the last 20 years. This causes more costs in the public health system. Ultrasound as the standard imaging method for diagnosing appendicitis showed poor sensitivity. CT scans had good results concerning sensitivity, but are expensive and involve exposure to radiation for the patient.

Transumbilical laparoscopically assisted appendectomy: an alternative minimally invasive technique in pediatric patients.

INTRODUCTION: Transumbilical laparoscopically assisted appendectomy (TULAA) has been reported in the literature as an alternative to traditional three-port laparoscopic appendectomy (LA). Our study compares outcomes between LA and the one-trocar transumbilical technique in a single institution over a concurrent time frame for all cases of pediatric appendicitis. METHODS: An Institutional Review Board-approved retrospective chart review of all appendectomies from July 2007 through June 2009 was performed. All appendectomies were performed either laparoscopically or transumbilically. One surgeon predominantly used the TULAA method, whereas the other 2 surgeons used strictly the LA method. No cases were converted to open. Categorization of specimens as normal, acute, or ruptured was based on pathology reports. Outcomes analyzed for each group included surgical duration, cost, length of stay, fever (>101.5F), wound infection, ileus, and postoperative abdominal-pelvic abscess. RESULTS: A total of 131 appendectomies were performed by 3 surgeons, 83 were LA and 48 were TULAA. For all stages of appendicitis, outcomes differed significantly only for operating room cost, with the TULAA being significantly less expensive. All other outcomes were similar between the two techniques. CONCLUSION: Our study suggests that TULAA is a reasonable alternative to the standard minimally invasive technique for appendicitis in both acute and ruptured situations. All analyzed complications were similar between the groups, suggesting that TULAA is an acceptable surgical method in pediatric patients for all stages of appendicitis.

Laparoscopic diaphragm pacing for tetraplegia.

(1) The NeuRx DPS is a laparoscopically implanted device that provides ventilatory support. (2) This device stimulates the diaphragm muscle, rather than the phrenic nerve, and is intended to lead to less risk of nerve damage than other therapies.(3) This technology provides an alternative to mechanical ventilation, and allows patients to increase day-to-day freedom and minimize the risk of respiratory infection. (4) The NeuRx DPS safety profile is based on clinical testing, which began with clinical trials starting in 2000. It has the potential to reduce costs, but this has not been well established.

Impact of clinical pathways in surgery.

BACKGROUND: One strategy to reduce the consumption of resources associated to specific procedures is to utilize clinical pathways, in which surgical care is standardized and preset by determination of perioperative in-hospital processes. The aim of this prospective study was to establish the impact of clinical pathways on costs, complication rates, and nursing activities. METHOD: Data was prospectively collected for 171 consecutive patients undergoing laparoscopic cholecystectomy (n = 50), open herniorrhaphy (n = 56), and laparoscopic Roux-en-Y gastric bypass (n = 65). RESULTS: Clinical pathways reduced the postoperative hospital stay by 28% from a mean of 6.1 to 4.4 days (p < 0.001), while the 30-day readmission rate remained unchanged (0.5% vs. 0.45%). Total mean costs per case were reduced by 25% from euro 6,390 to euro 4,800 (p < 0.001). Costs for diagnostic tests were reduced by 33% (p < 0.001). Nursing hours decreased, reducing nursing costs by 24% from euro 1,810 to euro 1,374 (p < 0.001). A trend was noted for lower postoperative complication rates in the clinical pathway group (7% vs. 14%, p = 0.07). CONCLUSIONS: This study demonstrates clinically and economically relevant benefits for the utilization of clinical pathways with a reduction in use of all resource types, without any negative impact on the rate of complications or re-hospitalization.