Laparoscopic versus open subtotal gastrectomy for gastric adenocarcinoma: cost-effectiveness analysis.

BACKGROUND: Laparoscopic subtotal gastrectomy (LSG) for cancer is associated with good perioperative outcomes and superior quality of life compared with the open approach, albeit at higher cost. An economic evaluation was conducted to compare the two approaches. METHODS: A cost-effectiveness analysis between LSG and open subtotal gastrectomy (OSG) for gastric cancer was performed using a decision-tree cohort model with a healthcare system perspective and a 12-month time horizon. Model inputs were informed by a meta-analysis of relevant literature, with costs represented in 2016 Canadian dollars (CAD) and outcomes measured in quality-adjusted life-years (QALYs). A secondary analysis was conducted using inputs extracted solely from European and North American studies. Deterministic (DSA) and probabilistic (PSA) sensitivity analyses were performed. RESULTS: In the base-case model, costs of LSG were $935 (€565) greater than those of OSG, with an incremental gain of 0·050 QALYs, resulting in an incremental cost-effectiveness ratio of $18 846 (€11 398) per additional QALY gained from LSG. In the DSA, results were most sensitive to changes in postoperative utility, operating theatre and equipment costs, as well as duration of surgery and hospital stay. PSA showed that the likelihood of LSG being cost-effective at willingness-to-pay thresholds of $50 000 (€30 240) per QALY and $100 000 (€60 480) per QALY was 64 and 68 per cent respectively. Secondary analysis using European and North American clinical inputs resulted in LSG being dominant (cheaper and more effective) over OSG, largely due to reduced length of stay after LSG. CONCLUSION: In this decision analysis model, LSG was cost-effective compared with OSG for gastric cancer.

ANTECEDENTES: Pese a su mayor coste, la gastrectomía subtotal laparoscópica se asocia con buenos resultados perioperatorios y una mejor calidad de vida en comparación con la cirugía abierta en el tratamiento del cáncer. Se realizó una evaluación económica comparando los dos abordajes. MÉTODOS: Se efectuó un análisis de coste-efectividad de la gastrectomía subtotal laparoscópica (laparoscopic subtotal gastrectomy, LSG) o de la gastrectomía subtotal abierta (open subtotal gastrectomy, OSG) en el cáncer gástrico utilizando un modelo de cohortes con árbol de decisión desde la perspectiva del sistema de salud y con un horizonte temporal de 12 meses. Los gastos del modelo fueron evaluados tras un metaanálisis de literatura relevante y expresados en dólares canadienses (Canadian dollars, CAD) del 2016. Los resultados se midieron en años de vida ajustados por su calidad (quality-adjusted life years, QALYs). Se realizó un análisis secundario utilizando los datos extraídos únicamente de estudios europeos y norteamericanos. Además, se realizaron análisis de sensibilidad determinístico y probabilístico (deterministic and probabilistic sensitivity analyses, DSA y PSA). RESULTADOS: En el modelo del caso base, los costes de la LSG fueron de 934,78$ (565€) más que en la OSG, con una ganancia incremental de 0,050 QALYs, que supuso una relación coste-efectividad incremental (incremental cost-effectiveness ratio, ICER) de 18.846,12$ (11.398€) por QALY adicional en la LSG. En el DSA, los resultados fueron más sensibles a cambios en el postoperatorio, quirófano y coste de los equipos, así como en la duración de la intervención y la hospitalización. El PSA demostró que la probabilidad de que la LSG fuera rentable en términos de disposición de pago (willingness-to-pay, WTP) para dos umbrales, de 50.000$ (30.240€) y 100.000$ (60.480€) por QALY fue del 64% y del 68%, respectivamente. En el análisis secundario utilizando los datos europeos y norteamericanos se demostró que la LSG era claramente dominante (más barata y más efectiva) que la OSG, en gran parte debido a la reducción de la estancia hospitalaria de la LSG. CONCLUSIÓN: En este modelo de análisis de decisión, la LSG fue coste-efectiva en comparación con la OSG para el cáncer gástrico.

[Contrast sensitivity and diabetes]. / Sensibilité au contraste et diabète.

Contrast sensitivity has been assessed in 24 diabetic patients in order to test the hypothesis that contrast sensitivity is impaired in the early stages of diabetes mellitus. All patients had 20/20 vision. Some evidence of visual dysfunction was observed in 33% of the diabetics with no retinopathy and 83% of the 6 patients with retinopathy when compared to 48 age-matched controls. Contrast sensitivity was mainly reduced in the mid-range spatial frequencies and correlated with the degree of retinopathy. The accurate assessment of visual dysfunction in diabetes is very important, as new drugs (i.e. aldose reductase inhibitors) are currently under evaluation.

[Atypical tapetoretinal degeneration simulating a neurologic syndrome]. / Dégénérescence tapéto-rétinienne atypique simulant un syndrome neurologique.

We report the case of a 57-year-old woman with progressive bilateral visual acuity loss, presumed during ten years to be secondary to a neurological disease. Ophthalmological examination showed for both eyes pallor of the optic discs and arteriolar narrowing. Periphery was normal, without pigment clumping. Fluorescein angiography showed a widespread irregular hypopigmentation and discovered a bilateral macular edema. Abnormal rod function was confirmed by electroretinography. A review of the literature data shows the variety of clinical symptoms in patients with retinitis pigmentosa and the frequency of atypical non-pigmented forms. Those forms are usually considered as early stages of the disease. Besides, macular lesions, and macular edema in particular, are frequently reported.

[Vitreous hemorrhage and neovascular proliferation in multiple sclerosis]. / Hémorragie vitréenne et prolifération néo-vasculaire au cours d'une sclérose en plaques.

We report the case of a 40 year-old man with multiple sclerosis, who presented a bilateral proliferative retinopathy responsible for a vitreous hemorrhage. Examination of the periphery of the retina showed diffuse retinal periphlebitis; fluorescein angiograms showed a peripheral retinal ischemic syndrome with secondary neovascularization. Several recent studies have show that retinal periphlebitis is a frequent finding in multiple sclerosis; but to our knowledge a retinal ischemic syndrome with neovascularization has seldom been reported.

[Trabeculectomy. Long-term retrospective study]. / Trabéculectomie. Etude rétrospective à long terme.

Long term follow up of 51 eyes treated by trabeculectomy between 1975 and 1978. The pressure remains below 20 mmHg in 94% of our cases and progression field loss is stopped in 60%. The control of pressure needs adjunction of a medical treatment in 47% of cases. Progression of glaucomatous field loss is stopped when the ocular pressure is very low (40% or more of initial pressure). Cataract is seen in oldest patients. These observations suggest that: glaucoma surgery must give a sufficient drop of ocular pressure in all cases with pressure between 15 and 20 adjuvant medical therapy is useful old patients are a poor material for glaucoma surgery.

[Multifocal inner choroiditis: pseudohistoplasmosis. The European form of the presumed American histoplasmosis]. / Choroïdite multifocale interne: pseudohistoplasmose. Forme européenne de l'histoplasmose présumée américaine.

We studied nine patients with the picture of presumed ocular histoplasmosis. All patients had the characteristic triad: punched out peripheral lesions, peripapillary atrophic scar and disciform process in the posterior pole. All patients had negative test for histoplasmosis (electrosyneresis). Four patients were observed for a long period (8, 8, 7 and 4 years). In two cases we could observe the first step of the basic choroidal lesions. One of these patients fundus was previously normal. Age, female to male ratio and in one case mild inflammatory lesions were similar to a new entity: multifocal choroiditis. The cause of European disseminated inner choroiditis remains unknown. There may be one or multiple causative agents including unidentified fungus.