Costos de las diversas modalidades posoperatorias de la colecistectomía laparoscópica. Cooperativa Médica de Florida (COMEF), 2016-2021 / Cost effectivenes of the different postoperative management modalities in laparoscopic cholecystectomy Florida Medical Cooperative (COMEF) 2016-2021 / Custos das várias modalidades pós-operatórias do colecistectomia laparoscópica. Cooperativa Médica da Flórida (COMEF). 2016-2021

Introducción: la colecistectomía laparoscópica constituye el patrón oro en el tratamiento de la litiasis biliar. Bajo una estricta selección de pacientes, la modalidad ambulatoria ha demostrado ser factible y segura. En COMEF se realiza desde el año 2016. El posoperatorio transcurrió por diferentes etapas, internación en cuidados moderados, internación en sala de cirugía del día más internación domiciliaria, internación únicamente en sala de cirugía del día y finalmente alta domiciliaria desde block quirúrgico. El objetivo del trabajo es calcular los costos de cada una de las modalidades posoperatorias de la colecistectomía laparoscópica en el período 2016-2021. Materiales y método: se realizó un estudio de costos de cada una de las modalidades posoperatorias mediante la determinación del costo del día cama ocupada en cuidados moderados e internación domiciliaria, así como la retribución de un auxiliar de enfermería encargado de la sala de cirugía del día. Los datos fueron obtenidos de la Estructura de Costos de Atención a la Salud y la producción de cada servicio. Resultados: el costo del día cama ocupada en cuidados moderados es de $15.056, el de internación en sala de cirugía del día y luego internación domiciliaria $4.953,69, únicamente en sala de cirugía del día $807,69 y finalmente el alta domiciliaria desde block quirúrgico $33. Conclusiones: los costos del posoperatorio de la colecistectomía laparoscópica en modalidad ambulatoria son menores que los que requieren internación en cuidados moderados, y dichos costos se reducen progresivamente cuando se pasa de la internación domiciliaria al alta sin internación domiciliaria y sin recuperación en sala de cirugía del día.

Introduction: laparoscopic cholecystectomy constitutes the gold standard to treat gallstones. Ambulatory treatment has proved to be feasible and safe for carefully selected patients. At COMEF, laparoscopic cholecystectomies have been performed since 2016, and postoperative management has covered different stages: intermediate care during hospitalization, admission in day surgery units plus home care or home admissions, hospitalization in day surgery units and discharge directly after surgery, directly from the ER. The study aims to calculate the cost of each one of the different postoperative management modalities for laparoscopic cholecystectomies between 2016 and 2021. Method: a cost study was conducted for each one of the postoperative management modalities by calculating the cost of the hospital bed day in intermediate care and house care, as well as the salary of the nurses' staff at the day surgery unit. Data was obtained from the Healthcare Services Cost Structure and the production of each one of the services mentioned. Results: the daily bed day cost in intermediate care is $ 15,056, the daily cost of day surgery unit plus home care afterwards is $ 4,953.69, the cost of surgery admission in the day surgery unit is $ 807.69 and discharge directly from the OR is $ 33. Conclusions: the postoperative cost of ambulatory laparoscopic cholecystectomy is lower than that requiring interaction in intermediate care and these costs are progressively reduced when moving from home care with and without interaction upon discharge towards no recovery in the day surgery unit.

Introdução: a colecistectomia laparoscópica é o padrão ouro no tratamento da litíase biliar. Com uma rigorosa seleção de pacientes, a modalidade ambulatorial tem se mostrado viável e segura. Na COMEF é realizada desde 2016, com o pós-operatório passando por diferentes etapas: internação em cuidados moderados, internação na sala de cirurgia do dia mais internação domiciliar, internação apenas na sala de cirurgia no dia e finalmente alta domiciliar do bloco cirúrgico. Objetivo: calcular os custos de cada uma das modalidades pós-operatórias de colecistectomia laparoscópica no período 2016-2021. Materiais e método: foi realizado um estudo dos custos de cada uma das modalidades pós-operatórias determinando o custo do dia de leito ocupado em cuidados moderados e internação atendimento domiciliar, bem como a remuneração de um auxiliar de enfermagem responsável pela cirurgia do dia. Os dados foram obtidos da Estrutura de Custos de Assistência à Saúde e da produção de cada serviço. Resultados: o custo do leito de dia ocupado em cuidados moderados, em é de $ 15.056, a hospitalização na sala de cirurgia de dia e depois internação domiciliar $ 4.953,69, apenas na sala da cirurgia de dia $ 807,69 e finalmente alta domiciliar do bloco cirúrgico $ 33 (valores em pesos uruguaios). Conclusões: os custos pós-operatórios da colecistectomia laparoscópica na modalidade ambulatorial são menores do que aqueles que requerem interação em cuidados moderados e são progressivamente reduzidos quando passa da internação em casa à alta sem interação em casa e sem recuperação na sala de cirurgia no dia.

One-step versus two-step procedure for management procedures for management of concurrent gallbladder and common bile duct stones. Outcomes and cost analysis.

BACKGROUND: The management of cholelithiasis and choledocholithiasis combined is controversial. The more frequent approach is a two-stage procedure, with endoscopic sphincterotomy and stone removal from the bile duct followed by laparoscopic cholecystectomy. This study aims to demonstrate how, on the basis of the personal experience, the Rendez-vous technique, that combines the two techniques in a single-stage operation is better than the sequential treatment. METHODS: Between June 2017 to December 2019, 40 consecutive patients with cholelithiasis and choledocholithiasis combined were enrolled for the study: 20 were treated with the sequential treatment and 20 with the Rendez-vous method. The preoperative diagnostic work-up was similar in the two group. The endpoints of the study included incidence of endoscopic and surgical complications, rate of hospitalization and cost analysis. RESULTS: The study showed no difference in demographic parameters between the two groups, but the success rate of clearance of CBD was significantly smaller for sequential arm, with the need of additional procedures. We found a statistical reduction of postoperative acute pancreatitis, hospital stay and charges in Rendez-vous group, at the expense of a prolonged total operating time. CONCLUSIONS: The data of the study confirm the superiority of the Rendez-vous technique because it resolves cholelithiasis associated with choledocholithiasis in a single surgical act, with greater acceptance of the patient who avoids a second invasive surgical act, and with a reduction in complications; moreover, it requires shorter hospitalization, resulting in reduced costs. We propose this option in the management of cases where preoperative ERCP-ES has failed. KEY WORDS: Common bile duct stones, Cholecysto-choledocholithiasis, Endoscopic retrograde cholangiopancreatography, Endoscopic sphincterotomy, Laparoscopic cholecystectomy, Laparo-endoscopic Rendez-vous.

Safety and feasibility of prolonged versus early laparoscopic cholecystectomy for acute cholecystitis: a single-center retrospective study.

BACKGROUND: Laparoscopic cholecystectomy (LC) is the standard treatment for acute cholecystitis (AC), and it should be performed within 72 h of symptoms onset if possible. In many undesired situations, LC was performed beyond the golden 72 h. However, the safety and feasibility of prolonged LC (i.e., performed more than 72 h after symptoms onset) are largely unknown, and therefore were investigated in this study. METHODS: We retrospectively enrolled the adult patients who were diagnosed as AC and were treated with LC at the same admission between January 2015 and October 2018 in an emergency department of a tertiary academic medical center in China. The primary outcome was the rate and severity of adverse events, while the secondary outcomes were length of hospital stay and costs. RESULTS: Among the 104 qualified patients, 70 (67.3%) underwent prolonged LC and 34 (32.7%) underwent early LC (< 72 h of symptom onset). There were no differences between the two groups in mortality rate (none for both), conversion rates (prolonged LC 5.4%, and early LC 8.8%, P = 0.68), intraoperative and postoperative complications (prolonged LC 5.7% and early LC 2.9%, P ≥ 0.99), operation time (prolonged LC 193.5 min and early LC 198.0 min, P = 0.81), and operation costs (prolonged LC 8,700 Yuan, and early LC 8,500 Yuan, P = 0.86). However, the prolonged LC was associated with longer postoperative hospitalization (7.0 days versus 6.0 days, P = 0.03), longer total hospital stay (11.0 days versus 8.0 days, P < 0.01), and subsequently higher total costs (40,400 Yuan versus 31,100 Yuan, P < 0.01). CONCLUSIONS: Prolonged LC is safe and feasible for patients with AC for having similar rates and severity of adverse events as early LC, but it is also associated with longer hospital stay and subsequently higher total cost.

Variation in Intraoperative and Postoperative Utilization for 3 Common General Surgery Procedures.

OBJECTIVE: The aim of this study was to understand variation in intraoperative and postoperative utilization for common general surgery procedures. SUMMARY BACKGROUND DATA: Reducing surgical costs is paramount to the viability of hospitals. METHODS: Retrospective analysis of electronic health record data for 7762 operations from 2 health systems. Adult patients undergoing laparoscopic cholecystectomy, appendectomy, and inguinal/femoral hernia repair between November 1, 2013 and November 30, 2017 were reviewed for 3 utilization measures: intraoperative disposable supply costs, procedure time, and postoperative length of stay (LOS). Crossed hierarchical regression models were fit to understand case-mixed adjusted variation in utilization across surgeons and locations and to rank surgeons. RESULTS: The number of surgeons performing each type of operation ranged from 20 to 63. The variation explained by surgeons ranged from 8.9% to 38.2% for supply costs, from 15.1% to 54.6% for procedure time, and from 1.3% to 7.0% for postoperative LOS. The variation explained by location ranged from 12.1% to 26.3% for supply costs, from 0.2% to 2.5% for procedure time, and from 0.0% to 31.8% for postoperative LOS. There was a positive correlation (ρ = 0.49, P = 0.03) between surgeons' higher supply costs and longer procedure times for hernia repair, but there was no correlation between other utilization measures for hernia repair and no correlation between any of the utilization measures for laparoscopic appendectomy or cholecystectomy. CONCLUSIONS: Surgeons are significant drivers of variation in surgical supply costs and procedure time, but much less so for postoperative LOS. Intraoperative and postoperative utilization profiles can be generated for individual surgeons and may be an important tool for reducing surgical costs.

Cost difference of enhanced recovery after surgery pathway vs. Conventional care In Elective Laparoscopic Cholecystectomy.

BACKGROUND: Enhanced recovery after surgery (ERAS) is a perioperative bundle aimed to reduce surgical stress. Significant reductions in length of hospital stay and associated costs have been reported in multiple studies in all surgical specialties. Purpose of the study was to compare the effect of Enhanced recovery protocols vs. conventional care on perioperative length of hospital stay and cost per patient in a government funded hospital. METHODS: this randomized controlled trial was conducted in the department of General Surgery, unit B, Lady reading hospital, Peshawar from April to December 2018. One hundred and fifty patients were selected based on consecutive sampling. Random allocation into two groups of 75 (ERAS vs Conventional) was done based on computer generated numbers. Length of hospital stay and total direct costs were calculated. Frequency of Surgical site infections, readmissions and mortality was also recorded. Patient reported outcomes were recorded by Surgical Recovery Scale SRS. RESULTS: Patients in the Enhanced recovery group showed a significant reduction in length of hospital stay 28.9 hours in ERAS group vs 40.5 hours in Conventional care group (p<0.001). Total per patient cost was reduced in the ERAS group PKR 6804 in comparison to the conventional care PKR 7682 (p<0.001). Patient reported outcomes measured on Surgical Recovery Scale SRS on discharge, day 3 of discharge and day 10 of discharge showed no significant difference between the two groups. CONCLUSIONS: Enhanced recovery protocols demonstrated a reduction in length of perioperative hospital stay and total cost despite similar post discharge recovery scores on Surgical Recovery Scale SRS and no increase in readmissions.

National trends and outcomes of inpatient robotic-assisted versus laparoscopic cholecystectomy.

BACKGROUND: Laparoscopic cholecystectomy has reached nearly universal adoption in the management of gallstone-related disease. With advances in operative technology, robotic-assisted cholecystectomy has been used increasingly in many practices, but few studies have examined the adoption of robotic assistance for inpatient cholecystectomy and the temporal outcomes on a national scale. The present study aimed to identify trends in utilization, as well as outcomes and factors associated with the use of robotic-assisted cholecystectomy. METHODS: The 2008 to 2017 database of the National Inpatient Sample was used to identify patients undergoing inpatient cholecystectomy. Independent predictors of the use of robotic assistance for cholecystectomy were identified using multivariable logistic regression adjusting for patient and hospital characteristics. RESULTS: Of an estimated 3,193,697 patients undergoing cholecystectomy, 98.7% underwent laparoscopic cholecystectomy and 1.3% robotic-assisted cholecystectomy. Rates of robotic-assisted cholecystectomy increased from 0.02% in 2008 to 3.2% in 2017 (nptrend < .001). Compared with laparoscopic cholecystectomy, patients undergoing robotic-assisted cholecystectomy had a greater burden of comorbidities as measured by the Elixhauser index (2.2 vs 1.9, P < .001). Although mortality rates were similar, robotic-assisted cholecystectomy was associated with greater complication rates (15.5% vs 11.7%, P < .001), most notably gastrointestinal-related complications (3.7% vs 1.5%, P < .001). On multivariable regression, robotic-assisted cholecystectomy was associated with increased costs of hospitalization (ß: $2,398, P < .001). CONCLUSION: Using the largest national database available, we found a dramatic increase in the use of robotic-assisted cholecystectomy with no difference in mortality or duration of hospital stay, but there was a statistically significant increase in complications and costs. These findings warrant further investigation.

Achieving Surgical Supply Savings through Preference Card Standardization.

Among high volume procedures considerable variation exists in the average cost per case (ACPC) of surgical supplies used between surgeons. A contributing factor to these cost differences are divergences in surgeons' preference cards, which act as a guide to hospital staff for the supplies a surgeon requires to successfully perform a procedure. This article documents efforts and results of an initiative to standardize preference cards for Laparoscopic Cholecystectomies. Data collected for this project outlined differences between surgeon's preference card composition, utilization of selected supplies and associated procedure costs. Reports were developed that grouped surgical supplies based on United Nations Standard Products and Services Code (UNSPC) product classes and highlighted classes with the highest per case standard deviations. Based on these findings and feedback from clinical partners, a composite set of supplies for use across all preference cards was developed in conjunction with the Chief of General Surgery. The net result of moving to a standardized set of supplies was an estimated $21,650 in annual supply expenses associated with Laparoscopic Cholecystectomies. Results suggest that standard deviation-based reports organized by product class facilitate effective surgeon-to-surgeon comparisons and make apparent readily available supply substitutes that are less expensive.

Normalization of Serum Lipase Levels Versus Resolution of Abdominal Pain: A Comparison of Preoperative Management in Children With Biliary Pancreatitis.

BACKGROUND: Controversy exists over the timing of cholecystectomy for biliary pancreatitis in children. Some surgeons await normalization of serum lipase levels while others are guided by resolution of abdominal pain; however, there are minimal data to support either practice. We hypothesized that resolution of abdominal pain is equivalent in outcome to awaiting normalization of lipase levels in patients undergoing cholecystectomy for biliary pancreatitis. METHODS: After institutional review board (IRB) approval, the medical record was retrospectively queried for all cases of cholecystectomy for biliary pancreatitis at our institution from 2007 to 2017. Patients undergoing chemotherapy, admitted for another cause, or who had severe underlying comorbidities like ventilator dependence were excluded. Patients were stratified into two cohorts: those managed preoperatively by normalization of serum lipase levels versus resolution of abdominal pain. Demographics, serum lipase levels, postoperative complications, cost of stay, readmissions, and return to the emergency department were collected and analyzed using multivariate regression. RESULTS: Seventy-four patients met inclusion: 29 patients had lipase levels trended until normalization compared with 45 patients who had resolution of abdominal pain prior to cholecystectomy. Among the two cohorts there was no statistical difference in age, gender, race, ethnicity, or type of preoperative imaging used. Trended patients were found to have more serum lipase levels tested (8.5 ± 6.2 versus 3.4 ± 2.5, P < 0.0001). The trended lipase cohort was significantly more likely to require preoperative total parenteral nutrition (48% versus 11%, P = 0.007) and consequently a longer time before resuming a diet (10 ± 7.3 versus 4.6 ± 2.4 d, P < 0.0001). When comparing the two groups, we found no significant difference in the duration of surgery, postoperative complications, or readmissions. Lipase trended patients had a significantly longer length of stay compared with nontrended patients (11.5 ± 8.1 versus 4.2 ± 2.3 d, P < 0.0001) and had a higher total cost of stay ($38,094 ± 25,910 versus $20,205 ± 5918, P = 0.0007). CONCLUSIONS: Our data suggest that in children with biliary pancreatitis, proceeding with cholecystectomy after resolution of abdominal pain is equivalent in outcomes to trending serum lipase levels but is more cost-effective with a decreased length of stay and decreased need for preoperative total parenteral nutrition.

Early vs. Delayed Laparoscopic Cholecystectomy for Acute Cholecystitis - Single Center Experience.

INTRODUCTION: Laparoscopic cholecystectomy is now considered the procedure of choice that achieves a shorter recovery period after the surgery and reduction in the cost of treatment. Aim: The aim of the study is to prove which method: early or delayed laparoscopic cholecystectomy is the method of choice in the treatment of acute cholecystitis by examining: duration of hospitalization, conversion rate, duration of surgery, postoperative complications, and total cost. METHODS: The study was conducted at the University Clinical Center of Republika Srpska as a retrospective-prospective study from May 1st 2013 until December 31st 2019. Patients diagnosed with acute cholecystitis were divided into two groups: Patients designated for early laparoscopic cholecystectomy within 72 hours of admission (group A-42 patients), Patients designated for initial conservative treatment followed by a delayed interval of 6-12 weeks until surgery (group B-42 patients). RESULTS: In both groups, there were statistically significantly more female respondents. The results showed that the average cost of treatment in the early treated group was statistically significantly lower than the cost of treatment in the delayed treatment group. The patients in the early group had shorter hospitalization times (an average of 2.8 days and 5.6 days in the delayed group of patients), a smaller percentage of conversions (4.8% in the early and 16.7 in the delayed group of patients), the total cost of in the early group it was 1300.83 KM, while in the delayed group it was 1645.43 KM. CONCLUSION: Early laparoscopic cholecystectomy is a method to be preferred in surgical treatment.

Benchmarking the value of care: Variability in hospital costs for common operations and its association with procedure volume.

BACKGROUND: Efforts to improve health care value (quality/cost) have become a priority in the United States. Although many seek to increase quality by reducing variability in adverse outcomes, less is known about variability in costs. In conjunction with the American Association for the Surgery of Trauma Healthcare Economics Committee, the objective of this study was to examine the extent of variability in total hospital costs for two common procedures: laparoscopic appendectomy (LA) and laparoscopic cholecystectomy (LC). METHODS: Nationally weighted data for adults 18 years and older was obtained for patients undergoing each operation in the 2014 and 2016 National Inpatient Sample. Data were aggregated at the hospital-level to attain hospital-specific median index hospital costs in 2019 US dollars and corresponding annual procedure volumes. Cost variation was assessed using caterpillar plots and risk-standardized observed/expected cost ratios. Correlation analysis, variance decomposition, and regression analysis explored costs' association with volume. RESULTS: In 2016, 1,563 hospitals representing 86,170 LA and 2,276 hospitals representing 230,120 LC met the inclusion criteria. In 2014, the numbers were similar (1,602 and 2,259 hospitals). Compared with a mean of US $10,202, LA median costs ranged from US $2,850 to US $33,381. Laparoscopic cholecystectomy median costs ranged from US $4,406 to US $40,585 with a mean of US $12,567. Differences in cost strongly associated with procedure volume. Volume accounted for 9.9% (LA) and 12.4% (LC) of variation between hospitals, after controlling for the influence of other hospital (8.2% and 5.0%) and patient (6.3% and 3.7%) characteristics and in-hospital complications (0.8% and 0.4%). Counterfactual modeling suggests that were all hospitals to have performed at or below their expected median cost, one would see a national cost savings of greater than US $301.9 million per year (95% confidence interval, US $280.6-325.5 million). CONCLUSION: Marked variability of median hospital costs for common operations exists. Differences remained consistent across changing coding structures and database years and were strongly associated with volume. Taken together, the findings suggest room for improvement in emergency general surgery and a need to address large discrepancies in an often-overlooked aspect of value. LEVEL OF EVIDENCE: Epidemiological, level III.

Robotic compared with laparoscopic cholecystectomy: A propensity matched analysis.

BACKGROUND: As robotic surgery becomes more ubiquitous, determining clinical benefit is necessary to justify the cost and time investment required to become proficient. We hypothesized that robotic cholecystectomy would be associated with improved clinical outcomes but also increased cost as compared with standard laparoscopic cholecystectomy. MATERIALS AND METHODS: All patients undergoing robotic or laparoscopic cholecystectomy at a single academic hospital between 2007 and 2017 were identified using an institutional clinical data repository. Patients were stratified by operative approach (robotic versus laparoscopic) for comparison and propensity score matched 1:10 based on relevant comorbidities and demographics. Categorical variables were analyzed by the χ2 test and continuous variables using the Mann-Whitney U test. RESULTS: A total of 3,255 patients underwent cholecystectomy during the study period. We observed no differences in demographics or body mass index, but greater rates of diabetes mellitus, hypertension, and gastroesophageal reflux disease were present in the laparoscopic group. After matching (n = 106 robotic, n = 1,060 laparoscopic), there were no differences in preoperative comorbidities. Patients who underwent robotic cholecystectomy had lesser durations of stay (robotic: 0.1 ± 0.7 versus laparoscopic: 0.8 ± 1.9, P < .0001) and lesser 90-day readmission rates (robotic: 0% [0], laparoscopic: 4.1% [43], P = 0.035); however, both operative and hospital costs were greater compared with laparoscopic cholecystectomy. CONCLUSION: Robotic cholecystectomy is associated with lesser duration of stay and lesser readmission rate within 90 days of the index operation, but also greater operative duration and hospital cost compared with laparoscopic cholecystectomy. Hospitals and surgeons need to consider the improved clinical outcomes but also the monetary and time investment required before pursuing robotic cholecystectomy.

Robot-assisted cholecystectomy is a safe but costly approach: A national database review.

BACKGROUND: This study sought to evaluate surgical outcomes, cost, and opiate utilization of patients who underwent laparoscopic (LC) or robotic cholecystectomy (RC). METHODS: The Vizient database was queried for patients admitted with mild to moderate severity of illness (SOI) scores who underwent LC or RC from January 2015 through December 2017. Rates of overall complications, postoperative infection, mortality, LOS, cost, and opiate utilization were compared between groups using IBM SPSS v.25.0, α = 0.05. RESULTS: 91,849 patients (LC:N = 89,878; RC:N = 1,971) met the inclusion criteria. Robotic approach was associated with more complications (LC:0.9%, RC:1.7%; p < 0.001), postoperative infections (LC:0.2%, RC:0.4%; p = 0.033) and a higher direct cost (LC:$6782 ±â€¯3421, RC:$9354 ±â€¯5497; p < 0.001). Opiates were prescribed more frequently in the laparoscopic group (LC:98.3%, RC:97.2%; p = 0.002). CONCLUSION: The direct cost of RC is significantly higher than LC with no added benefit. Routine use of the robotic platform for cholecystectomy should be discouraged until costs are reduced.

Reduced Port Laparoscopic Cholecystectomy: An Innovative, Cost-Effective Technique with Superior Cosmetic Outcomes.

INTRODUCTION: Patient demand for cosmetically superior surgical outcomes has driven minimally invasive technique development like single incision laparoscopic cholecystectomy (SILC). Implementation has been hindered by equipment factors, compromise of ergonomics, increased cost, and larger primary incision, leading to the associated risk of postoperative wound complications, incisional hernia, and fascial dehiscence. We present a method of reduced port laparoscopic cholecystectomy (RPLC), which utilises existing laparoscopic conventional equipment and an innovative MiniLap® grasper (Teleflex Incorporated, Wayne, Pennsylvania). The aim of the approach being enhanced cosmesis, cost equivalence with existing methods, and preservation of surgical ergonomics. MATERIALS AND METHODS: Twenty consecutive patients presenting to a single-surgeon practice with pathology requiring cholecystectomy and favourable body habitus were offered an RPLC procedure. Abdominal access was obtained via two laparoscopic working ports placed through a single incision within the umbilicus and with a 2.3mm port-less MiniLap® inserted via stab incision in the right upper quadrant utilised for retraction. Operative time, cost, cosmesis, postoperative pain, and patient demographics were compared with the standard four-port cholecystectomy. RESULTS: Twenty patients underwent RPLC with age ranging from 20 to 67 with a mean body mass index (BMI) of 31kg/m2. Mean operative time of 36.3 minutes was comparable to conventional multi-port laparoscopic cholecystectomy (LC). All operations were completed as RPLC, and no conversion to conventional four-port laparoscopic cholecystectomy was required. Gall bladder retraction with Teleflex grasper and an innovative swirling technique provides adequate exposure of the hepato-cystic triangle. Patient response regarding cosmetic outcome of the procedure was overwhelmingly positive. A single complication of the RPLC technique was documented-a superficial umbilical site wound infection, which was treated with oral antibiotics. Instrumental cost of the RPLC was $80 (AUD) greater than standard 4LP due to reduced port number but higher MiniLap® cost. CONCLUSION: The RPLC method utilises an ergonomically attractive technique with outcomes and a safety profile equal to the standard multi-port LC whilst minimizing the complications and prohibitive economic penalties of traditional SILC. A well-designed prospective randomised trial can provide more insight into the pros and cons of this innovative technique.

Feasibility and safety of single-incision laparoscopic cholecystectomy versus conventional laparoscopic cholecystectomy in an ambulatory setting.

BACKGROUND: Single-incision laparoscopic surgery has emerged as an alternative to conventional laparoscopic cholecystectomy (LC) in the clinical setting. Limited information is available on the possibility of performing single-incision laparoscopic surgery as an ambulatory procedure. This study aimed to determine the feasibility and safety of single-incision laparoscopic cholecystectomy (SILC) versus conventional LC in an ambulatory setting. METHODS: Ninety-one patients were randomized to SILC (n = 49) or LC (n = 42). The success rate, operative duration, blood loss, hospital stay, gallbladder perforation, drainage, delayed discharge, readmission, total cost, complications, pain score, vomiting, and cosmetic satisfaction of the two groups were then compared. RESULTS: There were significant differences in the operative time (46.89 ±â€¯10.03 min in SILC vs. 37.24 ±â€¯10.23 min in LC; P < 0.001). As compared with LC, SILC was associated with lower total costs (8012.28 ±â€¯752.67 RMB vs. 10258.91 ± 1087.63 RMB; P < 0.001) and better cosmetic satisfaction (4.94 ± 0.24 vs. 4.74 ± 0.54; P = 0.031). There were no significant differences between-group in terms of general data, success rate, blood loss, hospital stay, gallbladder perforation, drainage, delayed discharge, readmission, complications, pain score, and vomiting (P > 0.05). CONCLUSIONS: Ambulatory SILC is safe and feasible for selected patients. The advantages of SILC as compared with LC are improved cosmetic satisfaction and lower total costs.

10 years of laparoscopic common bile duct exploration: A single tertiary institution experience.

INTRODUCTION: Laparoscopic common bile duct exploration (LCBDE-LC) or ERCP plus laparoscopic cholecystectomy (ERCP-LC) represent minimally invasive choledocholithiasis treatments. We hypothesized that LCBDE-LC has a shorter length of stay (LOS) and lower charges than ERCP-LC. METHODS: Charts were reviewed for all LCBDE-LC or ERCP-LC for choledocholithiasis from 2007 to 2017. Exclusions included cholangitis, concomitant procedures, or history of Roux-en-Y or biliary surgery. Groups were determined via intention-to-treat with LCBDE-LC or ERCP-LC. RESULTS: 281 subjects were identified; 157 met inclusion criteria. 89 (56%) were in the LCBDE-LC group. There were no differences in age, sex, or ASA. LOS was shorter for LCBDE-LC (3.1 vs 4.4 days, p < 0.01) although total anesthesia time was longer (292 vs 262 min, p = 0.01). There was no difference in total charges ($44,412 vs $51,353, p = 0.08). Thirty (33%) LCBDE-LC were aborted due to challenges passing the dilator or scope (33%) or clearing stones (30%). Two ERCP-LC cases required post-procedure LCBDE. CONCLUSION: LCBDE-LC resulted in shorter LOS but had a high failure rate. Further research is needed to predict which cases suit each modality.

Meta-analysis of the cost-effectiveness of early versus delayed cholecystectomy for acute cholecystitis.

Background: Acute calculous cholecystitis (ACC) is a common disease across the world and is associated with significant socioeconomic costs. Although contemporary guidelines support the role of early laparoscopic cholecystectomy (ELC), there is significant variation among units adopting it as standard practice. There are many resource implications of providing a service whereby cholecystectomies for acute cholecystitis can be performed safely. Methods: Studies that incorporated an economic analysis comparing early with delayed laparoscopic cholecystectomy (DLC) for acute cholecystitis were identified by means of a systematic review. A meta-analysis was performed on those cost evaluations. The quality of economic valuations contained therein was evaluated using the Quality of Health Economic Studies (QHES) analysis score. Results: Six studies containing cost analyses were included in the meta-analysis with 1128 patients. The median healthcare cost of ELC versus DLC was €4400 and €6004 respectively. Five studies had adequate data for pooled analysis. The standardized mean difference between ELC and DLC was -2·18 (95 per cent c.i. -3·86 to -0·51; P = 0·011; I 2 = 98·7 per cent) in favour of ELC. The median QHES score for the included studies was 52·17 (range 41-72), indicating overall poor-to-fair quality. Conclusion: Economic evaluations within clinical trials favour ELC for ACC. The limited number and poor quality of economic evaluations are noteworthy.

Impact of body mass index on utilization of selected hospital resources for four common surgical procedures.

BACKGROUND: Evidence about the impact of obesity on surgical resource consumption in the Australian setting is equivocal. Our objectives were to quantify the prevalence of obesity in four frequently performed surgical procedures and explore the association between body mass index (BMI) and hospital resource utilization including procedural duration, length of stay (LOS) and costs. METHODS: A retrospective cohort study of patients undergoing four surgical procedures at a tertiary referral centre in New South Wales, between 1 January 2016 and 31 December 2016, was conducted. The four surgical procedures were total hip replacement, laparoscopic appendectomy, laparoscopic cholecystectomy and hysteroscopy with dilatation and curettage. Surgical groups were stratified according to BMI category. RESULTS: A total of 699 patients were included in the study. The prevalence of obesity was significantly higher than local and national population estimates for all procedures except appendectomy. BMI was not associated with increased hospital resource utilization (procedural, anaesthetic or intensive care stay duration) in any of the four surgical procedures examined after controlling for age, gender and complexity. For other outcomes of hospital resource utilization (LOS and cost), the relationship was inconsistent across the four procedures examined. A high BMI was positively associated with higher LOS, medical costs and allied health costs in those who underwent an appendectomy, and critical care costs in those who underwent laparoscopic cholecystectomy. CONCLUSION: Obesity was common in patients undergoing four frequently performed surgical procedures. The relationship between BMI and hospital resource utilization appears to be complex and varies across the four procedures examined.

Emergency Laparoscopic Cholecystectomy: Is Dedicated Hot Gall Bladder List Cost Effective?

BACKGROUND: Acute presentation of gall stone disease is a common emergency. Resource limitation often results in unnecessary long waiting times and repeat hospital admissions. The aim of this study was to investigate if funding a dedicated hot gall bladder list is justified. METHODS: Patients with acute gall stone related complications between 1st January 2016 and 31st December 2017 were studied. Outcome measures included the number of acute admissions, length of hospital stay (LOS), approximate cost per patient. The length of stay was identified as a critical outcome measure. RESULTS: Fourteen hundred and ninety-five (11%) out of 14189 acute surgical admissions were related to gall stone complications. These included acute cholecystitis 576 (39%), biliary colic 485 (32%), pancreatitis 405 (27%) and jaundice 34 (2%). Twelve hundred and twenty-two patients accounted for 1461 admissions. 182 (15%) patients had recurrent admissions (35%) and on average stayed 11.2 days in the hospital compared to 5.8 days for that of single presentation. The cost of emergency LC (£2053) was less than half of elective LC following single emergency admission (£5661) and less than one third of Elective LC following recurrent admissions (£7453). A trust can save £1,891,784 per year by achieving 80% target. The savings can be used to fund a dedicated hot gall bladder list, releasing hospital beds and additional benefit of reducing the workforce days lost to sickness in general. CONCLUSIONS: Emergency LC is cost effective and savings made for such a service is sufficient to fund a dedicated hot gall bladder list..

Barriers to adoption of laparoscopic cholecystectomy in a county hospital in Guatemala.

BACKGROUND: Despite international efforts to increase performance of laparoscopic cholecystectomy (LC) in rural Guatemala, the vast majority of cholecystectomies are still performed via the open cholecystectomy (OC) approach. Our goal was to explore barriers to the adoption of LC in Guatemala as well as possible mechanisms to overcome them. METHODS: We reviewed 9402 cholecystectomies performed over 14 years by surgeons at the Hospital Nacional de San Benito (HNSB) in El Peten, Guatemala, with either an open or a laparoscopic approach. We conducted personal interviews with all the surgeons who perform cholecystectomies at HNSB to determine current practice and barriers to adopting LC. RESULTS: Overall, seven general surgeons were interviewed who regularly perform cholecystectomy. Of the total number of cholecystectomies reviewed, 8440 (90%) were open and 962 (10%) were laparoscopic. The mean number of cholecystectomies performed per surgeon was 1341.1 ± 1244.9, with OC at 1205.7 ± 1194.9, and LC at 137.4 ± 188.0. Lack of formal training in laparoscopy was identified in 57% of surgeons. Lack of government funds to implement a laparoscopic program was noted by 71% of surgeons (29% felt there was insufficient ancillary staff, 29% poor allocation of hospital funding to purchase laparoscopic equipment/training). Lack of sufficient laparoscopic equipment was identified by 71% of surgeons. CONCLUSIONS: Ninety percent of cholecystectomies performed by surgeons at HNSB continue to be OC. The major limitation is the lack of funding to provide sufficient equipment or ancillary staff. The majority of surgeons preferred to perform LC if these problems could be addressed.

The heavy price of conversion from laparoscopic to open procedures for emergent cholecystectomies.

BACKGROUND: Laparoscopic cholecystectomy (LC) is the standard operative intervention for gallbladder disease. Complications may necessitate conversion to an open cholecystectomy (OC). This study aims to determine the cost-consequences of laparoscopic-to-open conversion using a nationally-representative sample. METHODS: Using the National Inpatient Sample (2007-2011), adult patients undergoing emergent LC were identified. Patients undergoing secondary-conversion to OC were subsequently identified. Multivariable regression analyses, accounting for differences in propensity-quintile, mortality, length of stay, and hospital-level factors were then performed to assess for differences in the odds of conversion and total predicted mean costs per index-hospitalization. RESULTS: Of 225,805 observations, conversion to open occurred in 1.86% (n = 4203) of cases. Increased age, African-American ethnicity, public-insurance and teaching-hospital status were associated with a higher likelihood of conversion (p < 0.05) after risk-adjustment. Risk-adjusted odds of conversion increased by 34% (95%CI:1.33-1.36) for each day surgery was delayed. Risk-adjusted costs, were 259% higher (absolute-difference $23,358,p < 0.05) with conversion. Mortality was higher amongst patients undergoing conversion to open (4.98% vs 0.34%,p < 0.001). CONCLUSION: Patients undergoing conversion from laparoscopic to open cholecystectomy are at an increased risk of receiving disparate care and increased mortality.