Hospital volume, postoperative mortality, and costs after gastrectomy for gastric cancer in colombia: is there any association? / Volume hospitalar, mortalidade pós-operatória e custos após gastrectomia por câncer gástrico na colômbia: existe associação?

ABSTRACT BACKGROUND: There are no information in the literature associating the volume of gastrectomies with survival and costs for the health system in the treatment of patients with gastric cancer in Colombia. AIMS: The aim of this study was to analyze how gastrectomy for gastric cancer is associated with hospital volume, 30-day and 180-day postoperative mortality, and healthcare costs in Bogotá, Colombia. METHODS: A retrospective cohort study based on hospital data of all adult patients with gastric cancer who underwent gastrectomy between 2014 and 2016 using a paired propensity score. The surgical volume was identified as the average annual number of gastrectomies performed by the hospital. RESULTS: A total of 743 patients were included in the study. Hospital mortality at 30 and 180 days postoperatively was 36 (4.85%) and 127 (17.09%) patients, respectively. The average health care cost was USD 3,200. A total of 26 or more surgeries were determined to be the high surgical volume cutoff. Patients operated on in hospitals with a high surgical volume had lower 6-month mortality (HR 0.44; 95%CI 0.27-0.71; p=0.001), and no differences were found in health costs (mean difference 398.38; 95%CI-418.93-1,215.69; p=0.339). CONCLUSIONS: This study concluded that in Bogotá (Colombia), surgery in a high-volume hospital is associated with better 6-month survival and no additional costs to the health system.

RESUMO RACIONAL: Não há informações na literatura relacionando o volume de gastrectomias bem como a sobrevida e os custos para o sistema de saúde, no tratamento de pacientes com câncer gástrico na Colômbia. OBJETIVOS: analisar como a gastrectomia para câncer gástrico está associada ao volume hospitalar, mortalidade pós-operatória de 30 e 180 dias e custos de saúde em Bogotá, Colômbia. MÉTODOS: Estudo de coorte retrospectivo baseado em dados hospitalares de todos os pacientes adultos com câncer gástrico submetidos à gastrectomia entre 2014 e 2016, utilizando um escore de propensão pareado. O volume cirúrgico foi identificado como o número médio anual de gastrectomias realizadas pelo hospital. RESULTADOS: Foram incluídos no estudo 743 pacientes. A mortalidade hospitalar aos 30 e 180 dias de pós-operatório, foram respectivamente, 36 (4,85%) e 127 (17,09%) pacientes. O custo médio de saúde foi de US$ 3.200. Vinte e seis ou mais cirurgias foram determinadas como ponto de corte de alto volume cirúrgico. Pacientes operados em hospitais de alto volume cirúrgico tiveram menor mortalidade em seis meses (HR 0,44; IC95% 0,27-0,71; p=0,001) e não foram encontradas diferenças nos custos com saúde (diferença média 398,38; IC95% −418,93-1215,69; p=0,339). CONCLUSÕES: Este estudo concluiu que em Bogotá (Colômbia), a cirurgia em um hospital com alto volume cirúrgico está associada a uma melhor sobrevida de seis meses e não há custos adicionais para o sistema de saúde.

Comparison of 4-Year Health Care Expenditures Associated With Roux-en-Y Gastric Bypass vs Sleeve Gastrectomy.

Importance: Data on the long-term health care expenditures associated with bariatric surgery consisting of Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy are lacking. Objective: To compare 4-year health care expenditures after RYGB vs sleeve gastrectomy, identify factors independently associated with 4-year health care expenditures, and compare the procedures in terms of subsequent hospitalizations, bariatric procedures, and all-cause mortality. Design, Setting, and Participants: In this propensity score-matched cohort study, all residents of Ontario, Canada, who underwent publicly funded surgery with RYGB (n = 6301) or sleeve gastrectomy (n = 926) from March 1, 2010, to March 31, 2015, and consented to participate in the Ontario Bariatric Registry were eligible for the study. Follow-up was completed on March 31, 2019, and data were analyzed from May 5, 2020, to May 20, 2021. Interventions: RYGB and sleeve gastrectomy. Main Outcomes and Measures: Publicly funded health care expenditures, subsequent hospitalizations, bariatric procedures, and mortality during the 4 years after RYGB or sleeve gastrectomy. Results: The 1:1 matched study cohorts consisted of 1624 patients (812 per cohort) with a mean (SD) age of 48.0 (10.6) years, and 1242 women (76.5%). The mean body mass index (calculated as weight in kilograms divided by height in square meters) was 51.9 (8.3) for the RYGB cohort and 51.9 (8.9) for the sleeve gastrectomy cohort. The 4-year cumulative costs were not statistically significantly different between RYGB and sleeve gastrectomy (mean [SD], $33 682 [$31 169] vs $33 948 [$32 633], respectively; P = .86). Having a history of coronary artery disease was associated with a 35% increase in overall health care expenditures; chronic kidney disease, a 54% increase; and mental health admissions, a 67% increase. There were no statistically significant differences in all-cause mortality between RYGB and sleeve gastrectomy (1.5% vs 2.2%, respectively; P = .26) or the total number of hospitalizations (754 vs 669, respectively; P = .11) during the 4-year follow-up period. However, nonelective hospitalizations occurred more frequently with RYGB vs sleeve gastrectomy (472 vs 339, respectively; P = .002). Roux-en-Y gastric bypass was associated with relatively fewer subsequent bariatric procedures during the 4-year follow-up period (9 vs 40, respectively; P < .001). Conclusions and Relevance: In this Canadian population-based study, key results indicated that 4-year health care expenditures, all-cause mortality, and number of hospital admissions associated with RYGB did not significantly differ from those for sleeve gastrectomy. The rate of subsequent bariatric surgery was lower with RYGB. This study identified important patient-level drivers of health care expenditures that need to be further investigated.

Cost-effectiveness of procedure-less intragastric balloon therapy as substitute or complement to bariatric surgery.

BACKGROUND: Procedure-less intragastric balloon (PIGB) eliminates costs and risks of endoscopic placement/removal and involves lower risk of serious complications compared with bariatric surgery, albeit with lower weight loss. Given the vast unmet need for obesity treatment, an important question is whether PIGB treatment is cost-effective-either stand-alone or as a bridge to bariatric surgery. METHODS: We developed a microsimulation model to compare the costs and effectiveness of six treatment strategies: PIGB, gastric bypass or sleeve gastrectomy as stand-alone treatments, PIGB as a bridge to gastric bypass or sleeve gastrectomy, and no treatment. RESULTS: PIGB as a bridge to bariatric surgery is less costly and more effective than bariatric surgery alone as it helps to achieve a lower post-operative BMI. Of the six strategies, PIGB as a bridge to sleeve gastrectomy is the most cost-effective with an ICER of $3,781 per QALY gained. While PIGB alone is not cost-effective compared with bariatric surgery, it is cost-effective compared with no treatment with an ICER of $21,711 per QALY. CONCLUSIONS: PIGB can yield cost savings and improve health outcomes if used as a bridge to bariatric surgery and is cost-effective as a stand-alone treatment for patients lacking access or unwilling to undergo surgery.

Outcomes of Complex Gastrointestinal Cancer Resection at US News & World Report Top-Ranked vs Non-Ranked Hospitals.

BACKGROUND: The US News & World Report (USNWR) annual ranking of the best hospitals for gastroenterology and gastrointestinal surgery offers direction to patients and healthcare providers, especially for recommendations on complex medical and surgical gastrointestinal (GI) conditions. The objective of this study was to examine the outcomes of complex GI cancer resections performed at USNWR top-ranked, compared to non-ranked, hospitals. STUDY DESIGN: Using the Vizient database, data for patients who underwent esophagectomy, gastrectomy, and pancreatectomy for malignancy between January and December 2018 were reviewed. Perioperative outcomes were analyzed according to USNWR rank status. Primary outcome was in-hospital mortality. Secondary outcomes include length of stay, mortality index (observed-to-expected mortality ratio), rate of serious complication, and cost. Secondary analysis was performed for outcomes of patients who developed serious complications. RESULTS: There were 3,054 complex GI cancer resections performed at 42 top-ranked hospitals vs 3,608 resections performed at 198 non-ranked hospitals. The mean annual case volume was 73 cases at top-ranked hospitals compared to 18 cases at non-ranked hospitals. Compared with non-ranked hospitals, top-ranked hospitals had lower in-hospital mortality (0.96% vs 2.26%, respectively, p < 0.001) and lower mortality index (0.71 vs 1.53, respectively). There were no significant differences in length of stay, rate of serious complications, or direct cost between groups. In patients who developed serious morbidity, top-ranked hospitals had a lower mortality compared with non-ranked hospitals (8.2% vs 16.8%, respectively, p < 0.01). CONCLUSIONS: Within the context of complex GI cancer resection, USNWR top-ranked hospitals performed a 4-fold higher case volume and were associated with improved outcomes. Patients with complex GI-related malignancies may benefit from seeking surgical care at high-volume regional USNWR top-ranked hospitals.

Histologic and Cost-Benefit Analysis of Laparoscopic Sleeve Gastrectomy Specimens Performed for Morbid Obesity.

CONTEXT.­: Laparoscopic sleeve gastrectomy (LSG) has quickly become the bariatric surgical procedure of choice for patients with obesity who have failed medical management. Laparoscopic sleeve gastrectomy results in a gastric remnant that is routinely subject to pathologic examination. OBJECTIVE.­: To perform a histologic and cost-benefit analysis of gastric remnants post-LSG. DESIGN.­: All LSG cases performed at University Health Network, Toronto, Ontario, Canada, between 2010 and 2019 were reviewed. Specimens that underwent routine histopathologic assessment and ancillary immunohistochemical analysis were analyzed. Baseline patient characteristics and surgical outcomes were obtained from our internal database. The total cost of specimen gross preparation, examination, sampling, and producing and reporting a hematoxylin-eosin slide was calculated. RESULTS.­: A total of 572 patients underwent LSG during the study period and had their specimens examined histologically. A mean of 4.87 blocks generating 4 hematoxylin-eosin slides was produced. The most common histologic findings reported in LSG specimens ranged from no pathologic abnormalities identified together with proton pump inhibitor-related change. A minority of cases demonstrated clinically actionable histologic findings, of which Helicobacter pylori infection was the most common. The total cost for the complete pathologic analysis of these cases amounted to CaD $66 383.10 (US $47 080.21) with a mean of CaD $116.05 (US $82.40) per case. A total of CaD $62 622.75 (US $44 413.30) was spent on full examination of cases that had no further postoperative clinical impact. CONCLUSIONS.­: There is a broad spectrum of pathologic findings in LSG specimens, ranging from clinically nonactionable to more clinically actionable. The vast majority of histologic findings had no clinical impact, with only a minority of cases being clinically significant. This study therefore recommends that LSG specimens be subject to gross pathologic examination in the vast majority of cases. However, sections should be submitted for microscopic analysis if grossly evident lesions are present and if there is a clinical/known history of clinically actionable findings.

Bariatric surgery for patients with type 2 diabetes mellitus requiring insulin: Clinical outcome and cost-effectiveness analyses.

BACKGROUND: Although bariatric surgery is well established as an effective treatment for patients with obesity and type 2 diabetes mellitus (T2DM), there exists reluctance to increase its availability for patients with severe T2DM. The aims of this study were to examine the impact of bariatric surgery on T2DM resolution in patients with obesity and T2DM requiring insulin (T2DM-Ins) using data from a national database and to develop a health economic model to evaluate the cost-effectiveness of surgery in this cohort when compared to best medical treatment (BMT). METHODS AND FINDINGS: Clinical data from the National Bariatric Surgical Registry (NBSR), a comprehensive database of bariatric surgery in the United Kingdom, were extracted to analyse outcomes of patients with obesity and T2DM-Ins who underwent primary bariatric surgery between 2009 and 2017. Outcomes for this group were combined with data sourced from a comprehensive literature review in order to develop a state-transition microsimulation model to evaluate cost-effectiveness of bariatric surgery versus BMT for patients over a 5-year time horizon. The main outcome measure for the clinical study was insulin cessation at 1-year post-surgery: relative risks (RR) summarising predictive factors were determined, unadjusted, and after adjusting for variables including age, initial body mass index (BMI), duration of T2DM, and weight loss. Main outcome measures for the economic evaluation were total costs, total quality-adjusted life years (QALYs), and incremental cost-effectiveness ratio (ICER) at willingness-to-pay threshold of GBP£20,000. A total of 2,484 patients were eligible for inclusion, of which 1,847 had 1-year follow-up data (mean age of 51 years, mean initial BMI 47.2 kg/m2, and 64% female). 67% of patients no longer required insulin at 1-year postoperatively: these rates persisted for 4 years. Roux-en-Y gastric bypass (RYGB) was associated with a higher rate of insulin cessation (71.7%) than sleeve gastrectomy (SG; 64.5%; RR 0.92, confidence interval (CI) 0.86-0.99) and adjustable gastric band (AGB; 33.6%; RR 0.45, CI 0.34-0.60; p < 0.001). When adjusted for percentage total weight loss and demographic variables, insulin cessation following surgery was comparable for RYGB and SG (RR 0.97, CI 0.90-1.04), with AGB having the lowest cessation rates (RR 0.55, CI 0.40-0.74; p < 0.001). Over 5 years, bariatric surgery was cost saving compared to BMT (total cost GBP£22,057 versus GBP£26,286 respectively, incremental difference GBP£4,229). This was due to lower treatment costs as well as reduced diabetes-related complications costs and increased health benefits. Limitations of this study include loss to follow-up of patients within the NBSR dataset and that the time horizon for the economic analysis is limited to 5 years. In addition, the study reflects current medical and surgical treatment regimens for this cohort of patients, which may change. CONCLUSIONS: In this study, we observed that in patients with obesity and T2DM-Ins, bariatric surgery was associated with high rates of postoperative cessation of insulin therapy, which is, in turn, a major driver of overall reductions in direct healthcare cost. Our findings suggest that a strategy utilising bariatric surgery for patients with obesity and T2DM-Ins is cost saving to the national healthcare provider (National Health Service (NHS)) over a 5-year time horizon.

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.

The CARDIA-trial protocol: a multinational, prospective, randomized, clinical trial comparing transthoracic esophagectomy with transhiatal extended gastrectomy in adenocarcinoma of the gastroesophageal junction (GEJ) type II.

BACKGROUND: Adenocarcinoma of the gastroesophageal junction (GEJ) Siewert type II can be resected by transthoracic esophagectomy or transhiatal extended gastrectomy. Both allow for a complete tumor resection, yet there is an ongoing controversy about which surgical approach is superior with regards to quality of life, oncological outcomes and survival. While some studies suggest a better oncological outcome after transthoracic esophagectomy, others favor transhiatal extended gastrectomy for a better postoperative quality of life. To date, only retrospective studies are available, showing ambiguous results. METHODS: This study is a multinational, multicenter, randomized, clinical superiority trial. Patients (n = 262) with a GEJ type II tumor resectable by both transthoracic esophagectomy and transhiatal extended gastrectomy will be enrolled in the trial. Type II tumors are defined as tumors with their midpoint between ≤1 cm proximal and ≤ 2 cm distal of the top of gastric folds on preoperative endoscopy. Patients will be included in one of the participating European sites and are randomized to either transthoracic esophagectomy or transhiatal extended gastrectomy. The trial is powered to show superiority for esophagectomy with regards to the primary efficacy endpoint overall survival. Key secondary endpoints are complete resection (R0), number and localization of tumor infiltrated lymph nodes at dissection, post-operative complications, disease-free survival, quality of life and cost-effectiveness. Postoperative survival and quality of life will be followed-up for 24 months after discharge. Further survival follow-up will be conducted as quarterly phone calls up to 60 months. DISCUSSION: To date, as level 1 evidence is lacking, there is no consensus on which surgery is superior and both surgeries are used to treat GEJ type II carcinoma worldwide. The CARDIA trial is the first randomized trial to compare transthoracic esophagectomy versus transhiatal extended gastrectomy in patients with GEJ type II tumors. Several quality control measures were implemented in the protocol to ensure data reliability and increase the trial's significance. It is hypothesized that esophagectomy allows for a higher rate of radical resections and a more complete mediastinal lymph node dissection, resulting in a longer overall survival, while still providing an acceptable quality of life and cost-effectiveness. TRIAL REGISTRATION: The trial was registered on August 2nd 2019 at the German Clinical Trials Register under the trial-ID DRKS00016923 .

Is routine post-sleeve gastrografin needed? Profile of 98 cases.

OBJECTIVE: Laparoscopic sleeve gastrectomy (LSG) is one of the most commonly performed bariatric procedures. Some surgeons still perform routine post-sleeve gastrografin (RSG) study believing that it would detect post-LSG complications, especially leak. In this study, we aimed to evaluate the cost-effectiveness of RSG by considering the cost of the study, length of hospital stay and complications-related costs RSG could prevent. RESULTS: A total of 98 eligible patients were included. Of them, 54 patients underwent RSG and 44 did not. Excluding the cost of LSG procedure, the average cost for those who underwent RSG and those who did not in Saudi Riyal (£) was 5193.15 (1054.77) and 4222.27 (857.58), respectively. The average length of stay (ALOS) was practically the same regardless of whether or not the patient underwent RSG. 90.8% (n = 89) of all patients stayed for 3 days. None of the patients developed postoperative bleeding, stenosis or leak. The mean weight, body mass index (BMI) and percentage weight loss (PWL) 6 months postoperatively were found to be 87.71 kg (SD = 17.51), 33.89 kg/m2 (SD = 7.29) and 26.41% (SD = 9.79), respectively. The PWL 6 months postoperatively was 23.99% (SD = 8.47) for females and 30.57 (SD = 10.6) for males (p = 0.01).

Extraction bags provide no benefit when compared to unprotected lateral stomach extraction during laparoscopic sleeve gastrectomy.

BACKGROUND: Currently, no evidence compares outcomes for techniques utilizing surgical specimen extractions bags versus unprotected extraction. METHODS: Evaluation of sleeve gastrectomies performed at two high-volume centers. Cases where an extraction bag was used (+EB) were compared to bag-less extraction (-EB). Outcomes included operative contamination, surgical site infections and extraction-site hernias. RESULTS: 674 patients were evaluated (417 in the +EB group and 257 in the -EB group). Preoperative characteristics were similar between groups. There was a trend toward shorter operative times with the -EB group (-EB = 100 min vs + EB = 106 min, p = 0.07). Gross spillage was documented as a contaminated case in 0.4% of -EB cases compared to 1.2% in +EB cases (p = 0.51). Two superficial infections were appreciated (1.2% = +EB vs 0.7% = -EB, p = 0.7) with one post-operative abscess in the -EB group (p = 0.61). One post-operative hernia was seen in each group (p = 0.62). DISCUSSION: Bag-less extraction is a safe, resource conscious method that may potentially decreased operative time.

Health-Care Workers' Perception of Reimbursement for Complex Surgical Oncology Procedures.

Perception of physician reimbursement for surgical procedures is not well studied. The few existing studies illustrate that patients believe compensation to be higher than in reality. These studies focus on patient perceptions and have not assessed health-care workers' views. Our study examined health-care workers' perception of reimbursement for complex surgical oncology procedures. An anonymous online survey was distributed to employees at our cancer center with descriptions and illustrations of three oncology procedures-hepatectomy, gastrectomy, and pancreaticoduodenectomy. Participants estimated the Medicare fee and gave their perceived value of each procedure. Participants recorded their perception of surgeon compensation overall, both before and after revealing the Medicare fee schedule. Most of the 113 participants were physicians (33.6%) and nurses (28.3%). When blinded to the Medicare fee schedules, most felt that reimbursements were too low for all procedures (60-64%) and that surgeons were overall undercompensated (57%). Value predictions for each procedure were discordant from actual Medicare fee schedules, with overestimates up to 374 per cent. After revealing the Medicare fee schedules, 55 per cent of respondents felt that surgeons were undercompensated. Even among health-care workers, a large discrepancy exists between perceived and actual reimbursement. Revealing actual reimbursements did not alter perception on overall surgeon compensation.

Direct endoscopic full-thickness resection for submucosal tumors with an intraluminal growth pattern originating from the muscularis propria layer in the gastric fundus.

BACKGROUND AND AIMS: Endoscopic full-thickness resection (EFTR) is difficult to perform in a retroflexed fashion in the gastric fundus. The present study aims at exploring whether direct EFTR can be a simple, effective and safe procedure to treat intraluminal-growth submucosal tumors originating from the muscularis propria. METHODS: The patients with intraluminal-growth submucosal tumors originating from the muscularis propria in gastric fundus treated by direct EFTR between 01 January 2017 and 01 September 2018 were retrospectively reviewed. In addition, we analyzed the patients with intraluminal-growth submucosal tumors originating from the muscularis propria in gastric fundus treated by traditional EFTR. The differences in tumor resection time, cost-effectiveness, and complication rate were evaluated. RESULTS: Forty patients were enrolled in the present study, 20 patients of which were in the direct EFTR group and 20 patients of which were in the traditional EFTR group. En-bloc resections of gastric tumors were successfully performed in all 40 cases. There was no significant difference in the average tumor size of the two groups (24.3 ± 2.9 mm in direct EFTR group verus 24.0 ± 2.6 mm in the traditional group, p = 0.731), but significant difference existed in the operative time between two groups (35.0 ± 8.2 min in direct EFTR group verus 130.6 ± 51.9 min in the traditional group, p<0.05). No complications, such as postoperative bleeding and perforation, occurred in any groups. CONCLUSIONS: Direct EFTR is a safe, simple and cost-effective procedure for SMTs with an intraluminal growth pattern originating from the muscularis propria layer in the gastric fundus.

Comparison of Comorbidity Treatment and Costs Associated With Bariatric Surgery Among Adults With Obesity in Canada.

Importance: Information on the associations between barriers to delivery of bariatric surgery and poor weight trajectory afterward is lacking. Estimates are needed to inform decisions by administrators and clinicians to improve care. Objective: To estimate the difference in patient-years of treatment for diabetes, hypertension, and dyslipidemia and public-payer cost between the Canadian standard and an improved bariatric surgery care pathway. Design, Setting, and Participants: Economic evaluation of a decision analytic model comparing the outcomes of the standard care in Canada with an improved bariatric care pathway with earlier sleeve gastrectomy delivery and better postsurgical weight trajectory. The model was informed by published clinical data (101 studies) and meta-analyses (11 studies) between January and May 2019. Participants were a hypothetical 100-patient cohort with demographic characteristics derived from a Canadian study. Interventions: Reduction of Canadian mean bariatric surgery wait time by 2.5 years following referral and improvement of patient postsurgery weight trajectory to levels observed in other countries. Main Outcomes and Measures: Modeling weight trajectory after sleeve gastrectomy and resolution rates for comorbidities in Canada in comparison with an improved care pathway to estimate differences in patient-years of comorbidity treatment over 10 years following referral and the associated costs. Results: For the 100-patient cohort (mean [SD] 88.2% [1.4%] female; mean [SD] age, 43.6 [9.2] years; mean [SD] body mass index, 49.4 [8.2]; and mean [SD] comorbidity prevalence of 50.0% [4.1%], 66.0% [3.9%], and 59.3% [4.0%] for diabetes, hypertension, and dyslipidemia, respectively) over 10 years following referral, the improved vs standard care pathway was associated with median reduction in patient-years of treatment of 324 (95% credibility interval [CrI], 249-396) for diabetes, 245 (95% CrI, 163-356) for hypertension, and 255 (95% CrI, 169-352) for dyslipidemia, corresponding to total savings of $900 000 (95% CrI, $630 000 to $1.2 million) for public payers in the base case. Relative to standard of care, the associated reduction in costs was approximately 29% (95% CrI, 20%-42%) in the improved pathway. Sensitivity analyses demonstrated independent associations of earlier surgical delivery and various levels of postsurgical weight trajectory improvements with overall savings. Conclusions and Relevance: This study suggests that health care burden may be decreased through improvements to delivery and management of patients undergoing sleeve gastrectomy. More data are needed on long-term patient experience with bariatric surgery in Canada to inform better estimates.

Robotic-assisted gastrectomy compared with open resection: a comparative study of clinical outcomes and cost-effectiveness analysis.

In the last decade, there have clearly been important changes in the surgical approach of gastric cancer treatment due to an increased interest in the minimally invasive surgical approach (MIS). The higher cost of robotic surgery procedures remains an important issue of debate. The objective of the study is to compare the main operative and clinical outcomes and to assess the incremental cost-effectiveness ratios (ICERs) of the two techniques. This is a prospective cost-effectiveness and clinical study when comparing the robotic gastrectomy (RG) technique with open gastrectomy (OG) in gastric cancer. Outcome parameters included surgical and post-operative costs, quality-adjusted life years (QALY) and incremental cost per QALY gained or the incremental cost-effectiveness ratio (ICER). The incremental utility was 0.038 QALYs and the estimated ICER for patients was dominated by robotic approach. The probability that the robotic approach was cost effective was 94.04% and 94.20%, respectively, at a WTP threshold of 20,000€ and 30,000€ per QALY gained. RG for gastric cancer represents a cost-effective procedure compared with the standard OG.

Three-dimensional vs 2-dimensional laparoscopic gastrectomy for gastric cancer: A systematic review and meta-analysis.

BACKGROUND: Both 3-dimensional (3D) laparoscopic gastrectomy (LG) and 2-dimensional (2D) LG are commonly used for gastric cancer (GC). To investigate their safety and efficacy, we performed this meta-analysis. METHODS: PubMed, The Cochrane Library, Science Direct, Embase, Scopus, and Web of Science were systematically searched to identify relevant studies. The total number of lymph node dissections (LNDs), operation time, blood loss, postoperative hospital stay, postoperative complications, and hospitalization cost were extracted as major endpoints. RESULTS: Among 904 articles that were enrolled, 9 studies were included for analysis. The 3D group was observed to have shorter operation times [95% confidence interval (CI): -0.54 to -0.06; P = .01] and less blood loss (95% CI: -0.41 to -0.19; P < .00001) than the 2D group. Compared with the 2D group, slightly higher hospitalization cost was found in the 3D group (95% CI: 0.06-0.37; P = .008). However, the outcomes among the total LNDs, postoperative hospital stay, and postoperative complications were similar. Subgroup analysis suggested that the 3D LG group had more 11p (2.22 ±â€Š1.80 vs 1.47 ±â€Š1.99, P = .019) and 8a (2.52 ±â€Š1.88 vs 1.48 ±â€Š1.43, P = .001) LNDs compared to the 2D LG group. CONCLUSIONS: 3D LG has advantages for GC, with shorter operation times, less blood loss, and possibly more LNDs. However, the cost was slightly higher than that of 2D LG.

Incremental Cost-Effectiveness of Aspiration Therapy vs Bariatric Surgery and No Treatment for Morbid Obesity.

INTRODUCTION: Despite its recent approval by the US Food and Drug Administration and Health Canada, aspiration therapy-one of the latest weight loss treatments-remains controversial. Critics have expressed concerns that the therapy could lead to bulimia and other binge eating disorders. Meanwhile, proponents argue that the therapy is less invasive, reversible, and cheaper than bariatric surgery. Cost-effectiveness of this therapy, however, is not yet established. METHODS: We developed a Markov model to estimate the incremental cost-effectiveness of aspiration therapy relative to 2 most common bariatric surgery procedures (gastric bypass and sleeve gastrectomy) and no treatment over a lifetime horizon. Costs were estimated from the health system's perspective using US data. Effectiveness was measured in terms of quality-adjusted life-years (QALYs). RESULTS: Despite being a cheaper procedure than bariatric surgery, aspiration therapy costs more than bariatric surgery in the long term because of its high maintenance costs (i.e., periodic replacement of device parts). It also yields lower QALYs than bariatric surgery because of its smaller weight loss effects. Thus, the therapy is dominated by bariatric surgery. In particular, compared with gastric bypass, it costs US$5,318 more and yields 1.31 fewer QALYs. However, aspiration therapy is cost-effective relative to no treatment with an incremental cost-effectiveness ratio of US$17,532 per QALY gained. DISCUSSION: Given its high lifetime costs and its modest weight loss effects, aspiration therapy is not cost-effective relative to bariatric surgery. However, it is a cost-effective treatment option for patients who lack access to bariatric surgery.

Current Practice of Global Bariatric Tourism-Survey-Based Study.

PURPOSE: Our goal was to present the experience of bariatric surgeons with medical tourism on a global scale. MATERIALS AND METHODS: An online-based survey was sent to bariatric surgeons worldwide regarding surgeon's country of practice, number and types of bariatric procedures performed, number of tourists treated, their countries of origin, reasons for travel, follow-up, and complications. RESULTS: Ninety-three responders performed 18,001 procedures in 2017. Sixty-four of those 93 responders operated on foreign patients performing a total of 3740 operations for them. The majority of the responders practice in India (n = 11, 17%), Mexico (n = 10, 16%), and Turkey (n = 6, 9%). Mexico dominated the number of bariatric surgeries for tourists with 2557 procedures performed in 2017. The most frequent procedures provided were laparoscopic sleeve gastrectomy (LSG) provided by 89.1% of the respondents, laparoscopic Roux-en-Y gastric bypass (40.6% of respondents), and one anastomosis gastric bypass (37.5% of respondents). CONCLUSION: At least 2% of worldwide bariatric procedures are provided for medical tourists. Countries such as Mexico, Lebanon, and Romania dominate as providers for patients mainly from the USA, UK, and Germany. The lack of affordable bariatric healthcare and long waiting lists are some of the reasons for patients choosing bariatric tourism.

Cost analysis of robotic sleeve gastrectomy (R-SG) compared with laparoscopic sleeve gastrectomy (L-SG) in a single academic center: debunking a myth!

BACKGROUND: Although use of the da Vinci robotic platform in bariatric surgery is gaining momentum, there are financial concerns. OBJECTIVES: Our retrospective study evaluated the cost of robotically assisted sleeve gastrectomy (R-SG) versus conventional laparoscopic sleeve gastrectomy (L-SG). SETTING: Center of Excellence bariatric surgery center in Allentown, Pennsylvania. METHODS: We analyzed consecutive patients who underwent primary R-SG and compared them with L-SG patients. Primary outcomes were overall cost for length of stay, operating time, and supplies. Secondary outcomes were 30-day complications, reoperations, and readmissions. RESULTS: We had no adverse events in either group. The overall cost for R-SG and L-SG was not statistically different (mean total cost for R-SG and L-SG was $5308.99 and $4918.88, respectively). Operating time cost was significantly higher for R-SG compared with L-SG ($1340 versus $112 for R-SG and L-SG, respectively). R-SG had a shorter length of stay compared with L-SG (1.4 versus 1.5 d, respectively). CONCLUSIONS: Our study revealed no difference in cost R-SG and L-SG, with a trend toward shorter length of stay for R-SG over time.

Where are sleeves performed? An analysis of inpatient versus outpatient databases in a large state.

BACKGROUND: The sleeve gastrectomy (SG) is the most common bariatric surgery in the United States today. There is a trend toward performing SG as an outpatient procedure, either in an ambulatory setting or as an outpatient at a larger hospital. The term "outpatient" is used to designate essentially any patient without an inpatient order. Texas maintains the Texas Inpatient Public Use Data File (IPUDF) database and the Texas Outpatient Public Use Data File (OPUDF) database for inpatient and outpatient settings, respectively. OBJECTIVES: To determine where SGs are performed by evaluating the Texas IPUDF and OPUDF for 2016. SETTING: University hospital, United States. METHODS: The Texas IPUDF and OPUDF were searched with the Current Procedural Terminology code of 43775 and the International Classification of Diseases, 10th revision, procedure code of 0DB64Z3. Patient demographic characteristics were also examined. We looked at the top 5 diagnoses in each database. RESULTS: Of the 16,855 SGs performed in Texas in 2016, outpatient SGs accounted for 31.0% (5227 cases), and inpatient SGs accounted for 69% of the total with 11,628 cases reported. For patients reported in the OPUDF, mean length of stay (LOS) was 2.1 (standard deviation 3.2) days with a median of 1.0 (interquartile range = 1, 2) days; for patients in the IPUDF, mean LOS was 1.6 (standard deviation 1.5) days, and the median was 1.0 (interquartile range = 1, 1) days. CONCLUSION: A third of SGs in Texas were performed under outpatient status. Further study is needed to determine the safety of this practice.