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1.
Medicine (Baltimore) ; 98(49): e18222, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31804348

RESUMO

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.


Assuntos
Gastrectomia/métodos , Laparoscopia/métodos , Neoplasias Gástricas/cirurgia , Perda Sanguínea Cirúrgica , Gastrectomia/economia , Humanos , Laparoscopia/economia , Excisão de Linfonodo , Duração da Cirurgia , Complicações Pós-Operatórias
2.
Am Surg ; 85(10): 1129-1133, 2019 Oct 01.
Artigo em Inglês | MEDLINE | ID: mdl-31657308

RESUMO

Best management for acute appendicitis (AA) in adults with liver cirrhosis is controversial and needs more investigation. We aimed to examine the impact of different treatment modalities on outcomes in this complex patient population. The Nationwide Inpatient Sample database from 2012 to 2014 was queried to identify AA patients with no cirrhosis, compensated cirrhosis (CC), and decompensated cirrhosis (DC). Each cohort was further stratified according to the treatment type: nonoperative management, open appendectomy, and laparoscopic appendectomy (LA). Chi-square, ANOVA, and binary regression analyses were used to determine differences between groups and risk factors for mortality and complications, with P < 0.05 considered statistically significant. A total of 108,289 AA patients were analyzed; of those, 304 with CC and 134 with DC were identified. Compared with CC and no cirrhosis, DC patients had significantly higher mortality, higher cost, and longer hospital length of stay. LA is accompanied by higher survival, lower cost, shorter duration of hospitalization, and lower incidence of complications across all groups. We conclude that LA is the best management strategy for AA in cirrhotic patients. Even in decompensated cirrhotics, which are associated with worse clinical outcomes, LA is still a favorable option over open appendectomy and nonoperative management.


Assuntos
Apendicectomia/métodos , Apendicite/cirurgia , Laparoscopia , Cirrose Hepática/complicações , Doença Aguda , Adulto , Análise de Variância , Apendicectomia/efeitos adversos , Apendicectomia/economia , Apendicectomia/mortalidade , Apendicite/complicações , Apendicite/mortalidade , Distribuição de Qui-Quadrado , Conversão para Cirurgia Aberta/estatística & dados numéricos , Custos e Análise de Custo , Feminino , Preços Hospitalares , Mortalidade Hospitalar , Humanos , Incidência , Laparoscopia/economia , Laparoscopia/mortalidade , Tempo de Internação/economia , Cirrose Hepática/classificação , Cirrose Hepática/mortalidade , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/epidemiologia , Análise de Regressão , Fatores de Risco , Resultado do Tratamento
3.
J Laparoendosc Adv Surg Tech A ; 29(11): 1436-1445, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31556797

RESUMO

Introduction: Major colorectal surgery procedures are complex operations that can result in significant postoperative pain and complications. More evidence is needed to demonstrate how opioid-related adverse drug events (ORADEs) after colorectal surgery can affect hospital length of stay (LOS), hospital revenue, and what their association is with clinical conditions. By understanding the clinical and economic impact of potential ORADEs within colorectal surgery, we hope to further guide approaches to perioperative pain management in an effort to improve patient care and reduce hospital costs. Materials and Methods: We conducted a retrospective study utilizing the Centers for Medicare and Medicaid Services (CMS) Administrative Database to analyze Medicare discharges involving three colorectal surgery diagnosis-related groups (DRGs) to identify potential ORADEs. The impact of potential ORADEs on mean hospital LOS and hospital revenue was analyzed. Results: The potential ORADE rate in patients undergoing colorectal surgery was 23.92%. The mean LOS for discharges with a potential ORADE was 5.35 days longer than without an ORADE. The mean hospital revenue per day with a potential ORADE was $418 less than without an ORADE. Any type of open surgery had a statistically significant higher potential ORADE rate than the matched laparoscopic case (P < .001). Clinical conditions most strongly associated with ORADEs in colorectal surgery included septicemia, pneumonia, shock, and fluid and electrolyte disorders. Conclusion: The incidence of ORADEs in colorectal surgery is high and is associated with longer hospital stays and reduced hospital revenue. Reducing the use of opioids in the perioperative setting, such as using multimodal analgesia strategies, may lead to positive outcomes with shorter hospital stays, increased hospital revenue, and improved patient care.


Assuntos
Analgésicos Opioides/efeitos adversos , Procedimentos Cirúrgicos do Sistema Digestório/estatística & dados numéricos , Custos Hospitalares , Laparoscopia/estatística & dados numéricos , Tempo de Internação , Complicações Pós-Operatórias/epidemiologia , Idoso , Idoso de 80 Anos ou mais , Colo/cirurgia , Bases de Dados Factuais , Procedimentos Cirúrgicos do Sistema Digestório/efeitos adversos , Procedimentos Cirúrgicos do Sistema Digestório/economia , Efeitos Colaterais e Reações Adversas Relacionados a Medicamentos , Feminino , Humanos , Incidência , Laparoscopia/efeitos adversos , Laparoscopia/economia , Masculino , Medicare/estatística & dados numéricos , Pessoa de Meia-Idade , Dor Pós-Operatória/tratamento farmacológico , Dor Pós-Operatória/etiologia , Pneumonia/epidemiologia , Complicações Pós-Operatórias/economia , Reto/cirurgia , Estudos Retrospectivos , Sepse/epidemiologia , Choque/epidemiologia , Resultado do Tratamento , Estados Unidos/epidemiologia , Desequilíbrio Hidroeletrolítico/epidemiologia
4.
J Laparoendosc Adv Surg Tech A ; 29(11): 1486-1491, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31486708

RESUMO

Purpose: To compare the results of two- versus three-staged laparoscopic anorectoplasty (LARP) in children with rectoprostatic and bladder neck fistulas. Materials and Methods: The present study was retrospectively initiated among 32 consecutive patients who underwent two-staged LARP from October 2010 to December 2012. The associated defects, age at the operation, operative time, complications, length of the postoperative hospital stay, total hospitalization cost, and functional results (according to the Krickenbeck scoring system) were evaluated. The results were compared with those of 19 cases who underwent three-staged LARP from October 2008 to September 2010. Results: The average age at the second operation was 4.5 ± 1.2 months in the two-staged group, and 4.2 ± 1.3 months in the three-staged group. In the two-staged group, there were statistically shorter overall operative time and postoperative hospital stay duration. Also, a significantly lower total hospitalization cost was achieved. There was no anastomotic leak in either group. The rates of perineal wound infection, recurrent fistula, and rectal prolapse were 3.85% versus 0% (P = 1.000), 0% versus 5.3% (P = .422), and 11.5% versus 15.8% (P = .686), respectively (two-staged versus three-staged group). The median follow-up time was 67 (range, 54-80) months and 88 (range, 81-104) months, respectively. No significant difference in functional outcome was observed. Conclusions: Two-staged LARP is feasible, safe, and more cost-effective, with comparable incidences of complications and functional outcomes with respect to a three-staged procedure.


Assuntos
Malformações Anorretais/cirurgia , Fístula/cirurgia , Doenças Prostáticas/cirurgia , Procedimentos Cirúrgicos Reconstrutivos/métodos , Fístula Retal/cirurgia , Fístula da Bexiga Urinária/cirurgia , Adolescente , Criança , Pré-Escolar , Análise Custo-Benefício , Feminino , Humanos , Lactente , Recém-Nascido , Laparoscopia/efeitos adversos , Laparoscopia/economia , Tempo de Internação/economia , Masculino , Pescoço/cirurgia , Duração da Cirurgia , Complicações Pós-Operatórias/etiologia , Procedimentos Cirúrgicos Reconstrutivos/efeitos adversos , Procedimentos Cirúrgicos Reconstrutivos/economia , Prolapso Retal/etiologia , Recidiva , Estudos Retrospectivos , Infecção da Ferida Cirúrgica/etiologia
5.
BJOG ; 126(12): 1499-1506, 2019 11.
Artigo em Inglês | MEDLINE | ID: mdl-31452295

RESUMO

OBJECTIVE: Deep endometriosis transvaginal ultrasound (DE TVS) is accurate in the detection of ovarian endometriosis and DE; however, realisation of its full potential and utilisation remains variable. As such, patients may require a two-step surgical approach (diagnostic followed by therapeutic laparoscopy) or experience incomplete surgical treatment. Besides the clinical implications, the economic impact of a two-step approach to diagnosis and treatment on the healthcare system is likely to be significant. We aim to compare the economic costs of two diagnostic models of care for patients with potential endometriosis. DESIGN: Cost analysis using Markov model with 12-month time horizon comparing the economic costs of two diagnostic models. SETTING: The study used a hypothetical population of 1000 women visiting a public tertiary gynaecology clinic. POPULATION: Women with potential endometriosis. Estimates for endometriosis prevalence and severity were drawn from local Australian hospital data. METHODS: The conventional model (M1) includes the basic TVS and diagnostic laparoscopy. The novel model (M2) includes the DE TVS. Probabilistic sensitivity analysis was conducted to capture the uncertainty in the information used to populate the models. MAIN OUTCOME MEASURE: Changes to government, health-service and patient costs with the adoption of the DE TVS compared with standard diagnostic methods. Costs are given in Australian dollars (AU$) and also in pound sterling (£). RESULTS: The total annual cost of the novel model (M2) is AU$12,547,724.03 (£6,826,673.63), cheaper than the conventional model (M1), which cost AU$13,472,161.67 (£7,329,620.15). CONCLUSIONS: For a population of 1000 women, the integration of the DE TVS may save healthcare costs of AU$924,437 (£502,946.17) annually. TWEETABLE ABSTRACT: An endometriosis-focused ultrasound may negate a two-step surgery pathway, including diagnostic surgery, and save healthcare money.


Assuntos
Endometriose/diagnóstico por imagem , Austrália , Custos e Análise de Custo , Endometriose/economia , Endometriose/cirurgia , Feminino , Humanos , Laparoscopia/economia , Cadeias de Markov , Sensibilidade e Especificidade , Ultrassonografia/economia , Serviços de Saúde da Mulher
6.
Surgery ; 166(4): 483-488, 2019 10.
Artigo em Inglês | MEDLINE | ID: mdl-31345565

RESUMO

BACKGROUND: Alvimopan has been shown to reduce length of stay after bowel resection. Use remains variable among institutions due to cost and efficacy concerns in laparoscopic surgery. Additionally, alvimopan's effects have not been isolated from other medications within enhanced recovery protocols. The aim of this study was to distinguish the relationship between alvimopan use, length of stay, and cost in both open and laparoscopic segmental colectomies. METHODS: The Vizient dataset was queried to identify patients undergoing open and laparoscopic colectomies from 2015 to 2017. Patient demographics and treatment details were collected. Primary outcomes of interest included duration of stay and total direct costs. RESULTS: In the study, 12,727 patients met inclusion criteria and 3,358 (26.4%) received alvimopan. For both open and laparoscopic groups, alvimopan was associated with decreased length of stay in unadjusted (4.0 vs 6.0 days, P < .01 and 3.0 vs 4.0 days, P < .01, respectively) and adjusted analysis (effect ratio 0.79, P < .01 and 0.85, P < .01, respectively). Alvimopan was associated with a 7% decrease in direct cost after adjustment (effect ratio 0.93, P = .04), with no cost difference in laparoscopic procedures (effect ratio 0.99, P = .71). CONCLUSION: Alvimopan use is associated with decreased length of stay for both open and laparoscopic colon resections, decreased cost in open procedures, and no cost difference for laparoscopic procedures.


Assuntos
Colectomia/métodos , Redução de Custos , Laparoscopia/economia , Laparotomia/economia , Tempo de Internação/economia , Piperidinas/uso terapêutico , Idoso , Estudos de Coortes , Colectomia/economia , Bases de Dados Factuais , Procedimentos Cirúrgicos Eletivos/economia , Procedimentos Cirúrgicos Eletivos/métodos , Feminino , Fármacos Gastrointestinais/uso terapêutico , Custos de Cuidados de Saúde , Humanos , Laparoscopia/efeitos adversos , Laparoscopia/métodos , Laparotomia/efeitos adversos , Laparotomia/métodos , Modelos Lineares , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Complicações Pós-Operatórias/tratamento farmacológico , Complicações Pós-Operatórias/prevenção & controle , Estudos Retrospectivos , Estados Unidos
7.
Surgery ; 166(2): 166-171, 2019 08.
Artigo em Inglês | MEDLINE | ID: mdl-31160061

RESUMO

BACKGROUND: Little is known regarding the impact of the minimally invasive approach to distal pancreatectomy on the aggregate costs of care for patients undergoing distal pancreatectomy. METHODS: We queried the Healthcare Cost and Utilization Project State Inpatient Database to identify patients undergoing elective laparoscopic distal pancreatectomy or open distal pancreatectomy between 2012 and 2014. Multivariable regression was used to evaluate postoperative outcomes including readmissions to 90 days after distal pancreatectomy. RESULTS: A total of 267 (11%) patients underwent laparoscopic distal pancreatectomy, and a total of 2,214 (89%) underwent open distal pancreatectomy. On multivariable regression, patients undergoing laparoscopic distal pancreatectomy had a decreased odds risk of having any severe adverse outcome (odds ratio 0.73, 95% confidence interval [0.54-0.97]), prolonged length of stay (odds ratio 0.49, 95% confidence interval [0.30-0.79]), and of being in the highest quartile for aggregate costs of care (odds ratio 0.46, 95% confidence interval [0.32-0.66]) relative to those undergoing open distal pancreatectomy. Patients undergoing laparoscopic distal pancreatectomy had a lower average 90-day aggregate cost of care than those undergoing open distal pancreatectomy when procedures were performed in high-volume (-$16,153, 95% CI: [-$23,342 to -$8,964]) centers. CONCLUSION: Patients undergoing laparoscopic distal pancreatectomy have a lower risk of severe adverse outcomes, prolonged overall length of stay, and lower associated costs of care relative to those undergoing open distal pancreatectomy. This association is independent of hospital volume.


Assuntos
Procedimentos Cirúrgicos Eletivos/economia , Custos de Cuidados de Saúde , Laparoscopia/economia , Pancreatectomia/métodos , Neoplasias Pancreáticas/cirurgia , Adulto , Idoso , Estudos de Coortes , Bases de Dados Factuais , Procedimentos Cirúrgicos Eletivos/métodos , Feminino , Hospitais com Alto Volume de Atendimentos , Humanos , Laparoscopia/métodos , Tempo de Internação/economia , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Invasividade Neoplásica/patologia , Estadiamento de Neoplasias , Pancreatectomia/efeitos adversos , Neoplasias Pancreáticas/mortalidade , Neoplasias Pancreáticas/patologia , Prognóstico , Análise de Regressão , Estudos Retrospectivos , Taxa de Sobrevida , Resultado do Tratamento , Estados Unidos
8.
Gut ; 68(10): 1774-1780, 2019 10.
Artigo em Inglês | MEDLINE | ID: mdl-31233395

RESUMO

OBJECTIVE: Evaluate the cost-effectiveness of laparoscopic ileocaecal resection compared with infliximab in patients with ileocaecal Crohn's disease failing conventional therapy. DESIGN: A multicentre randomised controlled trial was performed in 29 centres in The Netherlands and the UK. Adult patients with Crohn's disease of the terminal ileum who failed >3 months of conventional immunomodulators or steroids without signs of critical strictures were randomised to laparoscopic ileocaecal resection or infliximab. Outcome measures included quality-adjusted life-years (QALYs) based on the EuroQol (EQ) 5D-3L Questionnaire and the Inflammatory Bowel Disease Questionnaire (IBDQ). Costs were measured from a societal perspective. Analyses were performed according to the intention-to-treat principle. Missing cost and effect data were imputed using multiple imputation. Cost-effectiveness planes and cost-effectiveness acceptability curves were estimated to show uncertainty. RESULTS: In total, 143 patients were randomised. Mean Crohn's disease total direct healthcare costs per patient at 1 year were lower in the resection group compared with the infliximab group (mean difference €-8931; 95% CI €-12 087 to €-5097). Total societal costs in the resection group were lower than in the infliximab group, however not statistically significant (mean difference €-5729, 95% CI €-10 606 to €172). The probability of resection being cost-effective compared with infliximab was 0.96 at a willingness to pay (WTP) of €0 per QALY gained and per point improvement in IBDQ Score. This probability increased to 0.98 at a WTP of €20 000/QALY gained and 0.99 at a WTP of €500/point of improvement in IBDQ Score. CONCLUSION: Laparoscopic ileocaecal resection is a cost-effective treatment option compared with infliximab. CLINICAL TRIAL REGISTRATION NUMBER: Dutch Trial Registry NTR1150; EudraCT number 2007-005042-20 (closed on 14 October 2015).


Assuntos
Colectomia/métodos , Doença de Crohn/terapia , Custos de Cuidados de Saúde , Ileíte/terapia , Infliximab/uso terapêutico , Laparoscopia/economia , Adulto , Ceco/cirurgia , Colectomia/economia , Análise Custo-Benefício , Doença de Crohn/economia , Feminino , Seguimentos , Fármacos Gastrointestinais/economia , Fármacos Gastrointestinais/uso terapêutico , Humanos , Ileíte/diagnóstico , Ileíte/economia , Íleo/cirurgia , Infliximab/economia , Masculino , Estudos Retrospectivos , Resultado do Tratamento , Adulto Jovem
9.
Langenbecks Arch Surg ; 404(4): 469-475, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31065781

RESUMO

INTRODUCTION: Cost efficiency is important for hospitals in order to provide high-quality health care for all patients. As hemihepatectomies are increasingly being performed laparoscopically, the aims of this study were to evaluate the costs of laparoscopic hemihepatectomy and to compare them to conventional open techniques. PATIENTS AND METHODS: This is a retrospective analysis of clinical outcomes and financial calculations of all patients who underwent hemihepatectomy between January 2015 and December 2016 at the Department of Surgery, Campus Charité Mitte and Campus Charité Virchow-Klinikum, Berlin, Germany, being allocated to the DRG (diagnosis-related group) H01A (complex operations of the liver and pancreas with complex intensive care treatment) or H01B (operations of the liver and pancreas without complex intensive care treatment). To overcome selection bias, a 1:1 propensity score matching (PSM) analysis was performed. RESULTS: After PSM, a total of 64 patients were identified; 32 patients underwent laparoscopic hemihepatectomy (LH); and 32 patients received open hemihepatectomy (OH). After PSM, no significant differences were observed in clinical baseline characteristics. The duration of surgery was significantly longer for patients undergoing LH compared to OH (LH, 334 min, 186-655 min; OH, 274 min, 176-454 min; p = 0.005). Patients in the LH group had a significantly shortened median hospital stay of 5 d, when compared to OH (LH, 9.5 d, 3-35 d; OH, 14.5 d, 7-37d; p = 0.005). We observed a significant higher rate of postoperative complication in the OH group (p = 0.022). Cost analysis showed median overall costs of 17,369.85€ in the LH group and 16,103.64€ in the OH group (p = 0.390). CONCLUSION: Our data suggest that higher intraoperative costs of laparoscopic liver surgery, e.g., for surgical devices and due to longer operation times, are compensated by fewer postoperative complications and consecutive shorter length of stay when compared with OH.


Assuntos
Análise Custo-Benefício , Hepatectomia/economia , Laparoscopia/economia , Hepatopatias/cirurgia , Humanos , Tempo de Internação/economia , Duração da Cirurgia , Complicações Pós-Operatórias/epidemiologia , Pontuação de Propensão , Estudos Retrospectivos
10.
Tech Coloproctol ; 23(5): 461-470, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-31069557

RESUMO

BACKGROUND: The aim of this study was to assess, whether robotic-assistance in ventral mesh rectopexy adds benefit to laparoscopy in terms of health-related quality of life (HRQoL), cost-effectiveness and anatomical and functional outcome. METHODS: A prospective randomized study was conducted on patients who underwent robot-assisted ventral mesh rectopexy (RVMR) or laparoscopic ventral mesh rectopexy (LVMR) for internal or external rectal prolapse at Oulu University Hospital, Finland, recruited in February-May 2012. The primary outcomes were health care costs from the hospital perspective and HRQoL measured by the 15D-instrument. Secondary outcomes included anatomical outcome assessed by pelvic organ prolapse quantification method and functional outcome by symptom questionnaires at 24 months follow-up. RESULTS: There were 30 females (mean age 62.5 years, SD 11.2), 16 in the RVMR group and 14 in the LVMR group. The surgery-related costs of the RVMR were 1.5 times higher than the cost of the LVMR. At 3 months the changes in HRQoL were 'much better' (RVMR) and 'slightly better' (LVMR) but declined in both groups at 2 years (RVMR vs. LVMR, p > 0.05). The cost-effectiveness was poor at 2 years for both techniques, but if the outcomes were assumed to last for 5 years, it improved significantly. The incremental cost-effectiveness ratio for the RVMR compared to LVMR was €39,982/quality-adjusted life years (QALYs) at 2 years and improved to €16,707/QALYs at 5 years. Posterior wall anatomy was restored similarly in both groups. The subjective satisfaction rate was 87% in the RVMR group and 69% in the LVMR group (p = 0.83). CONCLUSIONS: Although more expensive than LVMR in the short term, RVMR is cost-effective in long-term. The minimally invasive VMR improves pelvic floor function, sexual function and restores posterior compartment anatomy. The effect on HRQoL is minor, with no differences between techniques.


Assuntos
Custos e Análise de Custo , Laparoscopia/economia , Qualidade de Vida , Prolapso Retal/cirurgia , Procedimentos Cirúrgicos Robóticos/economia , Telas Cirúrgicas , Feminino , Humanos , Masculino , Pessoa de Meia-Idade
11.
Dis Colon Rectum ; 62(6): 747-754, 2019 06.
Artigo em Inglês | MEDLINE | ID: mdl-31094961

RESUMO

BACKGROUND: The morbidity and mortality associated with colorectal resections are responsible for significant healthcare use. Identification of efficiencies is vital for decreasing healthcare cost in a resource-limited system. OBJECTIVE: The purpose of this study was to characterize the short-term cost associated with all colon and rectal resections. DESIGN: This was a population-based, retrospective administrative analysis. SETTINGS: This analysis was composed of all colon and rectal resections with anastomosis in Canada (excluding Quebec) between 2008 and 2015. PATIENTS: A total of 108,304 patients ≥18 years of age who underwent colon and/or rectal resections with anastomosis were included. MAIN OUTCOME MEASURES: Total short-term inpatient cost for the index admission and the incremental cost of each comorbidity and complication (in 2014 Canadian dollars) were measured. Cost predictors were modeled using hierarchical linear regression and Monte Carlo Markov Chain estimation. RESULTS: Multivariable regression demonstrated that the adjusted average cost of a 50-year-old man undergoing open colon resection for benign disease with no comorbidities or complications was $9270 ((95% CI, $7146-$11,624; p = <0.001). With adjustment for complications, laparoscopic colon resections carried a cost savings of $1390 (95% CI, $1682-$1099; p = <0.001) compared with open resections. Surgical complications were the main driver for increased cost, because anastomotic leaks added $9129 (95% CI, $8583-$9670; p = <0.001). Medical complications such as renal failure requiring dialysis ($16,939 (95% CI, $15,548-$18,314); p = <0.001) carried significant cost. Complications requiring reoperation cost $16,313 (95% CI, $15,739-$16,886; p = <0.001). The costliest complication cumulatively was reoperation, which exceeded $95 million dollars over the course of the study. LIMITATIONS: Inherent biases associated with administrative databases limited this study. CONCLUSIONS: Medical and surgical complications (especially those requiring reoperation) are major drivers of increased resource use. Laparoscopic colorectal resection with or without adjustment for complications carries a clear cost advantage. There is opportunity for considerable cost savings by reducing specific complications or by preoperatively optimizing select patients susceptible to costly complication. See Video Abstract at http://links.lww.com/DCR/A839.


Assuntos
Colectomia/economia , Custos de Cuidados de Saúde , Hospitalização/economia , Laparoscopia/economia , Complicações Pós-Operatórias/economia , Protectomia/economia , Idoso , Canadá , Colectomia/efeitos adversos , Feminino , Humanos , Laparoscopia/efeitos adversos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/etiologia , Protectomia/efeitos adversos , Estudos Retrospectivos
12.
Int J Surg ; 67: 54-60, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-31121328

RESUMO

BACKGROUND: Laparoscopic liver resection is recommended as the standard operation for left lateral sectionectomy (LLS). Robotic liver resection is theoretically better than laparoscopic liver resection in complex cases of liver resection. However, in a complex case of LLS, whether robotic LLS (R-LLS) is still better than laparoscopic LLS (L-LLS) is unclear. This study aims to assess the perioperative outcomes of R-LLS and L-LLS in the overall and in the subgroup of complex cases of LLS. METHODS: From January 2015 to June 2017, the data on consecutive patients who underwent R-LLS were retrospectively compared with those who underwent L-LLS. Based on defined criteria for complex cases, the subgroup of such patients who underwent R-LLS were compared with the subgroup of patients who underwent L-LLS. The patient characteristics and surgical outcomes in the whole groups and subgroups of patients were analyzed. RESULTS: The overall R-LLS and L-LLS groups showed no significance differences in operative time, intraoperative blood loss, postoperative hospital stay, blood transfusion and morbidity rates. The overall medical costs were significantly higher in the R-LLS group than in the L-LLS group (12786.4 vs. 7974.3 USD; p < 0.001). On subgroup analysis of the complex cases, the estimated blood loss was significantly less in the R-LLS subgroup than the L-LLS subgroup (131.9 vs. 320.8 ml, p = 0.003). The two subgroups showed no significant differences in postoperative hospital stay (4.7 vs. 5.3 days; p = 0.054) and operative times (126.4 vs. 110.8 min; p = 0.379). The R-LLS subgroup had significantly higher overall medical costs than the L-LLS subgroup (13536.9 vs. 9186.7 USD, p = 0.006). CONCLUSION: The overall R-LLS group was comparable to the overall L-LLS group in perioperative outcomes. Although the overall medical costs in the robotic subgroup was higher, R-LLS might be a better choice for the subgroup of patients with complex cases when compared to L-LLS.


Assuntos
Custos de Cuidados de Saúde , Hepatectomia/economia , Laparoscopia/economia , Complicações Pós-Operatórias/economia , Procedimentos Cirúrgicos Robóticos/economia , Adulto , Perda Sanguínea Cirúrgica , Transfusão de Sangue/estatística & dados numéricos , Feminino , Hepatectomia/efeitos adversos , Hepatectomia/métodos , Humanos , Laparoscopia/efeitos adversos , Laparoscopia/métodos , Tempo de Internação/economia , Fígado/cirurgia , Masculino , Pessoa de Meia-Idade , Duração da Cirurgia , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos , Procedimentos Cirúrgicos Robóticos/efeitos adversos , Procedimentos Cirúrgicos Robóticos/métodos , Resultado do Tratamento
13.
Br J Surg ; 106(7): 910-921, 2019 06.
Artigo em Inglês | MEDLINE | ID: mdl-31012498

RESUMO

BACKGROUND: Minimally invasive distal pancreatectomy decreases time to functional recovery compared with open distal pancreatectomy, but the cost-effectiveness and impact on disease-specific quality of life have yet to be established. METHODS: The LEOPARD trial randomized patients to minimally invasive (robot-assisted or laparoscopic) or open distal pancreatectomy in 14 Dutch centres between April 2015 and March 2017. Use of hospital healthcare resources, complications and disease-specific quality of life were recorded up to 1 year after surgery. Unit costs of hospital healthcare resources were determined, and cost-effectiveness and cost-utility analyses were performed. Primary outcomes were the costs per day earlier functional recovery and per quality-adjusted life-year. RESULTS: All 104 patients who had a distal pancreatectomy (48 minimally invasive and 56 open) in the trial were included in this study. Patients who underwent a robot-assisted procedure were excluded from the cost analysis. Total medical costs were comparable after laparoscopic and open distal pancreatectomy (mean difference €-427 (95 per cent bias-corrected and accelerated confidence interval €-4700 to 3613; P = 0·839). Laparoscopic distal pancreatectomy was shown to have a probability of at least 0·566 of being more cost-effective than the open approach at a willingness-to-pay threshold of €0 per day of earlier recovery, and a probability of 0·676 per additional quality-adjusted life-year at a willingness-to-pay threshold of €80 000. There were no significant differences in cosmetic satisfaction scores (median 9 (i.q.r. 5·75-10) versus 7 (4-8·75); P = 0·056) and disease-specific quality of life after minimally invasive (laparoscopic and robot-assisted procedures) versus open distal pancreatectomy. CONCLUSION: Laparoscopic distal pancreatectomy was at least as cost-effective as open distal pancreatectomy in terms of time to functional recovery and quality-adjusted life-years. Cosmesis and quality of life were similar in the two groups 1 year after surgery.


Assuntos
Análise Custo-Benefício , Custos Hospitalares/estatística & dados numéricos , Laparoscopia/economia , Pancreatectomia/métodos , Qualidade de Vida , Procedimentos Cirúrgicos Robóticos/economia , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Países Baixos , Pancreatectomia/economia , Satisfação do Paciente , Complicações Pós-Operatórias/economia , Complicações Pós-Operatórias/epidemiologia , Anos de Vida Ajustados por Qualidade de Vida , Recuperação de Função Fisiológica , Método Simples-Cego
14.
Zhonghua Wai Ke Za Zhi ; 57(2): 102-107, 2019 Feb 01.
Artigo em Chinês | MEDLINE | ID: mdl-30704212

RESUMO

Objective: To compare the short-term clinical outcomes and cost differences of robotic distal pancreatectomy (RDP) versus laparoscopic distal pancreatectomy (LDP). Methods: The retrospective descriptive study was adopted.The clinical data of 158 patients underwent minimally invasive distal pancreatectomy who were admitted to Fujian Medical University Union Hospital between January 2016 and July 2018 were collected.A 1∶1 matched propensity score (PSM) analysis was performed for the RDP group and the LDP group.Observed indexes included operative time, blood loss, spleen-preserving rate, postoperative hospital stay, morbidity, incidence of pancreatic fistula and hospital costs. T test or rank sum test was used to compare measurement data, χ(2) test or Fisher exact test was used to compare count data. Results: A well-balanced cohort of 41 patients was analyzed.There were 14 males and 27 females in the RDP group, aged (45.2±16.4)years. There were 15 males and 26 females in the LDP group, aged (47.4±14.9) years.The operation time was (209.7±52.9) minutes for the RDP group and (186.5±56.7) minutes for the LDP group (P=0.073). Median blood loss was less in RDP (50(15-175)ml) compared with LDP (100(50-350)ml) (Z=-2.689, P=0.007). Thirty-eight cases of non-malignant diseases were observed in each group and spleen-preserving rate was higher in RDP (76.3%) compared to LDP(44.7%) (χ(2)=7.930, P=0.005).Postoperative hospital stay was similar in the RDP group and the LDP group (RDP: 9.4 days vs. LDP: 10.6 days; P=0.372). The overall morbidity and incidence of pancreatic fistula major complication rates (RDP: 12.2% vs. LDP: 14.6%, P=0.746; RDP: 7.3% vs. LDP: 9.8%, P=1.000) were similar.Total cost of RDP group was higher than that of LDP group ((80 563.7±10 641.8) yuan vs. (57 792.8±8 943.0) yuan, t=4.515, P<0.01). Conclusions: Both RDP and LDP are safe and feasible procedures. RDP is more expensive, but RDP is associated with significantly less blood loss and higher spleen-preserving rate, which is more suitable for the non-malignant diseases of pancreatic body and tail with an expectation of splenic preservation.


Assuntos
Laparoscopia , Pancreatectomia/métodos , Neoplasias Pancreáticas/cirurgia , Procedimentos Cirúrgicos Robóticos , Adulto , Perda Sanguínea Cirúrgica , Feminino , Humanos , Laparoscopia/economia , Masculino , Pessoa de Meia-Idade , Pancreatectomia/economia , Neoplasias Pancreáticas/economia , Pontuação de Propensão , Estudos Retrospectivos , Procedimentos Cirúrgicos Robóticos/economia , Baço/cirurgia , Resultado do Tratamento
15.
Am Surg ; 85(1): 39-45, 2019 Jan 01.
Artigo em Inglês | MEDLINE | ID: mdl-30760343

RESUMO

The aim of this study was to compare postoperative outcomes after robotic-assisted and laparoscopic bariatric sleeve gastrectomy (SG). Sleeve gastrectomy is traditionally performed using laparoscopic techniques. Robotic-assisted surgery enables surgeons to perform minimally invasive SG, but with unknown benefits. Using a national database, we compared postoperative outcomes after laparoscopic SG and robotic-assisted SG. National data from individuals undergoing elective SG in the National Inpatient Sample database between 2011 and 2013 were analyzed. Propensity score matching was used to match robotic and laparoscopic groups by demographics, comorbidities, and hospital characteristics. The matching cohorts were compared. A total of 26,195 patients who underwent elective SG for morbid obesity were included. Of these, 25,391 (96.9%) were completed via laparoscopy, whereas 804 (3.1%) were performed with robotic assistance. There were no significant differences in demographics and subsequent postoperative complications. The inhospital mortality was similar. Length of hospital stay was statistically different, with a mean of 1.88 in laparoscopic versus 2.08 days in robotic (P < 0.001). Higher total hospital charges were noted in the robotic-assisted SG group (median US$38,569 vs US$54,658, P < 0.001). These differences were evident even after adjusting for confounding factors: wound infection, atelectasis, bowel obstruction, pneumonia, and bowel obstruction (P < 0.001).


Assuntos
Gastrectomia/economia , Custos Hospitalares , Laparoscopia/economia , Obesidade Mórbida/cirurgia , Procedimentos Cirúrgicos Robóticos/economia , Adulto , Bases de Dados Factuais , Feminino , Hospitalização/economia , Humanos , Masculino , Pessoa de Meia-Idade , Pontuação de Propensão , Estudos Retrospectivos
16.
J Robot Surg ; 13(4): 607-608, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-30805777

RESUMO

The costs of robot-assisted surgery (RAS) still represent a critical issue. Kulaylat et al. reported a propensity-matched study to compare the outcomes of colorectal surgery between a robotic and a laparoscopic group, concluding that RAS was burdened by higher costs. However, authors did not mention what da Vinci system, Si or Xi, they used and this could be crucial, as recently data published by our group on rectal resections showed that the use of the da Vinci Xi and the surgeon's increased experience could improve the results and significantly reduce the costs of RAS.


Assuntos
Cirurgia Colorretal/economia , Procedimentos Cirúrgicos Robóticos/economia , Colo/cirurgia , Cirurgia Colorretal/métodos , Análise Custo-Benefício , Custos de Cuidados de Saúde , Humanos , Laparoscopia/economia , Laparoscopia/métodos , Reto/cirurgia , Procedimentos Cirúrgicos Robóticos/métodos
17.
Int J Gynaecol Obstet ; 145(2): 199-204, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-30801700

RESUMO

OBJECTIVE: To evaluate transvaginal repair versus laparoscopic repair of cesarean scar defects (CSDs). METHODS: A retrospective cohort study was conducted among 67 symptomatic women with CSDs who attended a tertiary hospital in Beijing, China, between July 1, 2013, and March 31, 2017. The participants underwent either transvaginal repair (n=31) or laparoscopic repair (n=36). Medical costs, perioperative outcomes, and surgical outcomes were compared. RESULTS: No statistically significant between-group differences were found at baseline. The mean thickness of the residual myometrium increased from 1.71 ± 0.67 mm before surgery to 4.41 ± 2.09 mm after surgery in the transvaginal repair group (P<0.001), and from 1.81 ± 0.93 to 4.68 ± 1.96 mm in the laparoscopic repair group (P<0.001). The duration of menses after surgery was less than 10 days in both the transvaginal repair group (n=30, 96.3%) and the laparoscopic repair group (n=30, 83.9%; P=0.113). Operative time and medical costs were both lower in the transvaginal repair group than in the laparoscopic repair group (P<0.001). Conception rates for the two groups were similar among women who desired fertility. CONCLUSION: Transvaginal repair of CSD was associated with reduced operative times and medical costs when compared with laparoscopic repair.


Assuntos
Cicatriz/cirurgia , Laparoscopia/métodos , Adulto , Cesárea/efeitos adversos , China , Cicatriz/patologia , Feminino , Humanos , Laparoscopia/economia , Miométrio/patologia , Duração da Cirurgia , Gravidez , Estudos Retrospectivos , Resultado do Tratamento
18.
World J Surg ; 43(5): 1342-1350, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-30610271

RESUMO

INTRODUCTION: Colorectal cancer (CRC) is the second leading cause of cancer mortality in the USA. We aimed to determine racial and socioeconomic disparities in the surgical management and outcomes of patients with CRC in a contemporary, national cohort. METHODS: We performed a retrospective analysis of the National Inpatient Sample for the period 2009-2015. Adult patients diagnosed with CRC and who underwent colorectal resection were included. Multivariable linear and logistic regressions were used to assess the effect of race, insurance type, and household income on patient outcomes. RESULTS: A total of 100,515 patients were included: 72,552 (72%) had elective admissions and 27,963 (28%) underwent laparoscopic surgery. Patients with private insurance and higher household income were consistently more likely to have laparoscopic procedures, compared to other insurance types and income levels, p < 0.0001. Black patients, compared to white patients, were more likely to have postoperative complications (OR 1.23, 95% CI, 1.17, 1.29). Patients with Medicare and Medicaid, compared to private insurance, were also more likely to have postoperative complications (OR 1.30, 95% CI, 1.24, 1.37 and OR 1.40, 95% CI, 1.31, 1.50). Patients in low-household-income areas had higher rates of any complication (OR 1.11, 95% CI 1.06, 1.16). CONCLUSIONS: The use of laparoscopic surgery in patients with CRC is strongly influenced by insurance type and household income, with Medicare, Medicaid and low-income patients being less likely to undergo laparoscopic surgery. In addition, black patients, patients with public insurance, and patients with low household income have significant worse surgical outcomes.


Assuntos
Neoplasias Colorretais/cirurgia , Disparidades em Assistência à Saúde , Afro-Americanos , Idoso , Idoso de 80 Anos ou mais , Neoplasias Colorretais/etnologia , Grupo com Ancestrais do Continente Europeu , Feminino , Disparidades em Assistência à Saúde/economia , Humanos , Laparoscopia/efeitos adversos , Laparoscopia/economia , Modelos Logísticos , Masculino , Medicare , Pessoa de Meia-Idade , Complicações Pós-Operatórias/epidemiologia , Estudos Retrospectivos , Fatores Socioeconômicos , Estados Unidos
19.
J Robot Surg ; 13(1): 69-75, 2019 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-29696591

RESUMO

BACKGROUND: Laparoscopic adrenalectomy (LA) has become the standard treatment of adrenal lesions. Recently, robotic-assisted adrenalectomy (RA) has become an option, however, short-term outcomes for RA have not been well studied and benefits over LA are debatable. The aim of this study was to explore differences in short-term outcomes between LA and RA using the national inpatient sample (NIS) database. METHODS: Patient data were collected from the NIS. All patients undergoing LA or RA from January 2009 to December 2012 were included. Univariate analysis and propensity matching were performed to look for differences between the groups. RESULTS: A total of 1006 patients (66.4% in LA group and 33.6% in RA group) were identified. Patient age group, gender, race, risk of mortality, severity of illness or indication for adrenalectomy did not differ significantly between the LA or RA cohorts. Insurance type predicted procedure type (45% of medicare patients underwent RA versus 29% of patients with private insurance, p < 0.0001). Patients living in the highest income areas were more likely to receive the laparoscopic approach (31.7 versus 17.4%, p < 0.0001). Hospital volume, bed size and teaching status of the hospital were not significant factors in the decision of RA versus LA. There was no difference in complication and conversion rates between RA versus LA. The mean length of stay was shorter in the RA group (2.2 versus 1.9 days, p = 0.03). Total charges were higher in the RA group ($42,659 versus $33,748, p < 0.0001). There was a significant trend towards more adrenalectomies being performed robotic assisted by year. Only 22% of adrenalectomies were performed robotic-assisted in 2009 compared with 48% in 2012. CONCLUSIONS: The overall benefit for RA remains small and higher total charges for RA may currently outweigh the benefits. These findings may change as more cases are performed robotically assisted and robotic technology improves.


Assuntos
Adrenalectomia/métodos , Adrenalectomia/estatística & dados numéricos , Bases de Dados como Assunto , Pacientes Internados , Laparoscopia/métodos , Laparoscopia/estatística & dados numéricos , Procedimentos Cirúrgicos Robóticos/métodos , Procedimentos Cirúrgicos Robóticos/estatística & dados numéricos , Adolescente , Adrenalectomia/economia , Adulto , Idoso , Idoso de 80 Anos ou mais , Análise de Variância , Humanos , Laparoscopia/economia , Pessoa de Meia-Idade , Pontuação de Propensão , Procedimentos Cirúrgicos Robóticos/economia , Fatores de Tempo , Resultado do Tratamento , Adulto Jovem
20.
Minerva Ginecol ; 71(1): 4-17, 2019 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-30318878

RESUMO

Over the past two decades, minimally invasive surgery (MIS) abdominal surgery has increasingly been used to treat pelvic organ prolapse. Besides the several advantages associated with minimal invasiveness, this approach bridged the gap between the benefits of vaginal surgery and the surgical success rates of open abdominal procedures. The most commonly performed procedure for suspension of the vaginal apex for postoperative vaginal prolapse by robotic-assisted laparoscopy is the sacrocolpopexy. Conventional laparoscopic application of this procedure was first reported in 1994 by Nezhat et al. and had not gained widespread adoption due to lengthy learning curve associated with laparoscopic suturing. Since FDA approval of the da Vinci® robot for gynecologic surgery in 2005, minimally invasive abdominal surgery for pelvic organ prolapse has become increasingly popular, as robotic-assisted laparoscopic sacrocolpopexy is an option for those surgeons without experience or training in the conventional route. Robotic surgery has made its way into the armamentarium of POP treatment and has allowed pelvic surgeons to adapt the "gold standard" technique of abdominal sacrocolpopexy to a minimally invasive approach with improved intraoperative morbidity and decreased convalescence. In fact, repair of pelvic organ prolapse can be performed robotically, and sometimes surgeons can feel suturing and dissection during the procedures less challenging with the assistance of the robot. However, even if robotic surgery may confer many benefits over conventional laparoscopy, these advantages should continue to be weighed against the cost of the technology. To date, as long-term outcomes, evidence about robotic sacrocolpopexy for a repair of pelvic organ prolapse are not conclusive, and much more investigations are needed to evaluate subjective and objective outcomes, perioperative and postoperative adverse events, and costs associated with these procedures. It is plausible to think that the main advantage is that robotics may lead to a widespread adoption of minimally invasive techniques in the field of pelvic floor reconstructive surgery. The following review will address the development and current state of robotic assistance in treating pelvic floor reconstruction discussing available data about the techniques of robotic prolapse repair as well as morbidity, costs and clinical outcomes.


Assuntos
Procedimentos Cirúrgicos em Ginecologia/métodos , Prolapso de Órgão Pélvico/cirurgia , Procedimentos Cirúrgicos Robóticos/métodos , Feminino , Procedimentos Cirúrgicos em Ginecologia/economia , Humanos , Laparoscopia/economia , Laparoscopia/métodos , Procedimentos Cirúrgicos Minimamente Invasivos/economia , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Diafragma da Pelve/cirurgia , Procedimentos Cirúrgicos Reconstrutivos/economia , Procedimentos Cirúrgicos Reconstrutivos/métodos , Procedimentos Cirúrgicos Robóticos/economia
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