Cost analysis of open and laparoscopic pancreaticoduodenectomy: a single institution comparison.

INTRODUCTION: The laparoscopic approach to pancreaticoduodenectomy has been recently more frequently reported and is now being performed at multiple centers across the US. While laparoscopic pancreaticoduodenectomy (LPD) has been shown to be safe and feasible, comparing its cost in relation to open pancreaticoduodenectomy (OPD) has not been examined. The aim of this study is to examine the cost of LPD compared with OPD at a single institution over a 3-year time period. METHODS: An institutional database was analyzed to compare patients who underwent OPD and LPD (including Whipple resections and total pancreatectomy) between May 2009 and June 2012. A cost analysis was performed, which included the use the hospital billing database to assess surgical costs, hospital admission costs, and overall cost of the patient's care during the index admission. The operative costs were further analyzed with respect to OR time and surgical supplies. Standard statistical analysis was performed to assess for significance. RESULTS: In the study time period, 123 patients underwent pancreaticoduodenectomy, including 48 OPD (39%) and 75 LPD (61%). The groups were similar with respect to age, gender, ASA, vein resection, and indication for surgery. In the LPD group, the use of hand assist or conversion to OPD occurred in 3 (4%) and 10 (13%) patients, respectively. Additionally, 10% of the OPD group underwent total pancreatectomy (n = 5), compared to 21% of the LPD (n = 16). Mean operative time for OPD and LPD was 355 min (range 199-681) and 551 min (range 390-819) respectively (p < 0.0001). Median hospital stay for OPD and LPD was 8 days (range 5-63), and 7 days (range 4-68) respectively (p = 0.5). Morbidity rates were equal at 31% for the two groups. The LPD group was associated with significantly higher surgical cost due to both increased time and supply cost. However, mean hospital admission cost associated with OPD was greater in comparison to the LPD group, though not significant. The overall total cost of care was similar between the two groups. CONCLUSIONS: LPD is associated with equivalent overall cost compared with OPD. While operating time and supply costs were higher for LPD, this was balanced by decreased cost of the postoperative admission.

Laparoscopic central pancreatectomy and pancreaticogastrostomy for the management of a proximally migrated pancreatic stent.

CONTEXT: Pancreatic stents are used for both benign and malignant pancreatic disease but can be associated with complications such as proximal migration. CASE REPORT: A 43-year-old female with benign biliary disease underwent prophylactic pancreatic stent placement after endoscopic retrograde cholangiopancreatography. This stent migrated proximally into the pancreatic duct and could not be retrieved by endoscopic measures. Therefore, she underwent surgical retrieval via a laparoscopic central pancreatectomy with pancreaticogastrostomy reconstruction. The procedure took 250 minutes with minimal blood loss. The postoperative course was uneventful and the patient was discharged on the sixth postoperative day without any evidence of pancreatic fistula. CONCLUSION: Laparoscopic central pancreatectomy is a feasible option for the unusual indication of a retained proximally migrated pancreatic duct stent.

Minimally invasive surgical techniques for pancreatic cancer: ready for prime time?

BACKGROUND: Minimally invasive surgical techniques for pancreatic cancer are being applied with increasing frequency. With support of the literature, the location of the tumor within the pancreas is the factor which determines if these techniques can be safely used routinely by pancreatic surgeons. METHODS: Literature supporting minimally invasive techniques for all types of resections for pancreatic cancer was reviewed. RESULTS: Multiple meta-analysis regarding laparoscopic distal pancreatectomy all support the routine use of laparoscopy for these lesions. There are several case series describing the safety and efficacious use of laparoscopy in pancreaticoduodenectomy, and results have been promising in these highly specialized centers. CONCLUSIONS: The location of the tumor within the pancreas remains the most critical factor in the use of laparoscopy as the standard of care. Lesions in the body and tail, which are readily resected with a distal or subtotal pancreatectomy should be performed laparoscopically unless there is a clear reason why not to do so. Lesions in the head of the pancreas have been shown to be removed safely and effectively with laparoscopy. However, the technical skills necessary and the ability to teach these to trainees are the limiting factors to widespread use. Further series are necessary to assess if the laparoscopic approach to pancreaticoduodenectomy will play a similar role as the one it plays in the surgical treatment for distal lesions.