Real-life Perioperative Outcomes of Radical Prostatectomy using the French National Registry: A Plea for Promotion of Centralized Care and Access to Minimally Invasive Approaches

Radical prostatectomy (RP) can be performed using an open (ORP), laparoscopic (LRP) or robotic (RARP) approach. Most studies, even in experienced centers, have not provided solid evidence demonstrating better outcomes when using the robotic approach. In addition, one of the remaining concerns about RARP is its cost effectiveness, leading to no reimbursement for this surgical technique in some countries and thus health care inequality. We used data from a French national registry to improve knowledge of RP outcomes in a real-world scenario in order to guide and inform health care decision-makers. A total of 21 213 RP procedures were performed in 645 French centers in 2021 (ORP 20%, LRP 25%, and RARP 55% of cases). ORP was associated with longer hospital stay (p < 0.001), higher rates of postoperative complications (p < 0.001), fewer days out of hospital within 90 d of surgery (81.7 vs 83.6 vs 84.9 d for ORP vs LRP vs RARP; p < 0.00), and higher hospitalization costs (€2424 vs €1789 vs €1302). RARP is an optimal and cost-effective approach, with several advantages over ORP. Our data can be used by health care decision-makers to facilitate access to and reimbursement for the robotic approach for RP indications. PATIENT SUMMARY: For men with prostate cancer for whom surgery is recommended, surgeons can remove the prostate using open surgery or a keyhole approach with or without robot assistance. Open surgery has higher costs, more complications, and longer hospital stays.

Impact of 18FFDG-PET/CT and Laparoscopy in Staging of Locally Advanced Gastric Cancer: A Cost Analysis in the Prospective Multicenter PLASTIC-Study

BACKGROUND

Unnecessary D2-gastrectomy and associated costs can be prevented after detecting non-curable gastric cancer, but impact of staging on treatment costs is unclear. This study determined the cost impact of 18F-fluorodeoxyglucose positron emission tomography/computed tomography (18FFDG-PET/CT) and staging laparoscopy (SL) in gastric cancer staging.

MATERIALS AND METHODS

In this cost analysis, four staging strategies were modeled in a decision tree: (1) 18FFDG-PET/CT first, then SL, (2) SL only, (3) 18FFDG-PET/CT only, and (4) neither SL nor 18FFDG-PET/CT. Costs were assessed on the basis of the prospective PLASTIC-study, which evaluated adding 18FFDG-PET/CT and SL to staging advanced gastric cancer (cT3-4 and/or cN+) in 18 Dutch hospitals. The Dutch Healthcare Authority provided 18FFDG-PET/CT unit costs. SL unit costs were calculated bottom-up. Gastrectomy-associated costs were collected with hospital claim data until 30 days postoperatively. Uncertainty was assessed in a probabilistic sensitivity analysis (1000 iterations).

RESULTS

18FFDG-PET/CT costs were €1104 including biopsy/cytology. Bottom-up calculations totaled €1537 per SL. D2-gastrectomy costs were €19,308. Total costs per patient were €18,137 for strategy 1, €17,079 for strategy 2, and €19,805 for strategy 3. If all patients undergo gastrectomy, total costs were €18,959 per patient (strategy 4). Performing SL only reduced costs by €1880 per patient. Adding 18FFDG-PET/CT to SL increased costs by €1058 per patient; IQR €870-1253 in the sensitivity analysis.

CONCLUSIONS

For advanced gastric cancer, performing SL resulted in substantial cost savings by reducing unnecessary gastrectomies. In contrast, routine 18FFDG-PET/CT increased costs without substantially reducing unnecessary gastrectomies, and is not recommended due to limited impact with major costs.

TRIAL REGISTRATION

NCT03208621. This trial was registered prospectively on 30-06-2017.

From morbidity reduction to cost-effectiveness: Enhanced recovery after surgery (ERAS) society recommendations in minimal invasive liver surgery

PURPOSE

Minimal-invasive liver surgery (MILS) reduces surgical trauma and is associated with fewer postoperative complications. To amplify these benefits, perioperative multimodal concepts like Enhanced Recovery after Surgery (ERAS), can play a crucial role. We aimed to evaluate the cost-effectiveness for MILS in an ERAS program, considering the necessary additional workforce and associated expenses.

METHODS

A prospective observational study comparing surgical approach in patients within an ERAS program compared to standard care from 2018-2022 at the Charité - Universitätsmedizin Berlin. Cost data were provided by the medical controlling office. ERAS items were applied according to the ERAS society recommendations.

RESULTS

537 patients underwent liver surgery (46% laparoscopic, 26% robotic assisted, 28% open surgery) and 487 were managed by the ERAS protocol. Implementation of ERAS reduced overall postoperative complications in the MILS group (18% vs. 32%, p = 0.048). Complications greater than Clavien-Dindo grade II incurred the highest costs (€ 31,093) compared to minor (€ 17,510) and no complications (€13,893; p < 0.001). In the event of major complications, profit margins were reduced by a median of € 6,640.

CONCLUSIONS

Embracing the ERAS society recommendations in liver surgery leads to a significant reduction of complications. This outcome justifies the higher cost associated with a well-structured ERAS protocol, as it effectively offsets the expenses of complications.

Clinical and economic comparison of laparoscopic versus open hepatectomy for primary hepatolithiasis: a propensity score-matched cohort study

BACKGROUND

It is unclear whether laparoscopic hepatectomy (LH) for hepatolithiasis confers better clinical benefit and lower hospital costs than open hepatectomy (OH). This study aim to evaluate the clinical and economic value of LH versus OH.

METHODS

Patients undergoing OH or LH for primary hepatolithiasis at Yijishan Hospital of Wannan Medical College between 2015 and 2022 were divided into OH group and LH group. Propensity score matching (PSM) was used to balance the baseline data. Deviation-based cost modelling and weighted average median cost (WAMC) were used to assess and compare the economic value.

RESULTS

A total of 853 patients were identified. After exclusions, 403 patients with primary hepatolithiasis underwent anatomical hepatectomy (OH n=143; LH n=260). PSM resulted in 2 groups of 100 patients each. Although LH required a longer median operation duration compared with OH (285.0 versus 240.0 min, respectively, P<0.001), LH patients had fewer wound infections, fewer pre-discharge overall complications (26 versus 43%, respectively, P=0.009), and shorter median postoperative hospital stays (8.0 versus 12.0 days, respectively, P<0.001). No differences were found in blood loss, major complications, stone clearance, and mortality between the two matched groups. However, the median overall hospital cost of LH was significantly higher than that of OH (CNY¥52,196.1 versus 45,349.5, respectively, P=0.007). Although LH patients had shorter median postoperative hospital stays and fewer complications than OH patients, the WAMC was still higher for the LH group than for the OH group with an increase of CNY¥9,755.2 per patient undergoing LH.

CONCLUSION

The overall clinical benefit of LH for hepatolithiasis is comparable or even superior to that of OH, but with an economic disadvantage. There is a need to effectively reduce the hospital costs of LH and the gap between costs and diagnosis-related group reimbursement to promote its adoption.

Outcomes and Cost Comparison of 3 Different Laparoscopic Approach for Living Donor Nephrectomy: A Retrospective, Single-Center, Inverse Probability of Treatment Weighting Analysis of 551 Cases

BACKGROUND

At our institution, we switched from hand-assisted retroperitoneal laparoscopic donor nephrectomy (HRN) to hand-assisted transperitoneal laparoscopic donor nephrectomy (HTN); we later switched to standard retroperitoneal laparoscopic donor nephrectomy (SRN). This study was performed to evaluate outcomes and hospital costs among the 3 techniques.

METHODS

This retrospective, observational, single-center, inverse probability of treatment weighting analysis study compared the outcomes among 551 cases of living donor kidney transplantation between 2014 and 2022.

RESULTS

After the inverse probability of treatment weighting analysis, there were 114 cases in the HRN group, 204 cases in the HTN group, and 213 cases in the SRN group. Donor complication rates were lowest in the SRN group but did not differ between the HRN and HTN groups (1.1 vs 4.4 and 5.9%, P = .021). Donors in the SRN group had the lowest serum C-reactive protein concentrations on postoperative day 1 (4.3 vs 10.5 and 7.8 mg/dL, P < .001) and the shortest postoperative stay (4.3 vs 7.4 and 8.4 days, P < .001). Donors in the SRN group had the lowest total cost among the 3 groups (8868 vs 9709 and 10,592 USD, P < .0001). Donors in the SRN group also had the lowest costs in terms of "basic medical fees," "medication and injection fees," "Intraoperative drug and material costs," and "testing fees." Furthermore, the presence of complications was significantly correlated with higher total hospital costs (P < .001).

CONCLUSION

SRN appeared to have the least invasive and complication, and a potential cost savings compared with the HRN and HTN.

A systematic review comparing the safety, cost and carbon footprint of disposable and reusable laparoscopic devices

INTRODUCTION

The objective of this systematic review of the literature is to compare a selection of currently utilized disposable and reusable laparoscopic medical devices in terms of safety (1st criteria), cost and carbon footprint.

MATERIAL AND METHODS

A search was carried out on electronic databases for articles published up until 6 May 2022. The eligible works were prospective (randomized or not) or retrospective clinical or medical-economic comparative studies having compared disposable scissors, trocars, and mechanical endoscopic staplers to the same instruments in reusable. Two different independent examiners extracted the relevant data.

RESULTS

Among the 2882 articles found, 156 abstracts were retained for examination. After comprehensive analysis concerning the safety and effectiveness of the instruments, we included four articles. A study on trocars highlighted increased vascular complications with disposable instruments, and another study found more perioperative incidents with a hybrid stapler as opposed to a disposable stapler. As regards cost analysis, we included 11 studies, all of which showed significantly higher costs with disposable instruments. The results of the one study on carbon footprints showed that hybrid instruments leave four times less of a carbon footprint than disposable instruments.

CONCLUSION

The literature on the theme remains extremely limited. Our review demonstrated that from a medical and economic standpoint, reusable medical instruments, particularly trocars, presented appreciable advantages. While there exist few data on the ecological impact, those that do exist are unmistakably favorable to reusable instruments.

Transforming surgical landscapes: obstacles in the integration of robotic surgery in Pakistan -is cost the only limiting factor?

The advantages of Robotic Assisted Surgery (RAS) over laparoscopic surgery encompass enhanced precision, improved ergonomics, shorter learning curves, versatility in complex procedures, and the potential for remote surgery. These benefits contribute to improved patient outcomes which have led to a paradigm shift in robotic surgery worldwide and it is now being hailed as the future of surgery. Robotic surgery was introduced in Pakistan in 2011, but widespread adoption has been limited. The future of RAS in Pakistan demands a strategic and comprehensive plan due to the substantial investment in installation and maintenance costs. Considering Pakistan's status as a low to middle-income country, a well-designed economic model compatible with the existing health system is imperative. The debate over high investments in robotic surgery amid unmet basic surgical needs underscores the complex dynamics of healthcare challenges in the country. In this review, we discuss the potential benefits of robotics over other surgical techniques, where robotic surgery stands in Pakistan and the possible hurdles and barriers limiting its use along with solutions to overcome this in the future.

Value Analysis of Methods of Inguinal Hernia Repair

OBJECTIVE

Value is defined as health outcomes important to patients relative to cost of achieving those outcomes: Value = Quality/Cost. For inguinal hernia repair, Level 1 evidence shows no differences in long-term functional status or recurrence rates when comparing surgical approaches. Differences in value reside within differences in cost. The aim of this study is to compare the value of different surgical approaches to inguinal hernia repair: Open (Open-IH), Laparoscopic (Lap-IH), and Robotic (R-TAPP).

METHODS

Variable and fixed hospital costs were compared among consecutive Open-IH, Lap-IH, and R-TAPP repairs (100 each) performed in a university hospital. Variable costs (VC) including direct materials, labor, and variable overhead ($/min operating room [OR] time) were evaluated using Value Driven Outcomes, an internal activity-based costing methodology. Variable and fixed costs were allocated using full absorption costing to evaluate the impact of surgical approach on value. As cost data is proprietary, differences in cost were normalized to Open-IH cost.

RESULTS

Compared to Open-IH, VC for Lap-IH were 1.02X higher (including a 0.81X reduction in cost for operating room [OR] time). For R-TAPP, VC were 2.11X higher (including 1.36X increased costs for OR time). With allocation of fixed cost, a Lap-IH was 1.03X more costly, whereas R-TAPP was 3.18X more costly than Open-IH. Using equivalent recurrence as the quality metric in the value equation, Lap-IH decreases value by 3% and R-TAPP by 69% compared to Open-IH.

CONCLUSIONS

Use of higher cost technology to repair inguinal hernias reduces value. Incremental health benefits must be realized to justify increased costs. We expect payors and patients will incorporate value into payment decisions.

The impact of operative approach on postoperative outcomes and healthcare utilization after colectomy

BACKGROUND

To evaluate national trends in adoption of different surgical approaches for colectomy and compare clinical outcomes and resource utilization between approaches.

METHODS

Retrospective study of patients aged ≥18 years who underwent elective inpatient left or right colectomy between 2010 and 2019 from the Premier Healthcare Database. Patients were classified by operative approach: open, minimally invasive: either laparoscopic or robotic. Postoperative outcomes assessed within index hospitalization include operating room time, hospital length of stay, rates of conversion to open surgery, reoperation, and complications. Post-discharge readmission, hospital-based encounters, and costs were collected to 30 days post-discharge. Multivariable regression models were used to compare outcomes between operative approaches adjusted for patient baseline characteristics and clustering within hospitals.

RESULTS

Among 206,967 patients, the robotic approach rates increased from 2.1%/1.6% (2010) to 32.6%/26.8% (2019) for left/right colectomy, offset by a decrease in both open and laparoscopic approaches. Median length of stay for both left and right colectomies was significantly longer in open (6 days) and laparoscopic (5 days) compared to robotic surgery (4 days; all P values <.001). Robotic surgery compared to open and laparoscopic was associated with a significantly lower conversion rate, development of ileus, overall complications, and 30-day hospital encounters. Robotic surgery further demonstrated lower mortality, reoperations, postoperative bleeding, and readmission rates for left and right colectomies than open. Robotic surgery had significantly longer operating room times and higher costs than either open or laparoscopic.

CONCLUSIONS

Robotic surgery is increasingly being used in colon surgery, with outcomes equivalent and in some domains superior to laparoscopic.

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

OBJECTIVE

The aim of this study was to understand variation in intraoperative and postoperative utilization for common general surgery procedures.

SUMMARY BACKGROUND DATA

Reducing surgical costs is paramount to the viability of hospitals.

METHODS

Retrospective analysis of electronic health record data for 7762 operations from 2 health systems. Adult patients undergoing laparoscopic cholecystectomy, appendectomy, and inguinal/femoral hernia repair between November 1, 2013 and November 30, 2017 were reviewed for 3 utilization measures: intraoperative disposable supply costs, procedure time, and postoperative length of stay (LOS). Crossed hierarchical regression models were fit to understand case-mixed adjusted variation in utilization across surgeons and locations and to rank surgeons.

RESULTS

The number of surgeons performing each type of operation ranged from 20 to 63. The variation explained by surgeons ranged from 8.9% to 38.2% for supply costs, from 15.1% to 54.6% for procedure time, and from 1.3% to 7.0% for postoperative LOS. The variation explained by location ranged from 12.1% to 26.3% for supply costs, from 0.2% to 2.5% for procedure time, and from 0.0% to 31.8% for postoperative LOS. There was a positive correlation (ρ = 0.49, P = 0.03) between surgeons' higher supply costs and longer procedure times for hernia repair, but there was no correlation between other utilization measures for hernia repair and no correlation between any of the utilization measures for laparoscopic appendectomy or cholecystectomy.

CONCLUSIONS

Surgeons are significant drivers of variation in surgical supply costs and procedure time, but much less so for postoperative LOS. Intraoperative and postoperative utilization profiles can be generated for individual surgeons and may be an important tool for reducing surgical costs.

Enhanced Recovery Pathway Benefits Patients Undergoing Nonelective Colorectal Surgery

OBJECTIVE

The aim of our study was to determine if an enhanced recovery pathway (ERP) can successfully be applied in nonelective colorectal surgery.

BACKGROUND

ERPs have been shown to reduce hospital length of stay (LOS), complications, and costs after elective colorectal surgery. Yet, little data exist regarding the benefits of ERPs in patients undergoing nonelective colorectal surgery. We hypothesized that ERP implementation in a nonelective colorectal surgery population is associated with decreased postoperative LOS.

METHODS

A prospectively-maintained database was used to identify consecutive patients undergoing colorectal surgery after emergency room (ER) or hospital transfer admissions over a period from 2 years before until 1 year after implementation of a comprehensive ERP. The primary endpoint was LOS. Secondary endpoints included total LOS [TLOS = postoperative LOS + LOS of readmission(s)], readmission rates, complication rates, 30-day mortality, and hospital costs. Univariate and multivariate analyses were performed to assess the relationship between ERP implementation and LOS.

RESULTS

We identified 269 pre-ERP and 135 ERP patients fulfilling the inclusion criteria. Admit source (ER 43.4% vs transfers 56.7%), Charlson comorbidity index, American Society of Anesthesiologists (ASA) status, diagnosis (inflammatory bowel disease 45.8%, malignancy 19.6%, benign intestinal obstructions 10.4%, diverticulitis 9.4%, others 10.4%), and blood loss were comparable (P > 0.05) between the cohorts. Pre-ERP patients had a higher number of previous abdominal surgeries, whereas post-ERP patients had more laparoscopy and more compliance with ERP elements. ERP patients had a shorter postoperative LOS [6 (4, 10) vs 7 (5, 12) days; P = 0.0007]. Hospital costs were 13.4% lower (P = 0.004). Postoperative 30-day morbidity, mortality, and readmissions were comparable, although reoperation rate was higher in the ERP group. On multivariate analysis, ERP implementation and laparoscopy were the only modifiable variables independently associated with shorter LOS, whereas longer operative times and higher ASA classification were associated with longer LOS.

CONCLUSIONS

Patients undergoing nonelective colorectal surgery after ER or hospital transfer admission benefit from the use of an ERP, demonstrating decreased LOS and costs without an increase in complications.

Comparative clinical outcomes of robot-assisted liver resection versus laparoscopic liver resection: A meta-analysis

BACKGROUND

As an emerging technology, robot-assisted surgical system has some potential merits in many complicated endoscopic procedures compared with laparoscopic surgery. But robot-assisted liver resection is still a controversial problem on its advantages compared with laparoscopic liver resection. We aimed to perform the meta-analysis to assess and compare the clinical outcomes of robot-assisted and laparoscopic liver resection.

METHODS

We searched PubMed, Cochrane Library, Embase databases, Clinicaltrials, and Opengrey through March 24, 2020, including references of qualifying articles. English-language, original investigations in humans about robot-assisted and laparoscopic hepatectomy were included. Titles, abstracts, and articles were reviewed by at least 2 independent readers. Continuous and dichotomous variables were compared by the weighted mean difference (WMD) and odds ratio (OR), respectively.

RESULTS

Of 936 titles identified in our original search, 28 articles met our criteria, involving 3544 patients. Compared with laparoscopy, the robot-assisted groups had longer operative time (WMD: 36.93; 95% CI, 19.74-54.12; P < 0.001), lower conversion rate (OR: 0.63; 95% CI, 0.46-0.87; P = 0.005), higher transfusion rate (WMD: 2.39; 95% CI, 1.51-3.76; P < 0.001) and higher total cost (WMD:0.49; 95% CI, 0.42-0.55; P < 0.001). In addition, the baseline characteristics of patients about largest tumor size was larger (WMD: 0.36; 95% CI, 0.16-0.56; P < 0.001) and malignant lesions rate was higher (WMD: 1.50; 95% CI, 1.21-1.86; P < 0.001) in the robot-assisted versus laparoscopic hepatectomy. The subgroup analysis of minor hepatectomy showed robot-assisted was associated with longer operative time (WMD: 36.00; 95% CI, 12.59-59.41; P = 0.003), longer length of stay (WMD: 0.51; 95% CI, 0.02-1.01; p = 0.04) and higher total cost (WMD: 0.48; 95% CI, 0.25-0.72; P < 0.001) (Table 3); while the subgroup analysis of major hepatectomy showed robot-assisted was associated with lower estimated blood loss (WMD: -122.43; 95% CI, -151.78--93.08; P < 0.001).

CONCLUSIONS

Our meta-analysis revealed that robot-assisted was associated with longer operative time, lower conversion rate, higher transfusion rate and total cost, and robot-assisted has certain advantages in major hepatectomy compared with laparoscopic hepatectomy.

Robotic versus laparoscopic ventral hernia repair: multicenter, blinded randomized controlled trial

OBJECTIVE

To determine whether robotic ventral hernia repair is associated with fewer days in the hospital 90 days after surgery compared with laparoscopic repair.

DESIGN

Pragmatic, blinded randomized controlled trial.

SETTING

Multidisciplinary hernia clinics in Houston, USA.

PARTICIPANTS

124 patients, deemed appropriate candidates for elective minimally invasive ventral hernia repair, consecutively presenting from April 2018 to February 2019.

INTERVENTIONS

Robotic ventral hernia repair (n=65) versus laparoscopic ventral hernia repair (n=59).

MAIN OUTCOME MEASURES

The primary outcome was number of days in hospital within 90 days after surgery. Secondary outcomes included emergency department visits, operating room time, wound complications, hernia recurrence, reoperation, abdominal wall quality of life, and costs from the healthcare system perspective. Outcomes were pre-specified before data collection began and analyzed as intention to treat.

RESULTS

Patients from both groups were similar at baseline. Ninety day follow-up was completed in 123 (99%) patients. No evidence was seen of a difference in days in hospital between the two groups (median 0 v 0 days; relative rate 0.90, 95% confidence interval 0.37 to 2.19; P=0.82). For secondary outcomes, no differences were noted in emergency department visits, wound complications, hernia recurrence, or reoperation. However, robotic repair had longer operative duration (141 v 77 min; mean difference 62.89, 45.75 to 80.01; P≤0.001) and increased healthcare costs ($15 865 (£12 746; €14 125) v $12 955; cost ratio 1.21, 1.07 to 1.38; adjusted absolute cost difference $2767, $910 to $4626; P=0.004). Among patients with robotic ventral hernia repair, two had an enterotomy compared none with laparoscopic repair. The median one month postoperative improvement in abdominal wall quality of life was 3 with robotic ventral hernia repair compared with 15 following laparoscopic repair.

CONCLUSION

This study found no evidence of a difference in 90 day postoperative hospital days between robotic and laparoscopic ventral hernia repair. However, robotic repair increased operative duration and healthcare costs.

TRIAL REGISTRATION

Clinicaltrials.gov NCT03490266.

Robotic-assisted right colectomy versus laparoscopic approach: case-matched study and cost-effectiveness analysis

AIM

The aim of this study is to compare clinical and oncological outcomes of robot-assisted right colectomy with those of conventional laparoscopy-assisted right colectomy, reporting for the first time in literature, a cost-effectiveness analysis.

METHODS

This is a case-matched prospective non-randomized study conducted from October 2013 to October 2017 at Sanchinarro University Hospital, Madrid. Patients with right-sided colonic adenocarcinoma or adenoma, not suitable endoscopic resection were treated with robot-assisted right colectomy and a propensity score-matched (1:1) was used to balance preoperative characteristics of a laparoscopic control group. Perioperative, postoperative, long-term oncological results and costs were analysed, and quality-adjusted life years (QALY), and the cost-effectiveness ratio (ICER) were calculated. The primary end point was to compare the cost-effectiveness differences between both groups. A willingness-to-pay of 20,000 and 30,000 per QALY was used as a threshold to recognize which treatment was most cost effective.

RESULTS

Thirty-five robot-assisted right colectomies were included and a group of 35 laparoscopy-assisted right colectomy was selected. Compared with the laparoscopic group, the robotic group was associated with longer operation times (243 min vs. 179 min, p < 0.001). No significant difference was observed in terms of total costs between the robotic and laparoscopic groups (9455.14 vs 8227.50 respectively, p = 0.21). At a willingness-to-pay threshold of 20,000 and 30,000, there was a 78.78-95.04% probability that the robotic group was cost effective relative to laparoscopic group.

CONCLUSION

Robot-assisted right colectomy is a safe and feasible technique and is a cost-effective procedure.

Ethanol Sclerotherapy versus Laparoscopic Surgery for Endometrioma Treatment: A Prospective, Multicenter, Cohort Pilot Study

STUDY OBJECTIVE

To compare the cost-effectiveness of ultrasound (US)-guided aspiration and ethanol sclerotherapy versus laparoscopic surgery for benign-appearing ovarian endometrioma.

DESIGN

Prospective, cohort pilot study.

SETTING

Multiple centers, Spain.

PATIENTS

Forty patients with suspected ovarian endometrioma identified by US, with a maximum diameter of 35 to 100 mm, of whom 33 met inclusion criteria.

INTERVENTIONS

The study group (n = 17) underwent US-guided aspiration plus sclerotherapy with ethanol, and the control group (n = 14) underwent laparoscopic cystectomy.

MEASUREMENTS AND MAIN RESULTS

Recurrence, complications, and direct costs were compared. One of 17 sclerotherapy patients recurred (5.9%) compared with 4 of 14 laparoscopic surgery patients (28.6%) (odds ratio 0.18, 0.01-1.53). No serious adverse effects (Clavien-Dindo ≥ III) were observed in the sclerotherapy group; 1 patient in the surgery group had a Clavien-Dindo IIIb complication. Median hospital direct costs were significantly lower in the sclerotherapy group than those in the surgery group-266 euros versus 2189 euros.

CONCLUSION

Ethanol sclerotherapy seems to be cost-effective for endometrioma and also appears to reduce complications. In this pilot study, recurrence was not higher than with conventional surgery.

Robotic versus Laparoscopic Sigmoid Colectomy: Analysis of Healthcare Cost and Utilization Project Database

Minimally invasive sigmoid colectomy via the laparoscopic approach (LA) has numerous benefits. We seek to compare outcomes between laparoscopic and robotic sigmoid colectomies. We analyzed the data using the National Inpatient Sample database between 2008 and 2014. Utilization and outcome measures were compared. The seven-year average number of patients who underwent elective sigmoid colectomy in the United States from 2008 to 2014 was estimated to be 197,053. Of these, 95.1 per cent were conducted using the LA. The mean age was 58.33 + 13.6 years and 58.23 + 12.8 years in laparoscopic and robotic approaches, respectively. No significant differences existed in respect to morbidities. Postoperative complications were comparable with respect to other complications. Length of hospital stay was statistically significantly shorter in the robot-assisted approach compared with the LA (mean 4.8 + 4 vs 5.7 + 5 days, respectively, P < 0.001). Patients who underwent robotic surgery had significantly higher total hospital charges than those who underwent laparoscopic surgery (median $45,057 vs $57,871 USD, P < 0.001). The advent of robot-assisted surgery has provided more options for patients and surgeons. Compared with laparoscopy, robot-assisted sigmoid colectomy has no clinical advantages in morbidity and mortality. However, the robotic approach has a significantly higher total charge to the patient.

Nationwide Analysis of Inpatient Laparoscopic Versus Open Inguinal Hernia Repair

Background: Inguinal hernia repair is one of the more common procedures performed in the United States. The optimal surgical approach, however, remains controversial. We aimed to compare the postoperative outcomes and costs between laparoscopic and open inpatient inguinal hernia repairs in a national cohort. Materials and Methods: We performed a retrospective analysis of the National Inpatient Sample during the period 2009-2015. Adult patients (≥18 years old) undergoing laparoscopic and open inguinal hernia repair were included. Multivariable logistic, generalized logistic, and linear regression were used to assess the effect of the laparoscopic approach on postoperative complications, mortality, length of stay, and hospital charges. Results: A total of 41,937 patients undergoing open inguinal hernia repair (N = 36,575) and laparoscopic inguinal hernia repair (N = 5282) were included. Patients undergoing laparoscopic inguinal hernia repair were less likely to have postoperative wound complications (odds ratio [OR]: 0.64, 95% confidence interval [CI]: 0.41-0.98), infection (OR: 0.34, 95% CI: 0.27-0.42), bleeding (OR: 0.72, 95% CI: 0.63-0.82), cardiac failure (OR: 0.72, 95% CI: 0.64-0.82), renal failure (OR: 0.54, 95% CI: 0.47-0.62), respiratory failure (OR: 0.70, 95% CI: 0.58-0.85), and inpatient mortality (OR: 0.27, 95% CI: 0.17-0.40). On average, the laparoscopic approach reduced length of stay by 1.28 days (95% CI: -1.58 to -1.18), and decreased hospital costs by $2400 (95% CI: -$4700 to -$700). Conclusion: Laparoscopic hernia repair is associated with significantly lower rates of postoperative morbidity and mortality, shorter length of hospital stays, and lower hospital costs for inpatient repairs. The laparoscopic approach should be encouraged for the management of appropriate patients with inpatient inguinal hernias.

Letting the Numbers Speak for Themselves: A Simple Approach to Cost Reduction for Laparoscopic Appendectomy

Instrument choices are influenced primarily by a surgeon's training and individual preference. Cost is often of secondary interest, particularly in the absence of any contracted fiscal obligation to the hospital. The purpose of this study was to evaluate how a simple intervention involving dissemination of cost data among a surgeon peer group influenced behavior with respect to surgical instrument choice. Cost data for laparoscopic appendectomies between July-December 2016 were disseminated to surgeons belonging to the same department of a teaching hospital. Each surgeon was provided his or her own cost data along with blinded data for his or her peers for comparison. Cost for each disposable instrument used among the group was provided for reference. Costs of laparoscopic appendectomy performed after the intervention (June-December 2017) were compared with costs before the intervention, for both individual surgeons and the group as a whole. A random effects linear regression model clustered on surgeon was then used to assess the average cost saving of the intervention while accounting for the intracorrelation of surgeon costs. One outlier was removed from the analysis, resulting in a cohort of 89 cases before the intervention and 74 postintervention. After outlier removal, data were normally distributed. The mean cost per case decreased for 10 of the 11 surgeons analyzed (minimum decrease of $7 to maximum decrease of $725). The remaining surgeon increased from an average of $985 ± 235 pre-intervention to $1003 ± 227 postintervention. The average cost saving for the group was $238 ± 226 and was associated with an average reduction in cost of 21 per cent. A linear regression analysis clustered on surgeon suggested the intervention was associated with an average saving of $260 (β = -260, SE = 39, P < 0.001). After dissemination of cost data among surgeon peers, a reduction in costs was observed. Most notably, significant savings occurred in the absence of any mandate or incentive to reduce costs. Providing cost data to surgeons to facilitate natural competition among peers is a simple and effective tool for reducing operating room costs.

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 ± 1.80 vs 1.47 ± 1.99, P = .019) and 8a (2.52 ± 1.88 vs 1.48 ± 1.43, 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.

Laparoscopically assisted versus open oesophagectomy for patients with oesophageal cancer-the Randomised Oesophagectomy: Minimally Invasive or Open (ROMIO) study: protocol for a randomised controlled trial (RCT)

INTRODUCTION

Surgery (oesophagectomy), with neoadjuvant chemo(radio)therapy, is the main curative treatment for patients with oesophageal cancer. Several surgical approaches can be used to remove an oesophageal tumour. The Ivor Lewis (two-phase procedure) is usually used in the UK. This can be performed as an open oesophagectomy (OO), a laparoscopically assisted oesophagectomy (LAO) or a totally minimally invasive oesophagectomy (TMIO). All three are performed in the National Health Service, with LAO and OO the most common. However, there is limited evidence about which surgical approach is best for patients in terms of survival and postoperative health-related quality of life.

METHODS AND ANALYSIS

We will undertake a UK multicentre randomised controlled trial to compare LAO with OO in adult patients with oesophageal cancer. The primary outcome is patient-reported physical function at 3 and 6 weeks postoperatively and 3 months after randomisation. Secondary outcomes include: postoperative complications, survival, disease recurrence, other measures of quality of life, spirometry, success of patient blinding and quality assurance measures. A cost-effectiveness analysis will be performed comparing LAO with OO. We will embed a randomised substudy to evaluate the safety and evolution of the TMIO procedure and a qualitative recruitment intervention to optimise patient recruitment. We will analyse the primary outcome using a multi-level regression model. Patients will be monitored for up to 3 years after their surgery.

ETHICS AND DISSEMINATION

This study received ethical approval from the South-West Franchay Research Ethics Committee. We will submit the results for publication in a peer-reviewed journal.

TRIAL REGISTRATION NUMBER

ISRCTN10386621.

Comparison of outcome and cost between the open, laparoscopic, and robotic surgical treatments for colon cancer: a propensity score-matched analysis using nationwide hospital record database

BACKGROUND

There are limited studies that compare the cost and outcome of robotic-assisted surgery to open and laparoscopic surgery for colon cancer treatment. We aimed to compare the three surgical modalities for colon cancer treatment.

METHODS

We performed a cohort study using the population-based Nationwide Inpatient Sample database. Patients with a primary diagnosis of colon cancer who underwent robotic, laparoscopic, or open surgeries between 2008 and 2014 were eligible for enrollment. We compared in-hospital mortality, complications, length of hospital stay, and cost for patients undergoing one of these three procedures using a multivariate adjusted logistic regression analysis and propensity score matching.

RESULTS

Of the 531,536 patients undergoing surgical treatment for colon cancer during the study period, 348,645 (65.6%) patients underwent open surgeries, 174,748 (32.9%) underwent laparoscopic surgeries, and 8143 (1.5%) underwent robotic surgeries. In-hospital mortality, length of hospital stay, wound complications, general medical complications, general surgical complications, and costs of the three surgical treatment modalities. Compared to those undergoing laparoscopic surgery, patients undergoing open surgery had a higher mortality rate (OR 2.98, 95% CI 2.61-3.40), more general medical complications (OR 1.77, 95% CI 1.67-1.87), a longer length of hospital stay (6.60 vs. 4.36 days), and higher total cost ($18,541 vs. $14,487) in the propensity score matched cohort. Mortality rate and general medical complications were equivalent in the laparoscopic and robotic surgery groups, but the median cost was lower in the laparoscopic group ($14641 vs. $16,628 USD).

CONCLUSIONS

Laparoscopic colon cancer surgery was associated with a favourable short-term outcome and lower cost compared with open surgery. Robot-assisted surgery had comparable outcomes but higher cost as compared to laparoscopic surgery.

A National study on the adoption of laparoscopic colorectal surgery in the elderly population: current state and value proposition

BACKGROUND

The economic and clinical benefits of laparoscopic colorectal surgery are proven, yet may be underutilized in appropriate cases, especially in the elderly. Since the elderly constitute the greatest colorectal surgical volume, our goal was to identify trends in utilization and impact of laparoscopy in this cohort.

METHODS

A national review of elective inpatient colorectal resections from the Premier Inpatient Database between 2010 and 2015 was performed. Patients were included if elderly (≥ 65 years), then grouped into open or laparoscopic procedures. The main outcome measures were trends in utilization by approach and total costs for the episode of care, length of stay (LOS), readmission, and complications by approach in the elderly. Multivariable regression models controlled for differences across platforms, adjusting for patient demographic, comorbidities and hospital characteristics.

RESULTS

In 70,655 elderly patients evaluated, laparoscopic adoption remained lower than open throughout the study period. Rates increased until 2013, then declined, with increasing rates of open surgery. Laparoscopy was associated with significantly lower mean total costs ($4012 less/case), complications and readmissions (36% and 33% less, respectively), and shorter LOS (2.6 less days) than open cases (all p < 0.0001). When complications occurred, they were less severe and the readmission episodes were less costly with laparoscopy than open colorectal surgery.

CONCLUSION

The adoption of laparoscopy in the elderly has lagged behind open surgery and even declined in recent years despite being associated with improved clinical outcomes and reduced cost. With this tremendous value proposition to increase use of laparoscopic surgery in the elderly, further work needs to evaluate root causes of the disparity.

Management and Outcomes of Acute Appendicitis in the Presence of Cirrhosis: A Nationwide Analysis

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.

The laparoscopic approach to pancreatoduodenectomy is cost neutral in very high-volume centers

BACKGROUND

Little is known regarding the impact of minimally invasive approaches to pancreatoduodenectomy on the aggregate costs of care for patients undergoing pancreatoduodenectomy.

METHODS

We queried the Healthcare Cost and Utilization Project State Inpatient Database to identify patients undergoing elective laparoscopic or open pancreatoduodenectomy between 2014 and 2016.

RESULTS

In this database, 488 (10%) patients underwent elective laparoscopic; 4,544 (90%) underwent open pancreatoduodenectomy. On adjusted analysis, the risk of perioperative morbidity and overall duration of hospitalization for patients undergoing elective laparoscopic were identical to those for patients undergoing open pancreatoduodenectomy. Patients undergoing elective laparoscopic in low (+$10,399, 95% confidence interval [$3,700, $17,098]) and moderate to high (+$4,505, 95% confidence interval [$528, $8,481]) volume centers had greater costs than those undergoing open pancreatoduodenectomy in the same centers. In very high-volume centers (>127 pancreatoduodenectomies/year), aggregate costs of care for patients undergoing elective laparoscopic were essentially identical to those undergoing open pancreatoduodenectomy in the same centers (+$815, 95% confidence interval [-$1,530, $3,160]).

CONCLUSION

Rates of morbidity and overall duration of hospitalization for patients undergoing elective laparoscopic are not different than those undergoing open pancreatoduodenectomy. At low to moderate and high-volume centers, elective laparoscopic is associated with greater aggregate costs of care relative to open pancreatoduodenectomy. At very high-volume centers, elective laparoscopic is cost-neutral.

Comparison of surgical payer costs and implication on the healthcare expenses between laparoscopic magnetic sphincter augmentation (MSA) and laparoscopic Nissen fundoplication (LNF) in a large healthcare system

Introduction

Magnetic sphincter augmentation (MSA) is a promising antireflux surgical treatment. The cost associated with the device may be perceived as a drawback by payers, which may limit the adoption of this technique. There are limited data regarding the cost of MSA in the management of reflux disease. The aims of the study were to report the clinical outcome and quality of life measures in patients after MSA and to compare the pharmaceutical and procedure payer costs and the disease-related and overall expense of MSA compared to laparoscopic Nissen fundoplication (LNF) from a payer perspective.

Methods and procedures

This prospective observational study was performed in conjunction with the region’s largest health insurance company. Data were collected on patients who underwent MSA over a 2-year period beginning in September 2015 at the study network hospitals. The LNF comparison group was procured from members’ claims data of the payer. Inclusion was predicated by patients having continuous coverage during study period. The total procedural reimbursement and the disease-related and overall medical claims submitted up to 12 months prior to surgery and up to 12 months following surgery were obtained. The payer reimbursement data are presented as allowed cost per member per month (PMPM). These values were then compared between groups.

Results

There were 195 patients who underwent MSA and 1131 that had LNF. MSA results in comparable symptom control, PPI elimination rate, and quality of life measures compared to values reported for LNF in the literature. The median (IQR) reimbursement of surgery was $13,522 (13,195–14,439) for those who underwent MSA and $13,388 (9951–16,261) for patients with LNF, p = 0.02. In patients who underwent MSA, the median reimbursement related to the upper gastrointestinal disease was $ 305 PMPM, at 12 months prior to surgery and $ 104 at 12 months after surgery, representing 66% decrease in cost. These values were $ 233 PMPM and $126 PMPM for patients who underwent LNF, representing a 46% decrease (p = 0.0001). At 12 months following surgery, the reimbursement for overall medical expenses had decreased by 10.7% in the MSA group and 1.4% in the LNF group when compared to the preoperative baseline reimbursement. The reimbursement for PPI use after surgery showed a 95% decrease in the MSA group and 90% among LNF group when compared to the preoperative baseline (p = 0.10).

Conclusion

When compared with LNF, MSA results in a reduction of disease-related expenses for the payer in the year following surgery. While MSA is associated with a higher procedural payer cost compared to LNF, payer costs may offset due to reduction in the expenses after surgery.

Validation and Extension of the Ventral Hernia Repair Cost Prediction Model

BACKGROUND

Repair of ventral and incisional hernias remains a costly challenge for health care systems. In a previous study of a single surgeon's elective open ventral hernia repair (VHR) practice, a cost model was developed, which predicted over 70% of hospital cost variation. The purpose of the present study was to evaluate the ventral hernia cost model with multiple surgeons' elective open VHR cases and extending to include nonelective and laparoscopic VHR.

MATERIALS AND METHODS

With the University of Kentucky Institutional Review Board approval, elective and emergent cases of open and laparoscopic VHR performed by multiple surgeons over 3 y were identified. Perioperative variables were obtained from the local American College of Surgeons National Surgery Quality Improvement Program database and electronic medical record review. Hospital cost data were obtained from the hospital cost accounting system. Forward multivariable regression of log-transformed costs identified independent cost drivers (P for entry < 0.05, and P for exit > 0.10).

RESULTS

Of the 387 VHRs, 74% were open repairs; mean age was 55 y, and 52% of patients were female. For open, elective cases (n = 211; mean cost of $19,145), the previously reported six-factor cost model predicted 45% of the total cost variation. With all VHRs included, additional variables were found to independently drive costs, predicting 59% of the total cost variation from the base cost. The biggest cost drivers were inpatient status (+$1013), use of biologic mesh (+$1131), preoperative systemic inflammatory response syndrome/sepsis (+$894), and preoperative open wound (+$786).

CONCLUSIONS

Ventral hernia repair cost variability is predictable. Understanding the independent drivers of cost may be helpful in controlling costs and in negotiating appropriate reimbursement with payers.

Morbidity after surgical management of cervical cancer in low and middle income countries: A systematic review and meta-analysis

OBJECTIVE

To investigate morbidity for patients after the primary surgical management of cervical cancer in low and middle-income countries (LMIC).

METHODS

The Pubmed, Cochrane, the Cochrane Central Register of Controlled Trials, Embase, LILACS and CINAHL were searched for published studies from 1st Jan 2000 to 30th June 2017 reporting outcomes of surgical management of cervical cancer in LMIC. Random-effects meta-analytical models were used to calculate pooled estimates of surgical complications including blood transfusions, ureteric, bladder, bowel, vascular and nerve injury, fistulae and thromboembolic events. Secondary outcomes included five-year progression free (PFS) and overall survival (OS).

FINDINGS

Data were available for 46 studies, including 10,847 patients from 11 middle income countries. Pooled estimates were: blood transfusion 29% (95%CI 0.19-0.41, P = 0.00, I2 = 97.81), nerve injury 1% (95%CI 0.00-0.03, I2 77.80, P = 0.00), bowel injury, 0.5% (95%CI 0.01-0.01, I2 = 0.00, P = 0.77), bladder injury 1% (95%CI 0.01-0.02, P = 0.10, I2 = 32.2), ureteric injury 1% (95%CI 0.01-0.01, I2 0.00, P = 0.64), vascular injury 2% (95% CI 0.01-0.03, I2 60.22, P = 0.00), fistula 2% (95%CI 0.01-0.03, I2 = 77.32, P = 0.00,), pulmonary embolism 0.4% (95%CI 0.00-0.01, I2 26.69, P = 0.25), and infection 8% (95%CI 0.04-0.12, I2 95.72, P = 0.00). 5-year PFS was 83% for laparotomy, 84% for laparoscopy and OS was 85% for laparotomy cases and 80% for laparoscopy.

CONCLUSION

This is the first systematic review and meta-analysis of surgical morbidity in cervical cancer in LMIC, which highlights the limitations of the current data and provides a benchmark for future health services research and policy implementation.

The laparoscopic approach to distal pancreatectomy is a value-added proposition for patients undergoing care in moderate-volume and high-volume centers

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.

Open and Laparoscopic Inguinal Hernia Surgery: A Cost Analysis

Background: In the treatment of inguinal hernias, there is little hard evidence concerning the economic reimbursement in the diagnosis-related group (DRG) era. Factors that affect whether a hospital may earn or lose financially depending on open or laparoscopic approach is still underexplored. The aim of this study was to provide a reliable analysis of in-hospital costs and reimbursements in inguinal hernia surgery. Methods: This retrospective study analyzed the 1-year experience in inguinal hernia repair in patients undergoing open Lichtenstein (OL), laparoscopic totally extraperitoneal unilateral (UTEP), or bilateral (BTEP) hernia repair. Demographics, results, costs, and DRG-based reimbursements were recorded and analyzed. Results: During the study period, 39 patients underwent OL, 82 patients UTEP, and 16 patients BTEP. The average total cost amounted to 4126 EUR in OL, 5134 EUR in UTEP, and 7082 EUR in BTEP groups (P < .001). The hospital reimbursement amounted to 5486 EUR, 5252 EUR, and 6555 EUR in the OL, UTEP, and BTEP groups, respectively (P < .001). Finally, the mean hospital earnings were 1360 EUR, 118 EUR, and -527 EUR for each patient in OL, UTEP, and BTEP, respectively (P < .001). Conclusions: In-hospital costs were higher in UTEP and BTEP as compared with OL. The DRG-based reimbursement provided adequate compensation for patients with unilateral inguinal hernia, whereas hospital earnings were profitable in OL group only, and led an overall financial loss in the BTEP group. Surgeons should be conscious that clinical advantages of the laparoscopic approach are not adequately compensated for, from an economic point of view.

Clinical Outcomes and Healthcare Costs Associated with Laparoscopic Appendectomy in a Middle-Income Country with Universal Health Coverage

BACKGROUND

Although many studies have compared outcomes of laparoscopic appendectomy (LA) and open appendectomy (OA), some clinical and economic outcomes continue to be controversial, particularly in low-medium-income countries. We aimed at determining clinical and economic outcomes associated with LA versus OA in adult patients in Colombia.

METHODS

Retrospective, cohort study based on administrative healthcare records included all patients who underwent LA or OA in Colombia's contributory regime between July 1, 2013, and September 30, 2015. Outcomes were 30-day mortality rates, ICU admissions rates, length of stay (LOS), and hospital costs provided until discharge. Propensity score matching techniques were used to balance the baseline characteristics of patients (age, sex, comorbidities based on the Charlson index, insurer, and geographic location) and to estimate the average treatment effect (ATE) of LA as compared to OA over outcomes.

RESULTS

A total of 65,625 subjects were included, 92.9% underwent OA and 7.1% LA. For the entire population, 30-day mortality was 0.74 per 100 appendectomies (95% CI 0.67-0.81), the mean and median LOS were 3.83 days and 1 day, respectively, and the ICU admissions rate during the first 30 days was 7.92% (95% CI 7.71-8.12). The ATE shows an absolute difference in the mortality rate after 30 days of -0.35 per 100 appendectomies (p = 0.023), in favor of LA. No effects on ICU admissions or LOS were identified. LA was found to increase costs by 514.13 USD on average, with total costs of 772.78 USD for OA and 1286.91 USD for LA (p < 0.001).

CONCLUSIONS

In Colombia's contributory regime, LA is associated with lower 30-day mortality rate and higher hospital costs as compared to OA. No differences are found in ICU admissions or LOS.

Value-based assessment of hysterectomy approaches

AIM

By evaluating operative outcomes relative to cost, we compared the value of minimally invasive hysterectomy approaches, including a technique discussed less often in the literature, laparoscopic retroperitoneal hysterectomy (LRH), which incorporates retroperitoneal dissection and ligation of the uterine arteries at their vascular origin.

METHODS

Retrospective chart review of all women (N = 2689) aged greater than or equal to 18 years who underwent hysterectomy for benign conditions from 2011 to 2013 at a high-volume hospital in Maryland, USA. Procedures included: laparoscopic supracervical hysterectomy, robotic-assisted laparoscopic hysterectomy (RALH), total laparoscopic hysterectomy, laparoscopic-assisted vaginal hysterectomy, total vaginal hysterectomy (TVH), and LRH.

RESULTS

Total vaginal hysterectomy had the highest intraoperative complication rate (9.6%; P < 0.0001) but the lowest postoperative complication rate (1.8%; P < 0.0001). Robotics had the highest postoperative complication rate (11.4%; P < 0.0001). LRH had the shortest operative time (71.2 min; P < 0.0001) and the lowest intraoperative complication rates (2.1%; P < 0.0001). LRH and TVH were the least costly (averaging $4061 and $6416, respectively), while RALH was the most costly ($9354). Taking both operative outcomes and cost into account, LRH, TVH and laparoscopic-assisted vaginal hysterectomy yielded the highest value scores; total laparoscopic hysterectomy, RALH, and laparoscopic supracervical hysterectomy yielded the lowest.

CONCLUSION

Understanding the value of surgical interventions requires an evaluation of both operative outcomes and direct hospital costs. Using a quality-cost framework, the LRH approach as performed by high-volume laparoscopic specialists emerged as having the highest calculated value.

Robotic Surgery Is More Expensive with Similar Outcomes in Sleeve Gastrectomy: Analysis of the NIS Database

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).

Combined endo-laparoscopic surgery (CELS) for benign colon polyps: a single institution cost analysis

BACKGROUND

Endoscopic removal of benign colon polyps is not always possible, even with advanced endoscopic techniques. Segmental colectomy has been the traditional therapy but is associated with an increased risk of complications and may be unnecessary since fewer than 20% of these polyps harbor malignancy. Combined endo-laparoscopic surgery (CELS) has emerged as an alternative method to address these polyps. While feasibility, safety, and improved short-term patient outcomes have been demonstrated, there has never been an evaluation of cost comparing these two approaches within a single institution.

METHODS

In this observational cohort study, we compared short-term outcomes and costs of 11 patients who underwent CELS for right colon polyps with 11 patients who underwent a laparoscopic right colectomy between April 2014 and November 2017. The cost analysis covered the perioperative period from operating room to hospital discharge.

RESULTS

A total of 11 patients underwent an attempted CELS procedure for right colon polyps with a success rate of 90% (10/11). The median length of stay (LOS) for CELS patients was 1 day. LOS for patients who underwent a laparoscopic right colectomy at TMC was 3.82 days. The median OR time for CELS was 166.73 (± 57.88) min, compared to 204.73 (± 51.49) min for a laparoscopic right colectomy. The calculated total cost for a CELS patient was $5523.29, compared to $12,626.33 for a laparoscopic right colectomy, for a cost-savings of $7103.04 per patient.

CONCLUSIONS

CELS procedures are associated with good short-term outcomes and are performed at a lower cost compared to traditional laparoscopic colectomy, with the most significant cost saver being shorter hospital LOS. This is the first study to directly compare the cost of CELS to traditional laparoscopic colectomy in the surgical management of benign colon polyps within a single institution.

Laparoscopic transabdominal preperitoneal technique versus open surgery with the ULTRAPRO Hernia System for the repair of female primary femoral hernias-an observational retrospective study

Femoral hernias (FHs), predominantly seen in females, require surgery for cure. To date, surgical repair of primary FHs in female patients with either open surgery or laparoscopic operation has been poorly documented. We retrospectively investigated the treatment of female primary FHs with open surgery using the ULTRAPRO Hernia System (UHS procedure) or the laparoscopic procedure, namely, the transabdominal preperitoneal (TAPP) technique. A total of 41 female patients with primary FHs who had undergone UHS or TAPP were included in this study. The procedural parameters, post-surgical complications, treatment expense, and follow-up results were analyzed. The vast majority of patients (39/41) underwent elective operations: 15 received UHS (including 2 emergency cases) and 26 had TAPP (P = .08). The UHS group had a greater average age, due to the fact that FHs occur often in people with advanced age who tend to have systemic disease, limiting the use of general anesthesia required for TAPP. Compared with UHS, TAPP took a significantly shorter time to complete and patients undergoing TAPP had a dramatically shorter hospital stay. While no recurrence was observed in both groups, post-procedure pain and foreign body sensation were reported by significantly more patients in UHS group. The cost was greater with TAPP. Taken together, we concluded that both UHS and TAPP are effective in the management of female FHs. In view of the advantages and disadvantages between the open and the laparoscopic operation, surgeons can select a procedure according to their skills and patients' situation.

Assessing outcomes and costs of appendectomies performed at rural hospitals

BACKGROUND

The purpose of our study was to assess the outcomes and costs of appendectomies performed at rural and urban hospitals.

METHODS

The National Inpatient Sample (2001-2012) was queried for appendectomies at urban and rural hospitals. Outcomes (disease severity, laparoscopy, complications, length of stay (LOS), and cost) were analyzed.

RESULTS

Rural patients were more likely to be older, male, white, and have Medicaid or no insurance. Rural hospitals were associated with higher negative appendectomy rates (OR = 1.26,95%CI = 1.18-1.34,p < 0.01), less laparoscopy use (OR = 0.65,95%CI = 0.58-0.72,p < 0.01), and slightly shorter LOS (OR = 0.98,95%CI = 0.97-0.99,p < 0.01). There was no consistent association with perforated appendicitis and no difference in complications or costs after adjusting for hospital volume. Yearly trends showed a significant increase in the cases utilizing laparoscopy each year at rural hospitals.

CONCLUSIONS

Rural appendectomies are associated with increased negative appendectomy rates and less laparoscopy use with no difference in complications or costs compared to urban hospitals.

Application of shaft method assisted biological mesh in laparoscopic inguinal hernia repair

To compare the feasibility and advantage of traditional tiling method and shaft method to place biological mesh following laparoscopic repair of inguinal hernia.Sixty cases from January 2013 to January 2014 treated with laparoscopic inguinal hernia neoplasty with biological patches were included. All the cases were randomly divided into control group and observation group. Observation group was treated with shaft method to place biological mesh, while control group was treated with traditional tiling method. The length of the operation, hospital fees, and rate of occurrence of surgical complications were compared.All 60 cases were successfully treated with laparoscope inguinal hernia repair. None were converted to open operations. Total operation times for the observation group and control group were 54 ± 4.5 and 71 ± 7.2 minutes, respectively (P < .05). The hospital fees of the observation group and control group were 21,280 ± 365 RenMinBi Yuan (RMB) and 24,280 ± 428 RMB, respectively (P < .05). The rates of occurrence of surgical complications were 3.33% (1/30) and 16.7% (5/30), respectively (P < .05).The shaft method can be applied in laparoscopic inguinal hernia repair with biological mesh. Compared with the traditional method, the shaft method has apparent advantages, fewer complications during and after the operation.

Affordable Laparoscopic Camera System (ALCS) Designed for Low- and Middle-Income Countries: A Feasibility Study

BACKGROUND

Minimally invasive surgical techniques (MISTs) could have tremendous benefits in resource-poor environment. There is growing interest in MISTs in most low- and middle-income countries (LMIC), but its adoption has remained limited; this is largely due to high cost of the initial setup, lack of technological backup and limited access to training among others. An affordable laparoscopic setup will go a long way in improving access to MISTs.

METHODS

A common zero degrees 10 mm scope is attached on the camera of a low-price smartphone. Two elastic bands are used to fix the scope right in front of the smartphone's main camera; alternatively, a low-cost camera coupler can be used. The device is covered with sterile transparent drapes and a light source connected with a fiber-optic cable for endoscopic use. The image can be seen in real time on a common TV screen through an HDMI connection to the smartphone, with a sterile drape.

RESULTS

We were able to perform the five tasks of the Fundamentals of Laparoscopic Surgery curriculum, using our vision system with proficiency. In a pig model, we performed a tubal ligation to simulate an appendectomy and we were able to suture. No major differences were measured between the two connection systems.

CONCLUSIONS

A low-cost laparoscopic camera system can benefit surgeons and trainees in LMICs. The system is already attractive for use during training, but further studies are needed to evaluate its potential clinical role in LMICs.

Laparoscopic loop ileostomy reversal with intracorporeal anastomosis is associated with shorter length of stay without increased direct cost

BACKGROUND

Laparoscopic ileostomy closure with intracorporeal anastomosis offers potential advantages over open reversal with extracorporeal anastomosis, including earlier return of bowel function and reduced postoperative pain. In this study, we aim to compare the outcome and cost of laparoscopic ileostomy reversal (utilizing either intracorporeal or extracorporeal anastomosis) with open ileostomy reversal.

METHODS

A retrospective review of sequential patients undergoing elective loop ileostomy reversal between 2013 and 2016 at a single, high-volume institution was performed. Patients were stratified on the basis of operative approach: open reversal, laparoscopic-assisted reversal with extracorporeal anastomosis (LE), and laparoscopic reversal with intracorporeal anastomosis (LI). Linear and logistic regressions were utilized to perform multivariate analysis and determine risk-adjusted outcomes.

RESULTS

Of 132 sequential cases of loop ileostomy reversal, 50 (38%) underwent open, 49 (37%) underwent LE, and 33 (22%) underwent LI. Demographic data and preoperative comorbidities were similar between the three cohorts. Median length of stay was significantly shorter for LI (52.1 h, p < 0.05) compared to open (69.0 h) and LE (69.6 h). After risk-adjusted analysis, length of stay was significant shorter in LI compared to LE (GM 0.78, 95% CI 0.64-0.93, p < 0.01) and open reversal (GM 0.78, 95% CI 0.66-0.93, p < 0.01). Risk-adjusted 30-day morbidity rates were similar for LI compared to LE (OR 0.43, 95% CI 0.081-2.33, p = 0.33) and open reversal (OR 0.53, 95% CI 0.09-3.125, p = 0.48). Median in-hospital direct cost was similar for LI ($6575.00), LE ($6722.50), and open reversal ($6181.00).

CONCLUSION

Laparoscopic ileostomy reversal with intracorporeal anastomosis was associated with shorter length of stay without increased overall direct cost. The technique of laparoscopic ileostomy reversal warrants continued study in a randomized clinical trial.

Introduction of robotic surgery for endometrial cancer into a Brazilian cancer service: a randomized trial evaluating perioperative clinical outcomes and costs

OBJECTIVE

The purpose of this study was to evaluate the clinical outcome and costs after the implementation of robotic surgery in the treatment of endometrial cancer, compared to the traditional laparoscopic approach.

METHODS

In this prospective randomized study from 2015 to 2017, eighty-nine patients with endometrial carcinoma that was clinically restricted to the uterus were randomized in robotic surgery (44 cases) and traditional laparoscopic surgery (45 cases). We compared the number of retrieved lymph nodes, total time of surgery, time of each surgical step, blood loss, length of hospital stay, major and minor complications, conversion rates and costs.

RESULTS

The ages of the patients ranged from 47 to 69 years. The median body mass index was 31.1 (21.4-54.2) in the robotic surgery arm and 31.6 (22.9-58.6) in the traditional laparoscopic arm. The median tumor sizes were 4.0 (1.5-10.0) cm and 4.0 (0.0-9.0) cm in the robotic and traditional laparoscopic surgery groups, respectively. The median total numbers of lymph nodes retrieved were 19 (3-61) and 20 (4-34) in the robotic and traditional laparoscopic surgery arms, respectively. The median total duration of the whole procedure was 319.5 (170-520) minutes in the robotic surgery arm and 248 (85-465) minutes in the traditional laparoscopic arm. Eight major complications were registered in each group. The total cost was 41% higher for robotic surgery than for traditional laparoscopic surgery.

CONCLUSIONS

Robotic surgery for endometrial cancer presented equivalent perioperative morbidity to that of traditional laparoscopic surgery. The duration and total cost of robotic surgery were higher than those of traditional laparoscopic surgery.

Application of modified primary closure of the pelvic floor in laparoscopic extralevator abdominal perineal excision for low rectal cancer

AIM

To introduce a novel, modified primary closure technique of laparoscopic extralevator abdominal perineal excision (LELAPE) for low rectal cancer.

METHODS

We retrospectively analyzed data from 76 patients with rectal cancer who underwent LELAPE from March 2013 to May 2016. Patients were classified into the modified primary closure group (32 patients) and the biological mesh closure group (44 patients). The total operating time, reconstruction time, postoperative stay duration, total cost, postoperative complications and tumor recurrence were compared.

RESULTS

All surgery was successfully performed. The pelvic reconstruction time was 14.6 ± 3.7 min for the modified primary closure group, which was significantly longer than that of the biological mesh closure group (7.2 ± 1.9 min, P < 0.001). The total operating time was not different between the two groups (236 ± 20 min vs 248 ± 43 min, P = 0.143). The postoperative hospital stay duration was 8.1 ± 1.9 d, and the total cost was 9297 ± 1260 USD for the modified primary closure group. Notably, both of these categories were significantly lower in this group than those of the biological mesh closure group (P = 0.001 and P = 0.003, respectively). There were no differences observed between groups when comparing other perioperative data, long-term complications or oncological outcomes.

CONCLUSION

The modified primary closure method for reconstruction of the pelvic floor in LELAPE for low rectal cancer is technically feasible, safe and cost-effective.

Cost Effectiveness of Different Methods of Appendiceal Stump Closure during Laparoscopic Appendectomy

There is no standard method for closure of an appendiceal stump during laparoscopic appendectomy. This study compares stump closure using a stapler with closure using an Endoloop ligature. The charts of all patients who underwent laparoscopic appendectomy at a single tertiary care center over a two-year period were reviewed for demographics, comobidities, operative details and costs, and outcomes. There were 325 patients who underwent a laparoscopic appendectomy. The majority, 250 (77%), underwent stump closure with a stapler. They were equivalent in demographics and postoperative complication rates. Cases using an Endoloop were slightly faster in terms of procedure time and room time, and less expensive in terms of operative supply cost. The price difference is not explained by time saved in the operating room and more likely by the equipment price.

Polymeric clips are a quicker and cheaper alternative to endoscopic ligatures for securing the appendiceal stump during laparoscopic appendicectomy

Introduction The use of polymeric clips in securing the appendiceal stump has been increasingly reported as a viable alternative to current methods in emergency laparoscopic appendicectomy. We evaluated the operative outcomes following the use of polymeric clips versus endoscopic ligatures. The primary endpoint was operative time, with secondary outcomes including complications, inpatient stay, and cost analysis. Materials and methods Operative records were retrospectively analysed to identify patients undergoing laparoscopic appendicectomy between January 2014 and June 2015. Data collected included age, gender, body mass index, duration of surgery, length of hospital stay, antibiotic use, preoperative haematological and biochemical parameters, 30-day readmission rate and complications. Results A total of 125 patients were included within the study, with 78 within the endoloop group and 47 in the polymeric clip group. There were no differences in age, gender, body mass index, hospital stay, antibiotic use, 30-day readmission rates or postoperative complications. Operative time was significantly reduced in the polymeric clip group (59 vs. 68 minutes, P = 0.00751). The use of polymeric clips cost £21 compared with £49 for endoloops per operation, which rose to £70 if both clips and endoloops were used during the procedure. Discussion Polymeric clips are a safe, viable and economical method for securing the appendiceal stump during laparoscopic appendicectomy. The clinical significance of nine minutes of reduced operating time in the polymeric clip cohort warrants further study with an adequately powered randomised controlled trial.

Impact of Visceral Obesity and Sarcopenia on Short-Term Outcomes After Colorectal Cancer Surgery

BACKGROUND

With the increased prevalence of obesity and sarcopenia, those patients with both visceral obesity and sarcopenia were at higher risk of adverse outcomes.

AIM

The aim of this study was to ascertain the combined impact of visceral obesity and sarcopenia on short-term outcomes in patients undergoing colorectal cancer surgery.

METHODS

We conducted a prospective study from July 2014 to February 2017. Patients' demographic, clinical characteristics, physical performance, and postoperative short-term outcomes were collected. Patients were classified into four groups according to the presence of sarcopenia or visceral obesity. Clinical variables were compared. Univariate and multivariate analyses evaluating the risk factors for postoperative complications were performed.

RESULTS

A total of 376 patients were included; 50.8 and 24.5% of the patients were identified as having "visceral obesity" and "sarcopenia," respectively. Patients with sarcopenia and visceral obesity had the highest incidence of total, surgical, and medical complications. Patients with sarcopenia or/and visceral obesity all had longer hospital stays and higher hospitalization costs. Age ≥ 65 years, visceral obesity, and sarcopenia were independent risk factors for total complications. Rectal cancer and visceral obesity were independent risk factors for surgical complications. Age ≥ 65 years and sarcopenia were independent risk factors for medical complications. Laparoscopy-assisted operation was a protective factor for total and medical complications.

CONCLUSION

Patients with both visceral obesity and sarcopenia had a higher complication rate after colorectal cancer surgery. Age ≥ 65 years, visceral obesity, and sarcopenia were independent risk factors for total complications. Laparoscopy-assisted operation was a protective factor.

Propensity Score-Matched Analysis of Clinical and Financial Outcomes After Robotic and Laparoscopic Colorectal Resection

PURPOSE

The study aims to evaluate the clinical and financial outcomes of the use of robotic when compared to laparoscopic colorectal surgery and any changes in these over time.

METHODS

From the Premier Perspective database, patients who underwent elective laparoscopic and robotic colorectal resections from 2012 to 2014 were included. Laparoscopic colorectal resections were propensity score matched to robotic cases for patient, disease, procedure, surgeon specialty, and hospital type and volume. The two groups were compared for conversion, hospital stay, 30-day post-discharge readmission, mortality, and complications. Direct, cumulative, and total (including 30-day post-discharge) costs were evaluated. Clinical and financial outcomes were also separately assessed for each of the included years.

RESULTS

Of 36,701 patients, 32,783 (89.3%) had laparoscopic colorectal resection and 3918 (10.7%) had robotic colorectal resection; 4438 procedures (2219 in each group) were propensity score matched. For the entire period, conversion to open approach (4.7 vs. 3.7%, p = 0.1) and hospital stay (mean days [SD] 6 [5.3] vs. 5 [4.6], p = 0.2) were comparable between robotic and laparoscopic procedures. Surgical and medical complications were also the same for the two groups. However, the robotic approach was associated with lower readmission (6.3 vs. 4.8%, p = 0.04). Wound or abdominal infection (4.7 vs. 2.3%, p = 0.01) and respiratory complications (7.4 vs. 4.7%, p = 0.02) were significantly lower for the robotic group in the final year of inclusion, 2014. Direct, cumulative, and total (including 30-day post-discharge) costs were significantly higher for robotic surgery. The difference in costs between the two approaches reduced over time (direct cost difference: 2012, $2698 vs. 2013, $2235 vs. 2014, $1402).

CONCLUSION

Robotic colorectal surgery can be performed with comparable clinical outcomes to laparoscopy. With greater use of the technology, some further recovery benefits may be evident. The robotic approach is more expensive but cost differences have been diminishing over time.

The American Society of Anesthesiologists score influences on postoperative complications and total hospital charges after laparoscopic colorectal cancer surgery

The aim of this study was to investigate the influence of American Society of Anesthesiologists (ASA) scores on postoperative complication rates and total hospital charges following laparoscopic surgery for colorectal cancer.All patients (n = 664) underwent laparoscopic colorectal cancer surgery. A group of patients with an ASA score of 1 or 2 (n = 575) and a group of patients with an ASA score of 3 (n = 89) were compared.The mean age was higher in the group of patients with an ASA score of 3 than in the group of patients with an ASA score of 1 or 2 (70 vs 67 years). The rate of ICU admission (27% vs 15%) was higher in the ASA score 3 group. The mean hospital stay (14 vs 12 days) was longer in the ASA score 3 group. Postoperative 30-day complications (38% vs 27%), 30-day mortality (2% vs 0%), and a Clavien-Dindo classification of ≥3 (21% vs 11%) occurred more frequently in the ASA score 3 group. Mean total hospital charges were significantly higher in the ASA score 3 group (13,906 vs 11,575 USD). Independent risk factors that affected postoperative complications were older age [≥80 years, hazard ratio (HR) = 2.8], an ASA score of 3 (HR = 1.6), and the presence of a primary rectal tumor (HR = 1.6). Postoperative complication rates were 21.9%, 28.5%, and 38.2% in the ASA score 1, 2, and 3 groups, respectively. Total hospital charges were 14,376 USD and 10,877 USD in the groups with and without postoperative complications, respectively. Mean total hospital charges were 10,769 USD, 11,756 USD, and 13,906 USD in the ASA score 1, 2, and 3 groups, respectively.Preoperative ASA scores may be a predictor of postoperative complications and hospital costs when planning laparoscopic surgery for colorectal cancer.

Robotics in HPB surgery

Some major procedures and an assessment of their impact in the field

Feasibility of a multicentre, randomised controlled trial of laparoscopic versus open colorectal surgery in the acute setting: the LaCeS feasibility trial protocol

INTRODUCTION

Acute colorectal surgery forms a significant proportion of emergency admissions within the National Health Service. There is limited evidence to suggest minimally invasive surgery may be associated with improved clinical outcomes in this cohort of patients. Consequently, there is a need to assess the clinical effectiveness and cost-effectiveness of laparoscopic surgery in the acute colorectal setting. However,emergency colorectal surgical trials have previously been difficult to conduct due to issues surrounding recruitment and equipoise. The LaCeS (randomised controlled trial of Laparoscopic versus open Colorectal Surgery in the acute setting) feasibility trial will determine the feasibility of conducting a definitive, phase III trial of laparoscopic versus open acute colorectal resection.

METHODS AND ANALYSIS

The LaCeS feasibility trial is a prospective, multicentre, single-blinded, parallel group, pragmatic randomised controlled feasibility trial. Patients will be randomised on a 1:1 basis to receive eitherlaparoscopic or open surgery. The trial aims to recruit at least 66 patients from five acute general surgical units across the UK. Patients over the age of 18 with a diagnosis of acute colorectal pathology requiring resection on clinical and radiological/endoscopic investigations, with a National Confidential Enquiry into Patient Outcome and Death classification of urgent will be considered eligible for participation. The primary outcome is recruitment. Secondary outcomes include assessing the safety profile of laparoscopic surgery using intraoperative and postoperative complication rates, conversion rates and patient-safety indicators as surrogate markers. Clinical and patient-reported outcomes will also be reported. The trial will contain an embedded qualitative study to assess clinician and patient acceptability of trial processes.

ETHICS AND DISSEMINATION

The LaCeS feasibility trial is approved by the Yorkshire and The Humber, Bradford Leeds Research Ethics Committee (REC reference: 15/ YH/0542). The results from the trial will be presented at national and international colorectal conferences and will be submitted for publication to peer-reviewed journals.

TRIAL REGISTRATION NUMBER

ISRCTN15681041; Pre-results.