Limongelli P, Vitiello C, Belli A, Pai M, Tolone S, del Genio G, Brusciano L, Docimo G, Habib N, Belli G, Jiao LR, Docimo L. Costs of laparoscopic and open liver and pancreatic resection: A systematic review. World J Gastroenterol 2014; 20(46): 17595-17602 [PMID: 25516675 DOI: 10.3748/wjg.v20.i46.17595]
Corresponding Author of This Article
Paolo Limongelli, MD, PhD, XI Division of General and Obesity Surgery, Second University of Naples, Via Pansini 5, 80131 Naples, Italy. paolo.limongelli@unina2.it
Research Domain of This Article
Surgery
Article-Type of This Article
Systematic Reviews
Open-Access Policy of This Article
This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Paolo Limongelli, Chiara Vitiello, Salvatore Tolone, Gianmattia del Genio, Luigi Brusciano, Giovanni Docimo, Ludovico Docimo, XI Division of General and Obesity Surgery, Second University of Naples, 80131 Naples, Italy
Andrea Belli, Division of Surgical Oncology D, National Cancer Institute of Naples, Fondazione G. Pascale, 80131 Naples, Italy
Madhava Pai, Nagy Habib, Long Richard Jiao, Department of Surgery and Cancer, HPB Surgical Unit, Imperial College, Hammersmith Hospital Campus, London W12 0HS, United Kingdom
Giulio Belli, Department of General and Hepato-Pancreato-Biliary Surgery, S.M. Loreto Nuovo Hospital, 80142 Naples, Italy
ORCID number: $[AuthorORCIDs]
Author contributions: Limongelli P and Vitiello C contributed to conception, design and drafting of the article; Belli A, Pai M, Tolone S, del Genio G, Brusciano and Docimo G contributed to acquisition and interpretation of data; Habib N, Belli G, Jiao LR and Docimo L revised it critically and gave final approval of the version to be published.
Correspondence to: Paolo Limongelli, MD, PhD, XI Division of General and Obesity Surgery, Second University of Naples, Via Pansini 5, 80131 Naples, Italy. paolo.limongelli@unina2.it
Telephone: +39-81-5666237 Fax: +39-81-5666669
Received: March 5, 2014 Revised: April 20, 2014 Accepted: May 26, 2014 Published online: December 14, 2014
Abstract
AIM: To study costs of laparoscopic and open liver and pancreatic resections, all the compiled data from available observational studies were systematically reviewed.
METHODS: A systematic review of the literature was performed using the Medline, Embase, PubMed, and Cochrane databases to identify all studies published up to 2013 that compared laparoscopic and open liver [laparoscopic hepatic resection (LLR) vs open liver resection (OLR)] and pancreatic [laparoscopic pancreatic resection (LPR) vs open pancreatic resection] resection. The last search was conducted on October 30, 2013.
RESULTS: Four studies reported that LLR was associated with lower ward stay cost than OLR (2972 USD vs 5291 USD). The costs related to equipment (3345 USD vs 2207 USD) and theatre (14538 vs 11406) were reported higher for LLR. The total cost was lower in patients managed by LLR (19269 USD) compared to OLR (23419 USD). Four studies reported that LPR was associated with lower ward stay cost than OLR (6755 vs 9826 USD). The costs related to equipment (2496 USD vs 1630 USD) and theatre (5563 vs 4444) were reported higher for LPR. The total cost was lower in the LPR (8825 USD) compared to OLR (13380 USD).
CONCLUSION: This systematic review support the economic advantage of laparoscopic over open approach to liver and pancreatic resection.
Core tip: Laparoscopic hepatobiliary and pancreatic surgery has progressed over the last years but has been slow to gain widespread acceptance even in some referral centers worldwide. Cost implications of a mini-invasive approach to hepatobiliary and pancreatic surgery are still unknown. A systematic review of the literature was performed. The total cost was lower in patients managed by laparoscopic liver resection. The total cost was lower in the laparoscopic pancreatic resection than in open pancreatic resection. This systematic review support the economic advantage of laparoscopic over open approach to liver and pancreatic resection.
Citation: Limongelli P, Vitiello C, Belli A, Pai M, Tolone S, del Genio G, Brusciano L, Docimo G, Habib N, Belli G, Jiao LR, Docimo L. Costs of laparoscopic and open liver and pancreatic resection: A systematic review. World J Gastroenterol 2014; 20(46): 17595-17602
Laparoscopic hepatobiliary and pancreatic (HPB) surgery has undergone a consistent evolution and a progressive diffusion over the last decade, though it may be complex, technically demanding and requires specific high surgical skills[1]. Despite technical challenges, laparoscopic liver surgery has been widely reported with minor and major resections performed for benign and malignant lesions even in cirrhotic patients[2-9]. Although prospective randomized trials are lacking, the laparoscopic approach to liver resection seems to warrant reduced overall morbidity rate and comparable oncological outcomes than the open approach[10-12]. On the other hand, the progression of laparoscopic pancreatic surgery has been relatively slow among traditional surgeons, with only few emerging specialty centers reporting excellent outcomes for advanced and complex operations, such as laparoscopic pancreaticoduodenectomy (LPD)[13-15]. Whereas LPD should still be considered in its learning curve, due to longer operation time and complicated reconstruction steps, laparoscopic distal pancreatectomy (LDP) has been largely compared with the open approach in literature so far. A recent review, suggested that the mini-invasive approach is associated with lower risk of overall postoperative complications and wound infection, no substantial increase in the operative time, and with a comparable rate of positive resection margin[16]. Despite the above mentioned advantages, the laparoscopic approach to HPB surgery has been slow to gain widespread acceptance even in some referral centers worldwide. Multifactorial reasons to explain this exist, but one that may play an important role is related to the unknown cost implications of a mini-invasive approach to HPB surgical interventions. The systematic reviews and/or meta-analyses published so far have analyzed either short- and long-term results of open versus laparoscopic HPB surgery without focusing on cost-effectiveness[17,18]. The present systematic review of the literature compared costs of laparoscopic and open surgical treatment for liver and pancreatic resection, addressing direct and indirect costs.
MATERIALS AND METHODS
Study selection
A systematic review of the literature was performed using the Medline, Embase, PubMed, and Cochrane databases to identify all studies published form 1987 up to 2013 that compared laparoscopic and open liver and pancreatic resection. This study was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines[19]. The following medical subject heading (MeSH) terms and key words were used: “laparoscopy,”“minimally invasive surgery,”“laparotomy,”“hepatectomy,”“liver resection,”“open liver resection (OLR),”“hepatic resection,”“laparoscopic liver resection,”“segmentectomy,”“sectionectomy,”“treatment outcome,” and “wedge resections”, “pancreatectomy,” pancreatoduodenectomy, distal pancreatectomy, “open pancreatic resection,”“laparoscopic pancreatic resection,” and “comparative study”. Furthermore, the combinations of these terms were used. The term “vs” was used to find comparative studies. All the searched abstracts, studies, and citations were analyzed. All the potential articles were cross-referenced. The related article’s function was used to broaden the search, and all abstracts, studies, and citations obtained were reviewed. References of the articles acquired were also searched by hand. The last search was conducted on October 30, 2013.
Data extraction
Each study was independently evaluated by 2 reviewers (P.L. and C.V.) for inclusion or exclusion from the review and the following data was extracted: first author, year of publication, characteristics of study population, study design, indications for surgery, matching criteria, number of subjects operated with each technique and direct and indirect costs.
Inclusion criteria
To enter our analysis, studies had to fulfill the following: (1) comparison of costs of laparoscopic (with or without hand-assisted technique) to open approaches in patients undergoing liver and pancreatic resection; (2) objective evaluation of at least one of the outcome measures mentioned below; and (3) when 2 studies were reported by the same institution (and/or authors), either the study with the larger sample size or the one of higher quality was included. However, this was not applicable if the outcome measures were mutually exclusive or measured at different time intervals.
Exclusion criteria
Studies that failed to fulfill the inclusion criteria were excluded. In addition, the following criteria were used to exclude studies: (1) studies in which the outcome of interest mentioned below were not reported or if it was impossible to calculate these from the published reports; (2) studies that focused on other laparoscopic hepatobiliary and pancreatic operations rather than elective resection benign and malignant lesions; (3) studies involving exclusively robotic procedures. However, we included the conventional laparoscopic and open data, if presented by the same group and/or reported in the same study; and (4) studies written in languages other than English.
Assessment of methodological quality
The methodological quality of the studies was assessed independently by two authors. All studies were graded according to the Oxford Centre for Evidence-Based Medicine (CEBM) levels of evidence[20]. The risk of bias was assessed using a standardized list of ten potential risks of bias, based on the Oxford CEBM Critical Appraisal Skills Programme appraisal sheets for economic evaluation studies[21].
Outcomes of interest and definitions
Laparoscopic and open approaches to HPB surgery were compared on the basis of cost effectiveness analysis. Liver resections were defined according to the Brisbane 2000 classification[22]: minor (two or fewer segments) or major (at least three segments) according to Couinaud’s classification. Cost analysis included theatre costs, equips and equipment costs, nursing, blood transfusion requirement, laboratory testing, postoperative imaging, any re-intervention (radiological and/or surgical) and overall hospital stay. In addition, the cost for readmission from discharge including any associated re-intervention (radiological and/or surgical) and new hospital stay were reviewed. The direct cost of the operation, the direct cost of the postoperative hospital period and the total cost with and without readmission and intervention was analyzed both separately and together. Since most of the data were expressed in US dollars (USD), the remaining were converted to this currency using up to date exchange rates.
Statistical analysis
Mean ± SD or median (range) values were extracted from articles or obtained from the study authors if necessary. Weighted mean ± SD values were calculated using the mean ± SD values reported in the individual studies, or those derived from median (range) values using the methods described by Hozo et al[23]. Cost analysis included operative time and supplies, anesthesia, nursing, laboratory, and overall hospital stay costs. The direct cost of operation, as well as the direct cost of the entire associated hospital stay was calculated.
RESULTS
There were total of 15 studies that compared operative costs between laparoscopic and open hepatic and pancreatic resection for benign and/or malignant lesions. Nine studies compared costs between laparoscopic (344/682) and open (338/682) hepatic resection (LLR vs OLR)[24-32].
Whereas six studies[33-38] focused on costs differences between laparoscopic (249/495) and open (246/495) pancreatic resection (LPR vs OPR). Studies were carried out from different countries all over the word with eight of them reporting figures expressed in USD. The other currencies used to express data in the other studies (pound in 3; Euros in 2; Canadian dollars in 1; South Korean WOW in 1), were converted to USD. Twelve out of fifteen studies were retrospective, with only three reported as prospective cohort studies. All were conducted in a year interval ranging from a minimum of 3 to a maximum of 11 years and on a total number of patients ranging from 30 to 144 patients (Table 1).
Details of the methodological quality of the included studies are shown in Table 2. All the studies provided evidence that the effects of the intervention were measured and valued appropriately.
In none of the studies an analysis of costs and consequences adjusted for different times at which they occurred (discounting) was applicable. A sensitivity analysis was conducted only in one study[35]. Despite the peculiarity of each patient population and setting where the studies were carried out, the costs appeared to be partly translatable to other settings.
Liver resection
Four studies[24,29-31] reported that LLR was associated with lower ward stay cost than OLR (2972 USD vs 5291 USD). This trend concerning hospital costs was confirmed also for High Dependency Unit and Postoperative Anestesia Care Unit (HDU/PACU) that resulted more expensive in patients undergoing OLR (5857 USD vs 1829 USD) (Table 3)[24,29,31]. On the contrary, costs related to operation were higher in the group of patients undergoing LLR. Specifically both equipment (3345 USD vs 2207 USD) and theatre (14538 vs 11406) costs were reported higher for LLR respectively by four[24,26,30,31] and six studies[24,25,31,32]. The total cost was lower in patients managed by LLR (19269 USD) compared to OLR (23419 USD). By analyzing a subset of six[24,25,27,29-31] studies exclusively focused on outcome of minor laparoscopic resection, the total cost of LLR was lower (12720 USD) compared to OLR (17429 USD).
Table 3 Hospital and operative costs of laparoscopic hepatic resection vs open liver resection.
Four studies[35-38] reported that LPR was associated with lower ward stay cost than OLR (6755 USD vs 9826 USD). No studies specifically reported on HDU/PACU costs after either LPR or OPR (Table 4). On the contrary, costs related to operation were higher in the group of patients undergoing LPR. Specifically both equipment (2496 USD vs 1630 USD) and theatre (5563 vs 4444) costs were reported higher for LPR respectively by one[38] and four studies[35-38]. The total cost was lower in the LPR (8825 USD) compared to OLR (13380 USD).
Table 4 Hospital and operative costs of laparoscopic pancreatic resection vs open pancreatic resection.
This systematic review has compared the costs of laparoscopic and open approach to HPB resection and analyzed methodological quality of the studies. Laparoscopic liver resection was associated with higher costs related to equipment and theatre. On the other hand, LLR carried less expensive hospital costs, such as ward costs and peri-operative care. Specifically the costs of HDU and PACU resulted higher in OLR. Finally, when analyzing the total cost of the procedure, the economic advantage for LLR was greater than that for OLR. Laparoscopic pancreatic resection was associated with higher costs related to equipment and theatre. On the other hand, OPR was associated with higher hospital stay cost, such as ward costs, but no studies specifically reported data on costs related to HDU or PACU utilization after LPR or OPR. At last, the total cost of the procedure resulted higher for the group of patients undergoing OPR compared to those treated by LPR. This study is the one of the systematic review to be conducted that specifically compared costs of laparoscopic and open HPB resections. To our knowledge, there has been no randomized controlled trial or systemic review evaluating this topic before. This study included 9 observational studies comparing costs between laparoscopic and open hepatic resection. All studies with an overall participants’ size of 601 patients were retrospectively conducted, with only 2 of them reported as prospective comparisons[25,26]. The inclusion and exclusion criteria of majority of the studies were clearly stated, with most studies having laparoscopic and open resection matched for demographics and characteristics of the patients. None of the studies but one assess the financial implications of laparoscopy for major and minor liver resections[31]. Authors supported the cost advantage of left lateral sectionectomy (LLS), one of the most performed minor LLR. On the other hand they showed cost neutrality of laparoscopic compared to open right liver resection, suggesting that protocols of enhanced recovery after surgery would be likely to reduce costs of both OLR and LLR. In the present study, by analyzing a subset of six studies reporting only data on minor liver resection we found economic advantages in terms of total cost in the group of patients undergoing LLR than OLR.
Concerning pancreatic resections, we found no specific studies comparing laparoscopic versus open pancreaticoduodenectomy that still represents an uncommon indication to laparoscopic approach, and is still performed in few surgical centers worldwide. On the contrary, LDP seems to carry advantages related to minimal-access surgery, such as reduced postoperative pain, faster recovery, wound complications, lower intraoperative blood loss and fewer postoperative complications[39]. So far, six studies have compared costs between laparoscopic and open distal pancreatic resections (LPR vs OPR) and all were retrospective cohorts with a total of 433 patients. Each study had laparoscopic and open resections unmatched for demographics and characteristics of the patients except one who designed a case control comparison with a 2:1 matching[34]. One of the studies also compared the direct cost of operation and of the entire associated hospital stay between OPR, LPR and robotic distal pancreatectomy. Authors showed operative and postoperative costs were similar among all groups, indicating robotic distal pancreatectomy to be safe and cost effective in selected cases. There are some limitations that must be taken into account when interpreting the results of the current analysis. First, by grading down the level of the studies on the basis of study quality, it is clear this systematic review could include only studies of poor-moderate quality. Moreover, we choose not to perform a sensitivity analysis to evaluate the impact of methodological quality on the operative and hospital costs of laparoscopic and open liver and pancreatic resection. This was because of lack of data from studies of the highest quality, defined by a level of evidence of 1 and 2. Confounding by indication was a common risk of bias in most cohort studies because related to the choice of approach merely based on surgeon’s clinical judgment. Specifically, due to the severe heterogeneity of liver resection data collected in this analysis, it is safe to assume that centers would have chosen LLR for minor and uncomplicated cases and OLR for major and complicated cases. Despite the peculiarity of each patient population and setting where the studies were carried out, the methodological evaluation costs appeared to be in part translatable to other settings. However, the economic parameters used in the assessment are likely to differ from country to country, based on the type of healthcare and reimbursement system. In a recent study, a higher proportion of patients treated with LDP were readmitted to undergo interventional procedures after an initial shorter hospitalization[40]. Authors suggested that adding days spent in readmission to the initial length of hospital stay eliminates the perceived effect of the laparoscopic approach to pancreatic distal resection. The majority of studies included in this analysis did not assess and compare costs of laparoscopic and open liver and pancreatic resections before and after readmission to hospital. With respect to pancreatic resection, Fox et al[36] reported a major impact of pancreatic fistula on total hospital cost in the ODP cohort, but comparable in-hospital complications between LDP and ODP cohorts in terms of total hospital cost. In line with this figures, a recent study included in the present review showed the total cost of OLR and LPR were not significantly different after including patients readmission[37]. Among studies addressing comparative costs between OLR and LLR, two of them employed deviation-based cost modeling and weighted average mean cost. One study showed the overall cost savings per patient undergoing laparoscopic LLS was around three thousand dollars less that a patient undergoing a similar open operation[27]. This results were confirmed by Cannon and coworkers who showed an high average cost savings for patients undergoing LLR compared to those treated by OLR[32]. Authors did not find any advantages of laparoscopy in the subset of patients undergoing right hepatectomy, suggesting the benefit of laparoscopy is related to the difficulty of surgery, resulting into a compensation between higher operative costs and the financial benefits of a shorter and less complicated hospital stay. Whether this finding is due to the complexity of a laparoscopic approach associated with dramatic longer operative time or is the result of both higher morbidity and readmission rate after major LLR is still to be demonstrated.
In conclusion, this study summarized the available evidence on financial comparison between laparoscopic and open approach to liver and pancreatic resections including assessment of methodological quality, without an attempt at meta-analysis, as this would have been inappropriate given the heterogeneity in study designs and protocols.
COMMENT
Background
Laparoscopic hepatobiliary and pancreatic (HPB) surgery has undergone a consistent evolution and a progressive diffusion over the last decade, though it may be complex, technically demanding and requires specific high surgical skills.
Research frontiers
The present systematic review of the literature compared costs of laparoscopic and open surgical treatment for liver and pancreatic resection, addressing direct and indirect costs.
Innovations and breakthroughs
A systematic review of the literature was performed using the Medline, Embase, PubMed, and Cochrane databases to identify all studies published up to 2013 that compared laparoscopic and open liver and pancreatic resection.
Applications
This systematic review support the economic advantage of laparoscopic over open approach to liver and pancreatic resection.
Peer review
This study focused on the economical aspect of laparoscopic HPB for the first time in English review articles. This article is novel and well-described.
Footnotes
P- Reviewer: Anadol Z, Fabre JM, Hu H, Jani K, Ogiso S, Tsuchida A S- Editor: Ding Y L- Editor: A E- Editor: Zhang DN
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