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Minimally invasive esophagectomy (MIE) is reported to result in decreased length of hospital stay, blood loss and pulmonary complications compared to open esophagectomy (OE). However, MIE requires a longer operative duration and more advanced technology resulting in a more costly procedure. The purpose of this study was to determine the cost difference between MIE and OE.
METHOD: One hundred and forty one consecutive cases of esophagectomies were reviewed at a single institution between May 2005 and Jan 2012. We excluded in hospital mortalities and MIEs which were converted to OE. The MIE category consisted of laparoscopic Ivor-Lewis esophagectomies and laparoscopic 3-hole esophagectomies. The OE category consisted of transhiatal esophagectomies. A propensity score and quantile regression was used to estimate adjusted median costs associated with all esophagectomies. Propensity scores for MIE vs OE were modeled by logistic regression and adjusted for BMI, smoking status, American Society of Anesthesiology score, coronary artery disease, hyperlipidemia, hypertension, chronic obstructive pulmonary disease, gastroesophageal reflux disease, diabetes and neoadjuvant therapy. Data considered for the comparison analysis were: general surgeon's time, thoracic surgeon's time, anesthesiologist's time, medications administered, surgical equipment, Intensive Care Unit [ICU] cost, intermediate ICU cost and general floor cost.
RESULTS: One hundred and eleven esophagectomies (laparoscopic=78, open=33) were included in the study. Of the 78 MIE patients, two patients underwent laparoscopic Ivor Lewis Esophagectomy and 76 patients underwent thorascopic 3-hole esophagectomy which made up the majority of MIE cases. All 33 OE patients underwent transhiatal esophagectomies. Ten patients were converted from MIE to OE and were excluded from the study. Fourteen patients underwent a hybrid esophagectomy and were excluded from the study. Six hospital mortalities were excluded from the study. The median operative time was 488 (range, 299-651) minutes for MIE vs 266 (range, 146-542) minutes for OE. Median ICU stay for both groups was 3 days. Median Hospital stay was 9 (range, 5-62) days for MIE vs 10 (range, 7-56) days for OE. Perioperative morbidity was 32.6% for MIE vs 48.5% for OE. The estimated median total cost associated with an MIE procedure was $20,898.97 vs $22,577.66 for OE. The difference was substantial $1,678.69 (95% CI $-788.14-$6938.10); however, there was insufficient data to suggest statistical significance.
CONCLUSIONS: A systematic, prospective study analyzing cost differences between MIE and OE is required to better delineate true economic differences.