LAPAROSCOPIC VS OPEN PANCREATICODUODENECTOMY: A VALUE ANALYSIS
Tariq Almerey, David Hyman, Gina Porrazzo, Mary Tice, John Stauffer*
Surgery, Mayo Clinic, Jacksonville, FL
Introduction:
Laparoscopic pancreaticoduodenectomy (LPD) has been shown to be safe, feasible, and potentially advantageous over open pancreaticoduodenectomy (OPD). However, there are reports of higher complications, namely postoperative pancreatic fistula (POPF), with LPD. We hypothesized that OPD was associate with lower complications and the aim of this study was to compare LPD to OPD regarding postoperative outcomes (Quality) as well as the financial burden (Cost) in order to obtain an overview of the Value (Quality/Cost) of LPD compared to OPD.
Methods:
From January 2010 to December 2020, OPD (n=347) and LPD (n=242) were performed by a surgical team using the same selection criteria, operative technique, and recovery protocols at a single institution. Total pancreatectomy, additional complex multivisceral resections, and major vascular reconstructions were excluded to diminish selection bias. Operative data and 90 day outcomes were compared and a statistical analysis was performed. Additionally, Cost required for surgery and recovery (additional OR time, readmissions and total hospital days, ICU days, postoperative imaging studies, radiologic and GI interventions, and need for TPN and blood transfusions) gathered and tabulated.
Results:
In all, 261 patients undergoing OPD were compared to 183 patients undergoing LPD. LPD patients were significantly younger (64.3 vs. 67.4, p=0.009) with higher BMI (28.4 vs. 26.7, p=0.002) but had similar rates of comorbidities, ASA, and ECOG status. LPD was associated with similar operative blood loss, transfusion rates, and need for vascular resection but had significantly longer operative times (472 vs 271 min, p=0.0001).
Regarding Quality of the operation, LPD was associated with similar mortality but significantly higher major complications, pancreatic fistula, hemorrhage, delayed gastric emptying, intra-abdominal abscess, need for postop imaging, need for intensive care, readmission, and total hospital stay (Table 1).
Regarding Cost, the mean Cost for LPD was significantly higher than for OPD (Table 1).
Conclusions:
According to this review at our institution, performing LPD appears to significantly worsen the Quality as well as increase the Cost of PD, therefore detracting significant Value from patients requiring PD. Additional unmeasured Costs including quality of life for the patient, unnecessary burden on the interventional and endoscopic support systems, and opportunity costs lost by the surgeon and OR team by the increase resources necessary for LPD should be examined and added to the overall Cost of LPD in future analyses.
Postoperative outcomes of 261 patients undergoing Open Pancreaticoduodenectomy (OPD) versue 183 patients undergoing Laparoscopic Pancreaticoduodenectomy (LPD) over a 10 year time period.
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