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Laparoscopic Versus Open Major Hepatectomy: Analysis of Clinical Outcomes and Cost Effectiveness in a High-Volume Center

  • Federica CiprianiEmail author
  • Francesca Ratti
  • Arianna Cardella
  • Marco Catena
  • Michele Paganelli
  • Luca Aldrighetti
Original Article
  • 18 Downloads

Abstract

Background

Considering the increasing evidence on the feasibility of laparoscopic major hepatectomies (LMH), their clinical outcomes and associated costs were herein evaluated compared to open (OMH).

Methods

Major contributors of perioperative expenses were considered. With respect to the occurrence of conversion, a primary intention-to-treat analysis including conversions in the LMH group (ITT-A) was performed. An additional per-protocol analysis excluding conversions (PP-A) was undertaken, with calculation of additional costs of conversion analysis.

Results

One hundred forty-five LMH and 61 OMH were included (14.5% conversion rate). At the ITT-A, LMH showed lower blood loss (p < 0.001) and morbidity (global p 0.037, moderate p 0.037), shorter hospital stay (p 0.035), and a lower need for intra- and postoperative red blood cells transfusions (p < 0.001), investigations (p 0.004), and antibiotics (p 0.002). The higher intraoperative expenses (+ 32.1%, p < 0.001) were offset by postoperative savings (− 27.2%, p 0.030), resulting in a global cost-neutrality of LMH (− 7.2%, p 0.807). At the PP-A, completed LMH showed also lower severe complications (p 0.042), interventional procedures (p 0.027), and readmission rates (p 0.031), and postoperative savings increased to − 71.3% (p 0.003) resulting in a 29.9% cost advantage of completed LMH (p 0.020). However, the mean additional cost of conversion was significant.

Conclusions

Completed LMH exhibit a high potential treatment effect compared to OMH and are associated to significant cost savings. Despite some of these benefits may be jeopardized by conversion, a program of LMH can still provide considerable clinical benefits without cost disadvantage and appears worth to be implemented in high-volume centers.

Keywords

Laparoscopic liver resection Major hepatectomies Financial costs Conversion 

Abbreviations

LMH

Laparoscopic major hepatectomies

OMH

Open major hepatectomies

PP-A

Per-protocol analysis

ITT-A

Intention-to-treat analysis

ICU

Intensive care unit

USD

United States dollar

FFP

Fresh frozen plasma

RBC

Red blood cells

Notes

Authors’ Contribution

Federica Cipriani has given substantial contribution to the conception and design of the work, analysis, and interpretation of data; substantial contribution to drafting the manuscript; final approval to the version to be published; agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Francesca Ratti has given substantial contribution to the acquisition, analysis, and interpretation of data; substantial contribution to drafting the manuscript; final approval to the version to be published; agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Arianna Cardella has given substantial contribution to the acquisition, analysis and interpretation of data; substantial contribution to drafting the manuscript; final approval to the version to be published; agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Marco Catena has given substantial contribution to the acquisition, analysis, and interpretation of data; substantial contribution to revise the manuscript critically for important intellectual content; final approval to the version to be published; agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Michele Paganelli has given substantial contribution to the acquisition, analysis and interpretation of data; substantial contribution to revise the manuscript critically for important intellectual content; final approval to the version to be published; agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Luca Aldrighetti has given substantial contribution to the conception and design of the work and interpretation of data; substantial contribution to revise the manuscript critically for important intellectual content; final approval to the version to be published; agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Compliance with Ethical Standards

Conflict of Interest

The authors declare that they have no competing interests.

References

  1. 1.
    Ciria R, Cherqui D, Geller DA, Briceno J, Wakabayashi G. Comparative Short-term Benefits of Laparoscopic Liver Resection: 9000 Cases and Climbing. Ann Surg. 2016; 263:761–777CrossRefGoogle Scholar
  2. 2.
    Nguyen KT, Gamblin TC, Geller DA. World review of laparoscopic liver resection-2,804 patients. Ann Surg. 2009; 250:831–841CrossRefGoogle Scholar
  3. 3.
    Cipriani F, Fantini C, Ratti F, Lauro R, Tranchart H, Halls M, Scuderi V, Barkhatov L, Edwin B, Troisi RI, Dagher I, Reggiani P, Belli G, Aldrighetti L, Abu Hilal M. Laparoscopic liver resections for hepatocellular carcinoma. Can we extend the surgical indication in cirrhotic patients? Surg Endosc. 2018; 32:617–626CrossRefGoogle Scholar
  4. 4.
    Ratti F, Cipriani F, Ariotti R, Gagliano A, Paganelli M, Catena M, Aldrighetti L. Safety and feasibility of laparoscopic liver resection with associated lymphadenectomy for intrahepatic cholangiocarcinoma: a propensity score-based case-matched analysis from a single institution. Surg Endosc. 2016; 30:1999–2010CrossRefGoogle Scholar
  5. 5.
    Scuderi V, Barkhatov L, Montalti R, Ratti F, Cipriani F, Pardo F, Tranchart H, Dagher I, Rotellar F, Abu Hilal M, Edwin B, Vivarelli M, Aldrighetti L, Troisi RI. Outcome after laparoscopic and open resections of posterosuperior segments of the liver. Br J Surg. 2017; 104:751–759CrossRefGoogle Scholar
  6. 6.
    Cipriani F, Shelat VG, Rawashdeh M, Francone E, Aldrighetti L, Takhar A, Armstrong T, Pearce NW, Abu Hilal M. Laparoscopic Parenchymal-Sparing Resections for Nonperipheral Liver Lesions, the Diamond Technique: Technical Aspects, Clinical Outcomes, and Oncologic Efficiency. J Am Coll Surg 2015; 221:265–272.CrossRefGoogle Scholar
  7. 7.
    Conrad C, Ogiso S, Inoue Y, Shivathirthan N, Gayet B. Laparoscopic parenchymal-sparing liver resection of lesions in the central segments: feasible, safe, and effective. Surg Endosc 2015; 29:2410–2417.CrossRefGoogle Scholar
  8. 8.
    Cherqui D. Evolution of laparoscopic liver resection. Br J Surg. 2016;103:1405–1407.CrossRefGoogle Scholar
  9. 9.
    Abu Hilal M, Aldrighetti L, Dagher I, Edwin B, Troisi RI, Alikhanov R, Aroori S, Belli G, Besselink M, Briceno J, Gayet B, D'Hondt M, Lesurtel M, Menon K, Lodge P, Rotellar F, Santoyo J, Scatton O, Soubrane O, Sutcliffe R, Van Dam R, White S, Halls MC, Cipriani F, Van der Poel M, Ciria R, Barkhatov L, Gomez-Luque Y, Ocana-Garcia S, Cook A, Buell J, Clavien PA, Dervenis C, Fusai G, Geller D, Lang H, Primrose J, Taylor M, Van Gulik T, Wakabayashi, Asbun H, Cherqui D. The Southampton Consensus Guidelines for Laparoscopic Liver Surgery: From Indication to Implementation. Ann Surg. 2018;268:11–18CrossRefGoogle Scholar
  10. 10.
    Ratti F, Cipriani F, Ariotti R, Giannone F, Paganelli M, Aldrighetti L. Laparoscopic major hepatectomies: current trends and indications. A comparison with the open technique. Updates Surg. 2015; 67:157–167.CrossRefGoogle Scholar
  11. 11.
    Dagher I, Gayet B, Tzanis D, Tranchart H, Fuks D, Soubrane O, Han HS, Kim KH, Cherqui D, O'Rourke N, Troisi RI, Aldrighetti L, Bjorn E, Abu Hilal M, Belli G, Kaneko H, Jarnagin WR, Lin C, Pekolj J, Buell JF, Wakabayashi G. International experience for laparoscopic major liver resection. J Hepatobiliary Pancreat Sci. 2014; 21:732–736.CrossRefGoogle Scholar
  12. 12.
    Fuks D, Cauchy F, Ftériche S, Nomi T, Schwarz L, Dokmak S, Scatton O, Fusco G, Belghiti J, Gayet B, Soubrane O. Laparoscopy Decreases Pulmonary Complications in Patients Undergoing Major Liver Resection: A Propensity Score Analysis. Ann Surg. 2016;263:353–361CrossRefGoogle Scholar
  13. 13.
    Pearce NW, Di Fabio F, Abu Hilal M. Laparoscopic left hepatectomy with extraparenchymal inflow control. J Am Coll Surg. 2011;213(5):e23–7CrossRefGoogle Scholar
  14. 14.
    Zhang Y, Chen XM, Sun DL. Short-term Outcomes of Laparoscopic Versus Open Right Hemihepatectomy for Hepatocellular Carcinoma. Surg Laparosc Endosc Percutan Tech. 2016;26(6):e157-e160.CrossRefGoogle Scholar
  15. 15.
    Cleary SP, Han HS, Yamamoto M, Wakabayashi G, Asbun H. The comparative costs of laparoscopic and open liver resection: a report for the 2nd International Consensus Conference on Laparoscopic Liver Resection. Surg Endosc. 2016;30:4691–4696CrossRefGoogle Scholar
  16. 16.
    Polignano FM, Quyn AJ, de Figueiredo RS, Henderson NA, Kulli C, Tait IS. Laparoscopic versus open liver segmentectomy: prospective, case-matched, intention-to-treat analysis of clinical outcomes and cost effectiveness. Surg Endosc. 2008;22:2564–2570CrossRefGoogle Scholar
  17. 17.
    Vanounou T, Steel JL, Nguyen KT, Tsung A, Marsh JW, Geller DA, Gamblin TC. Comparing the clinical and economic impact of laparoscopic versus open liver resection. Ann Surg Oncol. 2010;17:998–1009.CrossRefGoogle Scholar
  18. 18.
    Kawaguchi Y, Otsuka Y, Kaneko H, Nagai M, Nomura Y, Yamamoto M, Otani M, Ohashi Y, Sugawara K, Koike D, Ishida T, Kokudo N, Tanaka N. Comparisons of financial and short-term outcomes between laparoscopic and open hepatectomy: benefits for patients and hospitals. Surg Today. 2016;46:535–542.CrossRefGoogle Scholar
  19. 19.
    Dokmak S, Raut V, Aussilhou B, Ftériche FS, Farges O, Sauvanet A, Belghiti J. Laparoscopic left lateral resection is the gold standard for benign liver lesions: a case–control study. HPB (Oxford). 2014;16:183–137CrossRefGoogle Scholar
  20. 20.
    Bell R, Pandanaboyana S, Hanif F, Shah N, Hidalgo E, Lodge JP, Toogood G, Prasad KR. A cost effective analysis of a laparoscopic versus open left lateral sectionectomy in a liver transplant unit. HPB (Oxford). 2015;17:332–336.CrossRefGoogle Scholar
  21. 21.
    Stoot JH, van Dam RM, Coelen RJ, Winkens B, Olde Damink SW, Bemelmans MH, Dejong CH. The introduction of a laparoscopic liver surgery programme: a cost analysis of initial experience in a university hospital. Scand J Surg. 2012;101:32–37.CrossRefGoogle Scholar
  22. 22.
    Halls MC, Cipriani F, Berardi G, Barkhatov L, Lainas P, Alzoubi M, D'Hondt M, Rotellar F, Dagher I, Aldrighetti L, Troisi RI, Edwin B, Hilal MA. Conversion for Unfavorable Intraoperative Events Results in Significantly Worst Outcomes During Laparoscopic Liver Resection: Lessons Learned From a Multicenter Review of 2861 Cases. Ann Surg. 2017;268:1051-1057. doi:  https://doi.org/10.1097/SLA.0000000000002332 CrossRefGoogle Scholar
  23. 23.
    Cauchy F, Fuks D, Nomi T, Schwarz L, Barbier L, Dokmak S, Scatton O, Belghiti J, Soubrane O, Gayet B. Risk factors and consequences of conversion in laparoscopic major liver resection. Br J Surg. 2015;102:785–795.CrossRefGoogle Scholar
  24. 24.
    Strasberg SM. Nomenclature of hepatic anatomy and resections: a review of the Brisbane 2000 system. J Hepatobiliary Pancreat Surg. 2005;12:351–355.CrossRefGoogle Scholar
  25. 25.
    Intention to treat analysis and per protocol analysis: complementary information. Prescrire Int. 2012;21:304–306.Google Scholar
  26. 26.
    NCT01441856 Available at: https://clinicaltrials.gov/ct2/show/NCT01441856. Accessed 20 Sep 2018.
  27. 27.
    Strasberg SM, Linehan DC, Hawkins WG. The accordion severity grading system of surgical complications. Ann Surg. 2009;250:177–186.CrossRefGoogle Scholar
  28. 28.
    Rahbari NN, Garden OJ, Padbury R, Brooke-Smith M, Crawford M, Adam R, Koch M, Makuuchi M, Dematteo RP, Christophi C, Banting S, Usatoff V, Nagino M, Maddern G, Hugh TJ, Vauthey JN, Greig P, Rees M, Yokoyama Y, Fan ST, Nimura Y, Figueras J, Capussotti L, Büchler MW, Weitz J. Posthepatectomy liver failure: a definition and grading by the International Study Group of Liver Surgery (ISGLS). Surgery. 2011;149:713–724CrossRefGoogle Scholar
  29. 29.
    Ishizawa T, Hasegawa K, Kokudo N, Sano K, Imamura H, Beck Y, Sugawara Y, Makuuchi M. Risk factors and management of ascites after liver resection to treat hepatocellular carcinoma. Arch Surg. 2009;144:46–51.CrossRefGoogle Scholar
  30. 30.
    Koch M, Garden OJ, Padbury R, Rahbari NN, Adam R, Capussotti L, Fan ST, Yokoyama Y, Crawford M, Makuuchi M, Christophi C, Banting S, Brooke-Smith M, Usatoff V, Nagino M, Maddern G, Hugh TJ, Vauthey JN, Greig P, Rees M, Nimura Y, Figueras J, DeMatteo RP, Büchler MW, Weitz J. Bile leakage after hepatobiliary and pancreatic surgery: a definition and grading of severity by the International Study Group of Liver Surgery. Surgery. 2011;149:680–688.CrossRefGoogle Scholar
  31. 31.
    Hamady ZZ, Cameron IC, Wyatt J, Prasad RK, Toogood GJ, Lodge JP. Resection margin in patients undergoing hepatectomy for colorectal liver metastasis. Eur J Surg Oncol. 2006;32:557–563CrossRefGoogle Scholar
  32. 32.
    Abu Hilal M, Di Fabio F, Syed S, Wiltshire R, Dimovska E, Turner D, Primrose JN, Pearce NW. Assessment of the financial implications for laparoscopic liver surgery: a single- centre UK cost analysis for minor and major hepatectomy. Surg Endosc. 2013;27:2542–2550.CrossRefGoogle Scholar
  33. 33.
    Medbery RL, Chadid TS, Sweeney JF, Knechtle SJ, Kooby DA, Maithel SK, Lin E, Sarmiento JM. Laparoscopic vs open right hepatectomy: a value based analysis. J Am Coll Surg. 2014;218:929–939.CrossRefGoogle Scholar

Copyright information

© The Society for Surgery of the Alimentary Tract 2019

Authors and Affiliations

  1. 1.Hepatobiliary SurgeryIRCCS San Raffaele HospitalMilanItaly

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