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

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.

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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

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Authors

Contributions

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.

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Correspondence to Federica Cipriani.

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Cipriani, F., Ratti, F., Cardella, A. et al. Laparoscopic Versus Open Major Hepatectomy: Analysis of Clinical Outcomes and Cost Effectiveness in a High-Volume Center. J Gastrointest Surg 23, 2163–2173 (2019). https://doi.org/10.1007/s11605-019-04112-4

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Keywords

  • Laparoscopic liver resection
  • Major hepatectomies
  • Financial costs
  • Conversion