Skip to main content

Advertisement

SpringerLink
Log in

A national evaluation of clinical and economic outcomes in open versus laparoscopic colorectal surgery

  • Published:
Surgical Endoscopy Aims and scope Submit manuscript

Abstract

Background

Surgical value is based on optimizing clinical and financial outcomes. The clinical benefits of laparoscopic surgery are well established; however, many patients are still not offered a laparoscopic procedure. Our objective was to compare the modern clinical and financial outcomes of laparoscopic and open colorectal surgery.

Methods

The Premier Perspective database identified patients undergoing elective colorectal resections from January 1, 2013 to December 31, 2013. Cases were stratified by operative approach into laparoscopic and open cohorts. Groups were controlled on all demographics, diagnosis, procedural, hospital characteristics, surgeon volume, and surgeon specialty and then compared for clinical and financial outcomes. The main outcome measures were length of stay (LOS), complications, readmission rates, and cost by surgical approach.

Results

A total of 6343 patients were matched and analyzed in each cohort. The most common diagnosis was diverticulitis (p = 0.0835) and the most common procedure a sigmoidectomy (p = 0.0962). The LOS was significantly shorter in laparoscopic compared to open (mean 5.78 vs. 7.80 days, p < 0.0001). The laparoscopic group had significantly lower readmission (5.82 vs. 7.68 %, p < 0.0001), complication (32.60 vs. 42.28 %, p < 0.0001), and mortality rates (0.52 vs. 1.28 %, p < 0.0001). The total cost was significantly lower in laparoscopic than in open (mean $17,269 vs. $20,552, p < 0.0001). By category, laparoscopy was significantly more cost-effective for pharmacy (p < 0.0001), room and board (p < 0.0001), recovery room (p = 0.0058), ICU (p < 0.0001), and laboratory and imaging services (both p < 0.0001). Surgical supplies (p < 0.0001), surgery (p < 0.0001), and anesthesia (p = 0.0053) were higher for the laparoscopic group.

Conclusions

Laparoscopy is more cost-effective and produces better patient outcomes than open colorectal surgery. Minimally invasive colorectal surgery is now the standard that should be offered to patients, providing value to both patient and provider.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

References

  1. Kohn LT, Corrigan JM, Donaldson MS (1999) To err is human: building a safer health system. National Academy Press, The Institute of Medicine, Washington, DC

    Google Scholar 

  2. Keller DS, Chien HL, Hashemi L, Senagore AJ, Delaney CP (2014) The HARM score: a novel, easy measure to evaluate quality and outcomes in colorectal surgery. Ann Surg 259:1119–1125

    Article  PubMed  Google Scholar 

  3. Wick EC, Shore AD, Hirose K et al (2011) Readmission rates and cost following colorectal surgery. Dis Colon Rectum 54:1475–1479

    Article  PubMed  Google Scholar 

  4. Giebel GD, Groeben N (2008) Social desirability in the measuring of patient satisfaction after treatment of coloproctologic disorders: on shortcomings of general bipolar satisfaction scales for quality management. Langenbecks Arch Surg 393:513–520

    Article  PubMed  Google Scholar 

  5. Gurland BH, Merlino J, Sobol T et al (2013) Surgical complications impact patient perception of hospital care. J Am Coll Surg 217:843–849

    Article  PubMed  Google Scholar 

  6. Dimick JB, Staiger DO, Hall BL, Ko CY, Birkmeyer JD (2013) Composite measures for profiling hospitals on surgical morbidity. Ann Surg 257:67–72

    Article  PubMed  Google Scholar 

  7. Collins TC, Daley J, Henderson WH, Khuri SF (1999) Risk factors for prolonged length of stay after major elective surgery. Ann Surg 230:251–259

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  8. Birkmeyer JD, Gust C, Dimick JB, Birkmeyer NJ, Skinner JS (2012) Hospital quality and the cost of inpatient surgery in the United States. Ann Surg 255:1–5

    Article  PubMed  PubMed Central  Google Scholar 

  9. Centers for Medicare and Medicaid Services. Physician quality reporting system. http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/index.html?redirect=/PQRS/. Last accessed Dec 2014

  10. Centers for Medicare and Medicaid Services, Baltimore, MD. http://www.hcahpsonline.org. Last accessed 2 Dec 2015

  11. Centers for Medicare and Medicaid Readmissions Reduction Program (2012). http://cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/Readmissions-Reduction-Program.html/. Last accessed March 2015

  12. Nelson H, Sargent DJ, COST Study Group (2004) A comparison of laparoscopically assisted and open colectomy for colon cancer. N Engl J Med 350:2050–2059

    Article  CAS  Google Scholar 

  13. Bonjer HJ, Hop WC, Nelson H et al (2007) Laparoscopically assisted vs open colectomy for colon cancer: a meta-analysis. Arch Surg 142:298–303

    Article  PubMed  Google Scholar 

  14. Lacy AM, Garcia-Valdecasas JC, Delgado S et al (2002) Laparoscopy-assisted colectomy versus open colectomy for treatment of non-metastatic colon cancer: a randomised trial. Lancet 359:2224–2229

    Article  PubMed  Google Scholar 

  15. Schwenk W, Haase O, Neudecker JJ, Müller JM (2005) Short term benefits for laparoscopic colorectal resection. Cochrane Database Syst Rev (2):CD003145. doi:10.1002/14651858.CD003145.pub2

  16. Delaney CP, Kiran RP, Senagore AJ, Brady K, Fazio VW (2003) Case-matched comparison of clinical and financial outcome after laparoscopic or open colorectal surgery. Ann Surg 238:67–72

    PubMed  PubMed Central  Google Scholar 

  17. Delaney CP, Marcello PW, Sonoda T, Wise P, Bauer J, Techner L (2010) Gastrointestinal recovery after laparoscopic colectomy: results of a prospective, observational, multicenter study. Surg Endosc 24:653–661

    Article  PubMed  Google Scholar 

  18. Veldkamp R, Kuhry E, Hop WC et al (2005) Laparoscopic surgery versus open surgery for colon cancer: short-term outcomes of a randomised trial. Lancet Oncol 6:477–484

    Article  PubMed  Google Scholar 

  19. Delaney CP, Chang E, Senagore AJ, Broder M (2008) Clinical outcomes and resource utilization associated with laparoscopic and open colectomy using a large national database. Ann Surg 247:819–824

    Article  PubMed  Google Scholar 

  20. Franks PJ, Bosanquet N, Thorpe H et al (2006) Short-term costs of conventional vs laparoscopic assisted surgery in patients with colorectal cancer (MRC CLASICC trial). Br J Cancer 95:6–12

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  21. Green BL, Marshall HC, Collinson F et al (2013) Long-term follow-up of the Medical Research Council CLASICC trial of conventional versus laparoscopically assisted resection in colorectal cancer. Br J Surg 100:75–82

    Article  CAS  PubMed  Google Scholar 

  22. Jayne DG, Guillou PJ, Thorpe H et al (2007) Randomized trial of laparoscopic-assisted resection of colorectal carcinoma: 3-year results of the UK MRC CLASICC Trial Group. J Clin Oncol 25:3061–3068

    Article  PubMed  Google Scholar 

  23. Jayne DG, Thorpe HC, Copeland J, Quirke P, Brown JM, Guillou PJ (2010) Five-year follow-up of the Medical Research Council CLASICC trial of laparoscopically assisted versus open surgery for colorectal cancer. Br J Surg 97:1638–1645

    Article  CAS  PubMed  Google Scholar 

  24. van der Pas MH, Haglind E, Cuesta MA et al (2013) Laparoscopic versus open surgery for rectal cancer (COLOR II): short-term outcomes of a randomised, phase 3 trial. Lancet Oncol 14:210–218

    Article  PubMed  Google Scholar 

  25. Kwon S, Billingham R, Farrokhi E et al (2012) Adoption of laparoscopy for elective colorectal resection: a report from the Surgical Care and Outcomes Assessment Program. J Am Coll Surg 214(909–18):e1

    PubMed  Google Scholar 

  26. Janson M, Bjorholt I, Carlsson P et al (2004) Randomized clinical trial of the costs of open and laparoscopic surgery for colonic cancer. Br J Surg 91:409–417

    Article  CAS  PubMed  Google Scholar 

  27. Park JS, Kang SB, Kim SW, Cheon GN (2007) Economics and the laparoscopic surgery learning curve: comparison with open surgery for rectosigmoid cancer. World J Surg 31:1827–1834

    Article  PubMed  Google Scholar 

  28. Choi YS, Lee SI, Lee TG, Kim SW, Cheon G, Kang SB (2007) Economic outcomes of laparoscopic versus open surgery for colorectal cancer in Korea. Surg Today 37:127–132

    Article  PubMed  Google Scholar 

  29. Braga M, Frasson M, Zuliani W, Vignali A, Pecorelli N, Di Carlo V (2010) Randomized clinical trial of laparoscopic versus open left colonic resection. Br J Surg 97:1180–1186

    Article  CAS  PubMed  Google Scholar 

  30. Ridgway PF, Boyle E, Keane FB, Neary P (2007) Laparoscopic colectomy is cheaper than conventional open resection. Colorectal Dis 9:819–824

    Article  CAS  PubMed  Google Scholar 

  31. Dowson HM, Huang A, Soon Y, Gage H, Lovell DP, Rockall TA (2007) Systematic review of the costs of laparoscopic colorectal surgery. Dis Colon Rectum 50:908–919

    Article  PubMed  Google Scholar 

  32. Jensen CC, Prasad LM, Abcarian H (2012) Cost-effectiveness of laparoscopic vs open resection for colon and rectal cancer. Dis Colon Rectum 55:1017–1023

    Article  PubMed  Google Scholar 

  33. Biondi A, Grosso G, Mistretta A et al (2013) Laparoscopic vs. open approach for colorectal cancer: evolution over time of minimal invasive surgery. BMC Surg 13(Suppl 2):S12

    Article  PubMed  PubMed Central  Google Scholar 

  34. Thompson BS, Coory MD, Gordon LG, Lumley JW (2014) Cost savings for elective laparoscopic resection compared with open resection for colorectal cancer in a region of high uptake. Surg Endosc 28:1515–1521

    Article  PubMed  Google Scholar 

  35. Jordan J, Dowson H, Gage H, Jackson D, Rockall T (2014) Laparoscopic versus open colorectal resection for cancer and polyps: a cost-effectiveness study. Clinicoecon Outcomes Res 6:415–422

    PubMed  PubMed Central  Google Scholar 

  36. Keller DS, Champagne BJ, Reynolds HLJ, Stein SL, Delaney CP (2014) Cost-effectiveness of laparoscopy in rectal cancer. Dis Colon Rectum 57:564–569

    Article  PubMed  Google Scholar 

  37. Premier Research Services. https://www.premierinc.com/transforming-healthcare/healthcare-performance-improvement/premier-research-services/. Last accessed Feb 2015

  38. Charlson ME, Pompei P, Ales KL, MacKenzie CR (1987) A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis 40:373–383

    Article  CAS  PubMed  Google Scholar 

  39. Berg GD, Fleegler E, vanVonno CJ, Thomas E (2005) A matched-cohort study of health services utilization outcomes for a heart failure disease management program. Dis Manag 8:35–41

    Article  PubMed  Google Scholar 

  40. Rotheram-Borus MJ, Song J, Gwadz M, Lee M, Van Rossem R, Koopman C (2003) Reductions in HIV risk among runaway youth. Prev Sci 4:173–187

    Article  PubMed  Google Scholar 

  41. Rubin DB (1997) Estimating causal effects from large data sets using propensity scores. Ann Intern Med 127:757–763

    Article  CAS  PubMed  Google Scholar 

  42. Braitman LE, Rosenbaum PR (2002) Rare outcomes, common treatments: analytic strategies using propensity scores. Ann Intern Med 137:693–695

    Article  PubMed  Google Scholar 

  43. Rosenbaum JE (2009) Patient teenagers? A comparison of the sexual behavior of virginity pledgers and matched nonpledgers. Pediatrics 123:e110–e120

    Article  PubMed  PubMed Central  Google Scholar 

  44. Noblett SE, Horgan AF (2007) A prospective case-matched comparison of clinical and financial outcomes of open versus laparoscopic colorectal resection. Surg Endosc 21:404–408

    Article  CAS  PubMed  Google Scholar 

  45. Aly OE, Quayyum Z (2012) Has laparoscopic colorectal surgery become more cost-effective over time? Int J Colorectal Dis 27:855–860

    Article  CAS  PubMed  Google Scholar 

  46. Agachan F, Joo JS, Sher M, Weiss EG, Nogueras JJ, Wexner SD (1997) Laparoscopic colorectal surgery. Do we get faster? Surg Endosc 11:331–335

    Article  CAS  PubMed  Google Scholar 

  47. Schlachta CM, Mamazza J, Seshadri PA, Cadeddu M, Gregoire R, Poulin EC (2001) Defining a learning curve for laparoscopic colorectal resections. Dis Colon Rectum 44:217–222

    Article  CAS  PubMed  Google Scholar 

  48. Prakash K, Kamalesh NP, Pramil K, Vipin IS, Sylesh A, Jacob M (2013) Does case selection and outcome following laparoscopic colorectal resection change after initial learning curve? Analysis of 235 consecutive elective laparoscopic colorectal resections. J Minim Access Surg 9:99–103

    Article  PubMed  PubMed Central  Google Scholar 

  49. Waters JA, Chihara R, Moreno J, Robb BW, Wiebke EA, George VV (2010) Laparoscopic colectomy: Does the learning curve extend beyond colorectal surgery fellowship? JSLS 14:325–331

    Article  PubMed  PubMed Central  Google Scholar 

  50. Azimuddin K, Rosen L, Reed JF, Stasik JJ, Riether RD, Khubchandani IT (2001) Readmissions after colorectal surgery cannot be predicted. Dis Colon Rectum 44:942–946

    Article  CAS  PubMed  Google Scholar 

  51. Cohen ME, Bilimoria KY, Ko CY, Richards K, Hall BL (2009) Variability in length of stay after colorectal surgery: assessment of 182 hospitals in the national surgical quality improvement program. Ann Surg 250:901–907

    Article  PubMed  Google Scholar 

  52. Delaney CP (2008) Outcome of discharge within 24 to 72 hours after laparoscopic colorectal surgery. Dis Colon Rectum 51:181–185

    Article  PubMed  Google Scholar 

  53. Kalish RL, Daley J, Duncan CC, Davis RB, Coffman GA, Iezzoni LI (1995) Costs of potential complications of care for major surgery patients. Am J Med Qual 10:48–54

    Article  CAS  Google Scholar 

  54. Dimick JB, Staiger DO, Birkmeyer JD (2010) Ranking hospitals on surgical mortality: the importance of reliability adjustment. Health Serv Res 45:1614–1629

    Article  PubMed  PubMed Central  Google Scholar 

  55. Kariv Y, Wang W, Senagore AJ, Hammel JP, Fazio VW, Delaney CP (2006) Multivariable analysis of factors associated with hospital readmission after intestinal surgery. Am J Surg 191:364–371

    Article  PubMed  Google Scholar 

  56. Fox J, Gross CP, Longo W, Reddy V (2012) Laparoscopic colectomy for the treatment of cancer has been widely adopted in the United States. Dis Colon Rectum 55:501–508

    Article  PubMed  Google Scholar 

  57. Carmichael JC, Masoomi H, Mills S, Stamos MJ, Nguyen NT (2011) Utilization of laparoscopy in colorectal surgery for cancer at academic medical centers: Does site of surgery affect rate of laparoscopy? Am Surg 77:1300–1304

    Google Scholar 

  58. Mackenzie H, Cuming T, Miskovic D et al (2015) Design, delivery, and validation of a trainer curriculum for the national laparoscopic colorectal training program in England. Ann Surg 261:149–156

    Article  PubMed  Google Scholar 

Download references

Acknowledgments

The authors acknowledge Niraj Parikh, MS for assistance with data analysis.

Funding

There was no financial support received or funding for this study.

Author information

Authors and Affiliations

  1. Colorectal Surgical Associates, 7900 Fannin, Suite 2700, Houston, TX, 77054, USA

    Deborah S. Keller & Eric M. Haas

  2. University Hospitals-Case Medical Center, Cleveland, OH, USA

    Conor P. Delaney

  3. Healthcare Outcomes and Research, Covidien, Mansfield, MA, USA

    Lobat Hashemi

  4. Division of Colon and Rectal Surgery, Houston Methodist Hospital, Houston, TX, USA

    Deborah S. Keller & Eric M. Haas

  5. Department of Surgery, University of Texas Medical School at Houston, Houston, TX, USA

    Eric M. Haas

Authors
  1. Deborah S. Keller
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Conor P. Delaney
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Lobat Hashemi
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Eric M. Haas
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Deborah S. Keller.

Ethics declarations

Disclosures

Dr. Delaney is a consultant for Covidien (Mansfield, MA, USA)—educational courses. Ms. Hashemi is an employee of Covidien (Mansfield, MA, USA). Dr. Haas is a consultant for Ethicon (Cincinnati, OH, USA)—educational courses. Dr. Keller has no relevant conflicts of interest to disclose.

Appendix

Appendix

See Table 5.

Table 5 ICD-9 diagnosis and procedure codes
Full size table

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Keller, D.S., Delaney, C.P., Hashemi, L. et al. A national evaluation of clinical and economic outcomes in open versus laparoscopic colorectal surgery. Surg Endosc 30, 4220–4228 (2016). https://doi.org/10.1007/s00464-015-4732-6

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00464-015-4732-6

Keywords

Search

Navigation