Laparoscopic vs Open Right Hepatectomy: A Value-Based Analysis Rachel L Medbery, MD, Tatiana S Chadid, MD, John F Sweeney, MD, FACS, Stuart J Knechtle, MD, FACS, David A Kooby, MD, FACS, Shishir K Maithel, MD, FACS, Edward Lin, DO, FACS, Juan M Sarmiento, MD, FACS Current literature lacks sufficient data on outcomes after extensive laparoscopic liver resections. We hypothesized that laparoscopic right hepatectomy (LRH) is associated with better clinical outcomes and less overall hospital costs than open right hepatectomy (ORH), supporting the notion that major laparoscopic hepatic resections carry increased value when compared with the open approach. STUDY DESIGN: We reviewed medical records of all patients at our institution who underwent elective LRH (n ¼ 48) or ORH (n ¼ 57) from May 16, 2008 to March 1, 2012. Patient demographics, preoperative comorbidities, operative details, and postoperative outcomes were compared between the 2 groups. Hospital billing data were collected for each case to determine the average hospital costs per case. RESULTS: Average operative duration, estimated blood loss, intravenous fluid resuscitation requirements, high-grade postoperative complications, the need for postoperative admission to the ICU, and hospital length of stay were significantly less within the LRH cohort. Thirty-day mortality and readmission rates were equivalent between the 2 groups. Despite higher operative costs for LRH ($16,605 vs $10,411, p < 0.001), total postoperative costs were significantly less ($9,075 for LRH vs $16,341 for ORH, p < 0.001), resulting in equivalent overall costs ($25,679 for LRH vs $26,751 for ORH, p ¼ 0.65). CONCLUSIONS: Although overall costs between LRH and ORH are equivalent, clinical outcomes after LRH are comparable to those after ORH, supporting the value of laparoscopy in extensive right hepatic resections. Efforts to reduce operative costs of LRH, while maintaining optimal patient outcomes, should be the focus of surgeons and hospitals moving forward. (J Am Coll Surg 2014;218:929e939. 2014 by the American College of Surgeons)
BACKGROUND:
as a safe and efficient procedure when performed by highly specialized surgeons in centers with extensive experience, studies with greater numbers of cases are needed to confirm the role of a laparoscopic approach to major liver resection. Furthermore, given the current state of health care reform and emphasis on improving quality while cutting costs (therefore increasing value), it is necessary to analyze whether or not laparoscopic liver surgery is associated with potential cost savings. Two recent studies investigated the cost-effectiveness of laparoscopic liver resection.3,4 Although the results of these 2 studies are promising, there are currently no data regarding the financial impact of the laparoscopic approach in major liver resections. This study aimed to compare the clinical and economic impact of laparoscopic right hepatectomy (LRH) vs open right hepatectomy (ORH) in both benign and malignant conditions. We chose right hepatectomy because it is the most commonly performed major liver resection, it is well standardized and reproducible (open approach), and it
To date, only 2 relatively small case-controlled, nonrandomized, comparative studies have evaluated postoperative outcomes comparing minimally invasive right hepatectomy vs an open approach.1,2 The data suggest that the laparoscopic approach in major hepatic resections is associated with less bleeding and fewer transfusion requirements, lower frequency of postsurgical complications, and reduced intensive care and postoperative length of stay. Although such data support the role of laparoscopy Disclosure Information: Nothing to disclose. Received October 23, 2013; Revised December 30, 2013; Accepted January 7, 2014. From the Divisions of General and Gastrointestinal Surgery (Medbery, Chadid, Sweeney, Lin, Sarmiento), Transplantation (Knechtle), and Surgical Oncology (Kooby, Mathiel), Department of Surgery, Emory University School of Medicine, Atlanta, GA. Correspondence address: Juan M Sarmiento, MD, FACS, Department of Surgery, Emory University School of Medicine, 1365 Clifton Rd, Suite A5039, Atlanta, GA 30322. email: [email protected]
ª 2014 by the American College of Surgeons Published by Elsevier Inc.
929
ISSN 1072-7515/14/$36.00 http://dx.doi.org/10.1016/j.jamcollsurg.2014.01.045
930
Table 1.
Medbery et al
J Am Coll Surg
Laparoscopic vs Open Right Hepatectomy
Indications for Operation, Patient Demographics and Comorbidities
Variable
Indication for surgery, n (%) Malignant Benigny Sex (female), n (%) Age, y, mean (SD) Race, n (%) White African-American Hispanic Asian Unknown BMI, kg/m2, mean (SD) Comorbidity, n (%) Hypertension Smoker Diabetes Cerebrovascular disease Coronary artery disease Chronic kidney disease COPD Cirrhosis Neoadjuvant systemic chemotherapy,z n (%) Previous abdominal operations, n, mean (SD)
LRH (n ¼ 48)
ORH (n ¼ 57)
25 23 29 51.9
(52.1) (47.9) (60.4) (15.0)
45 12 34 57.0
(78.9) (21.1) (59.6) (12.4)
27 14 2 2 3 27.9
(56.3) (29.2) (4.2) (4.2) (6.3) (5.6)
37 14 1 2 3 27.8
(64.9) (25.0) (1.8) (3.5) (5.3) (5.7)
0.95
21 11 5 8 3
(43.8) (22.9) (10.4) (16.7) (6.3) 0 (4.2) (2.1) (22.9) (1.4)
30 11 7 5 2 1 2 2 17 1.4
(52.6) (19.3) (12.3) (8.8) (3.5) (1.8) (3.5) (3.5) (29.8) (1.2)
0.36 0.65 0.77 0.22 0.66 1.00 1.00 1.00 0.43 0.45
p Value
0.004*
2 1 11 1.6
0.94 0.06 0.89
*Significant. y Includes hemangioma, adenoma, abscess, right hepatic duct stricture, and cystic disease. z Within 90 days of surgery.
induces the physiologic changes associated with a major liver resection. We hypothesized that LRH is associated with better clinical outcomes and less overall hospital costs than ORH, supporting the notion that major laparoscopic hepatic resections carry increased value when compared with the open approach.
METHODS Case selection and operative technique We reviewed the medical records for all patients who underwent elective LRH or ORH for both benign and malignant conditions from May 16, 2008 to March 1, 2012 at Emory University Hospital. Before May 16, 2008, LRH was not performed at our institution. All laparoscopic cases were performed by a single team of surgeons (EL and JS) and subsequently compared with all the open cases performed by the entire group of hepatobiliary surgeons at Emory University Hospital. All LRH cases were performed using a periumbilical gel port to allow for hand-assistance. Our technique for LRH resembles our approach for ORH, and in brief, is as follows. The abdominal cavity is entered under direct
visualization using the Optiview trocar (Ethicon EndoSurgery, Inc). After that, the hand port and remaining trocars are placed and laparoscopic intraoperative ultrasound is typically used at this point to evaluate the hepatic lesion. Next, the gallbladder is removed and followed by dissection of the right hepatic artery and right portal vein. Mobilization of the liver is performed and the inferior vena cava is dissected. At this point, the right hepatic vein is exposed with additional dissection, ligated, and then divided. The liver is then transected over the line of demarcation. Parenchyma is typically dissected with an ultrasonic device and major blood vessels with staplers. We do not use the Pringle maneuver, and the right hepatic duct is taken intraparenchymally. The specimen is then removed via the hand port and hemostasis is achieved with cautery, suture, and/or hemostatic agents according to the intensity of the bleeding. There were no strict criteria dictating operative approach (laparoscopic vs open), but instead was decided by each individual operating surgeon. One of the surgeons who performed LRH (JS) also performed ORH (n ¼ 22; 38.6% of all ORH cases) and his decision to proceed with an open vs laparoscopic approach was based
Vol. 218, No. 5, May 2014
Table 2.
Medbery et al
Laparoscopic vs Open Right Hepatectomy
931
Preoperative Data
Variable
Preoperative imaging* Tumor/lesion size, cm, mean (SD) Tumor/lesion number, n (%) 1 2 3 4 Liver biochemistry profile, mean (SD) Hemoglobin, g/dL Platelets, 103/mcl Prothrombin time, s International normalized ratio Creatinine, mg/dL Aspartate aminotransferase, U/L Alanine aminotransferase, U/L Alkaline phosphatase, U/L Total bilirubin, mg/dL MELD score, mean (SD) ECOG, n (%) 0 1 2 3 ASA class, n (%) 1 2 3 4
LRH (n ¼ 48)
ORH (n ¼ 57)
p Value
6.2 (3.4)
7.6 (6.5)
0.22 0.14
15 10 4 12
26 3 7 14
12.8 245.3 12.0 0.99 0.85 33.5 27.7 101.9 0.63 6.9
(31.3) (20.8) (8.3) (25.0) (1.5) (108.6) (1.8) (0.07) (0.27) (35.1) (18.9) (58.6) (0.27) (1.4)
20 (41.7) 22 (45.8) 6 (12.5) 0
12.7 228.9 11.7 1.00 1.03 35.9 32.1 129.6 0.84 7.6 29 21 6 1
(45.6) (5.3) (12.3) (24.6) (1.4) (228.9) (1.2) (0.1) (1.25) (25.1) (20.7) (130.4) (0.73) (2.6)
0.63 0.43 0.31 0.76 0.32 0.35 0.34 0.18 0.06 0.11 0.59
(51.0) (36.8) (10.5) (1.8) 0.03y
2 16 29 1
(4.2) (33.3) (60.4) (2.1)
0 9 (15.8) 48 (84.2) 0
*Based on CT and/or MRI; not available in 14 patients (7 LRH and 7 ORH) as imaging was obtained at outside institutions for these patients. y Significant. ASA, American Society of Anesthesiologists; ECOG, Eastern Cooperative Oncology Group performance status; LRH, laparoscopic right hepatectomy; MELD, Model for End-Stage Liver Disease scoring system; ORH, open right hepatectomy.
on preoperative evaluation of cross-sectional imaging as well as patient history of previous abdominal surgery. Cases started laparoscopically but then converted to open are noted in the results and are defined as LRH after an intention-to-treat analysis. Cases with bile duct excision and/or reconstruction, as well as cases with concurrent procedures (ie, bowel resection) were excluded. Data collection Hospital charts were analyzed for patient demographics, preoperative comorbidities, operative technique, pathology, postoperative complications, hospital length of stay, perioperative mortality, and unplanned hospital readmission. Postoperative complications were recorded if they occurred within 30 days of surgery and were graded using the Clavien-Dindo classification system.5,6
Financial data were collected for each case to determine the overall hospital costs associated with each operation. Approval for the study was obtained from the Institutional Review Board of Emory University Healthcare. Data analysis Data are presented as either median with ranges, mean values with standard deviations, or as counts with percentages. All data are complete except where noted within the text or footnotes of tables. Comparisons of proportions between the 2 groups were made by using chisquare analyses or Fisher’s exact tests, and for continuous variables, either 2-sample t-tests for means or MannWhitney tests for medians where appropriate. Univariate analysis was used to compare patient risk factors and perioperative outcomes associated with LRH vs ORH.
932
Table 3.
Medbery et al
J Am Coll Surg
Laparoscopic vs Open Right Hepatectomy
Operative Data
Variable
Converted to open, n (%) Case time (incision to close), min, mean SD Operative room time, min, mean SD Estimated blood loss, mL, mean SD Portal triad clamping, n (%) IV fluid requirement, mL, mean SD Crystalloid Colloid Transfusion requirements, units Red blood cells Platelets Fresh frozen plasma Invasive monitoring, n (%) Arterial line Central venous line Pathology Tumor/lesion size, cmy, mean SD Margin status: positive, n (%)
LRH (n ¼ 48)
5 174 233 281 4
(10.4) (29) (32) (306) (8.3)
ORH (n ¼ 57)
222 285 737 28
e (81) (85) (947) (49.1)
p Value
e
BACKGROUND:
as a safe and efficient procedure when performed by highly specialized surgeons in centers with extensive experience, studies with greater numbers of cases are needed to confirm the role of a laparoscopic approach to major liver resection. Furthermore, given the current state of health care reform and emphasis on improving quality while cutting costs (therefore increasing value), it is necessary to analyze whether or not laparoscopic liver surgery is associated with potential cost savings. Two recent studies investigated the cost-effectiveness of laparoscopic liver resection.3,4 Although the results of these 2 studies are promising, there are currently no data regarding the financial impact of the laparoscopic approach in major liver resections. This study aimed to compare the clinical and economic impact of laparoscopic right hepatectomy (LRH) vs open right hepatectomy (ORH) in both benign and malignant conditions. We chose right hepatectomy because it is the most commonly performed major liver resection, it is well standardized and reproducible (open approach), and it
To date, only 2 relatively small case-controlled, nonrandomized, comparative studies have evaluated postoperative outcomes comparing minimally invasive right hepatectomy vs an open approach.1,2 The data suggest that the laparoscopic approach in major hepatic resections is associated with less bleeding and fewer transfusion requirements, lower frequency of postsurgical complications, and reduced intensive care and postoperative length of stay. Although such data support the role of laparoscopy Disclosure Information: Nothing to disclose. Received October 23, 2013; Revised December 30, 2013; Accepted January 7, 2014. From the Divisions of General and Gastrointestinal Surgery (Medbery, Chadid, Sweeney, Lin, Sarmiento), Transplantation (Knechtle), and Surgical Oncology (Kooby, Mathiel), Department of Surgery, Emory University School of Medicine, Atlanta, GA. Correspondence address: Juan M Sarmiento, MD, FACS, Department of Surgery, Emory University School of Medicine, 1365 Clifton Rd, Suite A5039, Atlanta, GA 30322. email: [email protected]
ª 2014 by the American College of Surgeons Published by Elsevier Inc.
929
ISSN 1072-7515/14/$36.00 http://dx.doi.org/10.1016/j.jamcollsurg.2014.01.045
930
Table 1.
Medbery et al
J Am Coll Surg
Laparoscopic vs Open Right Hepatectomy
Indications for Operation, Patient Demographics and Comorbidities
Variable
Indication for surgery, n (%) Malignant Benigny Sex (female), n (%) Age, y, mean (SD) Race, n (%) White African-American Hispanic Asian Unknown BMI, kg/m2, mean (SD) Comorbidity, n (%) Hypertension Smoker Diabetes Cerebrovascular disease Coronary artery disease Chronic kidney disease COPD Cirrhosis Neoadjuvant systemic chemotherapy,z n (%) Previous abdominal operations, n, mean (SD)
LRH (n ¼ 48)
ORH (n ¼ 57)
25 23 29 51.9
(52.1) (47.9) (60.4) (15.0)
45 12 34 57.0
(78.9) (21.1) (59.6) (12.4)
27 14 2 2 3 27.9
(56.3) (29.2) (4.2) (4.2) (6.3) (5.6)
37 14 1 2 3 27.8
(64.9) (25.0) (1.8) (3.5) (5.3) (5.7)
0.95
21 11 5 8 3
(43.8) (22.9) (10.4) (16.7) (6.3) 0 (4.2) (2.1) (22.9) (1.4)
30 11 7 5 2 1 2 2 17 1.4
(52.6) (19.3) (12.3) (8.8) (3.5) (1.8) (3.5) (3.5) (29.8) (1.2)
0.36 0.65 0.77 0.22 0.66 1.00 1.00 1.00 0.43 0.45
p Value
0.004*
2 1 11 1.6
0.94 0.06 0.89
*Significant. y Includes hemangioma, adenoma, abscess, right hepatic duct stricture, and cystic disease. z Within 90 days of surgery.
induces the physiologic changes associated with a major liver resection. We hypothesized that LRH is associated with better clinical outcomes and less overall hospital costs than ORH, supporting the notion that major laparoscopic hepatic resections carry increased value when compared with the open approach.
METHODS Case selection and operative technique We reviewed the medical records for all patients who underwent elective LRH or ORH for both benign and malignant conditions from May 16, 2008 to March 1, 2012 at Emory University Hospital. Before May 16, 2008, LRH was not performed at our institution. All laparoscopic cases were performed by a single team of surgeons (EL and JS) and subsequently compared with all the open cases performed by the entire group of hepatobiliary surgeons at Emory University Hospital. All LRH cases were performed using a periumbilical gel port to allow for hand-assistance. Our technique for LRH resembles our approach for ORH, and in brief, is as follows. The abdominal cavity is entered under direct
visualization using the Optiview trocar (Ethicon EndoSurgery, Inc). After that, the hand port and remaining trocars are placed and laparoscopic intraoperative ultrasound is typically used at this point to evaluate the hepatic lesion. Next, the gallbladder is removed and followed by dissection of the right hepatic artery and right portal vein. Mobilization of the liver is performed and the inferior vena cava is dissected. At this point, the right hepatic vein is exposed with additional dissection, ligated, and then divided. The liver is then transected over the line of demarcation. Parenchyma is typically dissected with an ultrasonic device and major blood vessels with staplers. We do not use the Pringle maneuver, and the right hepatic duct is taken intraparenchymally. The specimen is then removed via the hand port and hemostasis is achieved with cautery, suture, and/or hemostatic agents according to the intensity of the bleeding. There were no strict criteria dictating operative approach (laparoscopic vs open), but instead was decided by each individual operating surgeon. One of the surgeons who performed LRH (JS) also performed ORH (n ¼ 22; 38.6% of all ORH cases) and his decision to proceed with an open vs laparoscopic approach was based
Vol. 218, No. 5, May 2014
Table 2.
Medbery et al
Laparoscopic vs Open Right Hepatectomy
931
Preoperative Data
Variable
Preoperative imaging* Tumor/lesion size, cm, mean (SD) Tumor/lesion number, n (%) 1 2 3 4 Liver biochemistry profile, mean (SD) Hemoglobin, g/dL Platelets, 103/mcl Prothrombin time, s International normalized ratio Creatinine, mg/dL Aspartate aminotransferase, U/L Alanine aminotransferase, U/L Alkaline phosphatase, U/L Total bilirubin, mg/dL MELD score, mean (SD) ECOG, n (%) 0 1 2 3 ASA class, n (%) 1 2 3 4
LRH (n ¼ 48)
ORH (n ¼ 57)
p Value
6.2 (3.4)
7.6 (6.5)
0.22 0.14
15 10 4 12
26 3 7 14
12.8 245.3 12.0 0.99 0.85 33.5 27.7 101.9 0.63 6.9
(31.3) (20.8) (8.3) (25.0) (1.5) (108.6) (1.8) (0.07) (0.27) (35.1) (18.9) (58.6) (0.27) (1.4)
20 (41.7) 22 (45.8) 6 (12.5) 0
12.7 228.9 11.7 1.00 1.03 35.9 32.1 129.6 0.84 7.6 29 21 6 1
(45.6) (5.3) (12.3) (24.6) (1.4) (228.9) (1.2) (0.1) (1.25) (25.1) (20.7) (130.4) (0.73) (2.6)
0.63 0.43 0.31 0.76 0.32 0.35 0.34 0.18 0.06 0.11 0.59
(51.0) (36.8) (10.5) (1.8) 0.03y
2 16 29 1
(4.2) (33.3) (60.4) (2.1)
0 9 (15.8) 48 (84.2) 0
*Based on CT and/or MRI; not available in 14 patients (7 LRH and 7 ORH) as imaging was obtained at outside institutions for these patients. y Significant. ASA, American Society of Anesthesiologists; ECOG, Eastern Cooperative Oncology Group performance status; LRH, laparoscopic right hepatectomy; MELD, Model for End-Stage Liver Disease scoring system; ORH, open right hepatectomy.
on preoperative evaluation of cross-sectional imaging as well as patient history of previous abdominal surgery. Cases started laparoscopically but then converted to open are noted in the results and are defined as LRH after an intention-to-treat analysis. Cases with bile duct excision and/or reconstruction, as well as cases with concurrent procedures (ie, bowel resection) were excluded. Data collection Hospital charts were analyzed for patient demographics, preoperative comorbidities, operative technique, pathology, postoperative complications, hospital length of stay, perioperative mortality, and unplanned hospital readmission. Postoperative complications were recorded if they occurred within 30 days of surgery and were graded using the Clavien-Dindo classification system.5,6
Financial data were collected for each case to determine the overall hospital costs associated with each operation. Approval for the study was obtained from the Institutional Review Board of Emory University Healthcare. Data analysis Data are presented as either median with ranges, mean values with standard deviations, or as counts with percentages. All data are complete except where noted within the text or footnotes of tables. Comparisons of proportions between the 2 groups were made by using chisquare analyses or Fisher’s exact tests, and for continuous variables, either 2-sample t-tests for means or MannWhitney tests for medians where appropriate. Univariate analysis was used to compare patient risk factors and perioperative outcomes associated with LRH vs ORH.
932
Table 3.
Medbery et al
J Am Coll Surg
Laparoscopic vs Open Right Hepatectomy
Operative Data
Variable
Converted to open, n (%) Case time (incision to close), min, mean SD Operative room time, min, mean SD Estimated blood loss, mL, mean SD Portal triad clamping, n (%) IV fluid requirement, mL, mean SD Crystalloid Colloid Transfusion requirements, units Red blood cells Platelets Fresh frozen plasma Invasive monitoring, n (%) Arterial line Central venous line Pathology Tumor/lesion size, cmy, mean SD Margin status: positive, n (%)
LRH (n ¼ 48)
5 174 233 281 4
(10.4) (29) (32) (306) (8.3)
ORH (n ¼ 57)
222 285 737 28
e (81) (85) (947) (49.1)
p Value
e
