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Brierley RC, Gaunt D, Metcalfe C, Blazeby JM, Blencowe NS, Jepson M, Berrisford RG, Avery KNL, Hollingworth W, Rice CT, Moure-Fernandez A, Wong N, Nicklin J, Skilton A, Boddy A, Byrne JP, Underwood T, Vohra R, Catton JA, Pursnani K, Melhado R, Alkhaffaf B, Krysztopik R, Lamb P, Culliford L, Rogers C, Howes B, Chalmers K, Cousins S, Elliott J, Donovan J, Heys R, Wickens RA, Wilkerson P, Hollowood A, Streets C, Titcomb D, Humphreys ML, Wheatley T, Sanders G, Ariyarathenam A, Kelly J, Noble F, Couper G, Skipworth RJE, Deans C, Ubhi S, Williams R, Bowrey D, Exon D, Turner P, Daya Shetty V, Chaparala R, Akhtar K, Farooq N, Parsons SL, Welch NT, Houlihan RJ, Smith J, Schranz R, Rea N, Cooke J, Williams A, Hindmarsh C, Maitland S, Howie L, Barham CP. Laparoscopically assisted versus open oesophagectomy for patients with oesophageal cancer-the Randomised Oesophagectomy: Minimally Invasive or Open (ROMIO) study: protocol for a randomised controlled trial (RCT). BMJ Open 2019; 9:e030907. [PMID: 31748296 PMCID: PMC6887040 DOI: 10.1136/bmjopen-2019-030907] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Revised: 06/17/2019] [Accepted: 08/19/2019] [Indexed: 12/24/2022] Open
Abstract
INTRODUCTION Surgery (oesophagectomy), with neoadjuvant chemo(radio)therapy, is the main curative treatment for patients with oesophageal cancer. Several surgical approaches can be used to remove an oesophageal tumour. The Ivor Lewis (two-phase procedure) is usually used in the UK. This can be performed as an open oesophagectomy (OO), a laparoscopically assisted oesophagectomy (LAO) or a totally minimally invasive oesophagectomy (TMIO). All three are performed in the National Health Service, with LAO and OO the most common. However, there is limited evidence about which surgical approach is best for patients in terms of survival and postoperative health-related quality of life. METHODS AND ANALYSIS We will undertake a UK multicentre randomised controlled trial to compare LAO with OO in adult patients with oesophageal cancer. The primary outcome is patient-reported physical function at 3 and 6 weeks postoperatively and 3 months after randomisation. Secondary outcomes include: postoperative complications, survival, disease recurrence, other measures of quality of life, spirometry, success of patient blinding and quality assurance measures. A cost-effectiveness analysis will be performed comparing LAO with OO. We will embed a randomised substudy to evaluate the safety and evolution of the TMIO procedure and a qualitative recruitment intervention to optimise patient recruitment. We will analyse the primary outcome using a multi-level regression model. Patients will be monitored for up to 3 years after their surgery. ETHICS AND DISSEMINATION This study received ethical approval from the South-West Franchay Research Ethics Committee. We will submit the results for publication in a peer-reviewed journal. TRIAL REGISTRATION NUMBER ISRCTN10386621.
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Affiliation(s)
- Rachel C Brierley
- Clinical Trials and Evaluation Unit, Bristol Trials Centre, University of Bristol, University of Bristol, Bristol, UK
| | - Daisy Gaunt
- Bristol Randomised Trials Collaboration, Bristol Trials Centre, University of Bristol, Bristol, UK
| | - Chris Metcalfe
- Bristol Randomised Trials Collaboration, Bristol Trials Centre, University of Bristol, Bristol, UK
| | - Jane M Blazeby
- Centre for Surgical Research, School of Social and Community Medicine, University of Bristol, Bristol, UK
- Division of Surgery, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Natalie S Blencowe
- Centre for Surgical Research, School of Social and Community Medicine, University of Bristol, Bristol, UK
- Division of Surgery, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Marcus Jepson
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | | | - Kerry N L Avery
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - William Hollingworth
- Bristol Medical School: Population Health Sciences, University of Bristol, Bristol, UK
| | - Caoimhe T Rice
- Bristol Medical School: Population Health Sciences, University of Bristol, Bristol, UK
| | - Aida Moure-Fernandez
- Bristol Medical School: Population Health Sciences, University of Bristol, Bristol, UK
| | - Newton Wong
- Department of Cellular Pathology, North Bristol NHS Trust, Southmead Hospital, Bristol, UK
| | - Joanna Nicklin
- Division of Surgery, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Anni Skilton
- Medical Illustration, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Alex Boddy
- Department of Surgery, Leicester Royal Infirmary, Leicester, Leicester, UK
| | - James P Byrne
- Division of Surgery, University Hospital Southampton NHS Foundation Trust, Southampton, Hampshire, UK
| | - Tim Underwood
- Division of Surgery, University Hospital Southampton NHS Foundation Trust, Southampton, Hampshire, UK
| | - Ravi Vohra
- Department of General Surgery, Nottingham City Hospital, Nottingham, UK
| | - James A Catton
- Department of General Surgery, Nottingham City Hospital, Nottingham, UK
| | - Kish Pursnani
- Department of Upper GI Surgery, Royal Preston Hospital, Preston, UK
| | - Rachel Melhado
- Department of Oesophago-Gastric Surgery, Salford Royal NHS Foundation Trust, Salford, UK
| | - Bilal Alkhaffaf
- Department of Oesophago-Gastric Surgery, Salford Royal NHS Foundation Trust, Salford, UK
| | - Richard Krysztopik
- Gastroenterology Department, Royal United Hospital Bath NHS Trust, Bath, UK
| | - Peter Lamb
- General Surgery Department, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Lucy Culliford
- Clinical Trials and Evaluation Unit, Bristol Trials Centre, University of Bristol, University of Bristol, Bristol, UK
| | - Chris Rogers
- Clinical Trials and Evaluation Unit, Bristol Trials Centre, University of Bristol, University of Bristol, Bristol, UK
| | - Benjamin Howes
- Division of Surgery, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Katy Chalmers
- Bristol Medical School: Population Health Sciences, University of Bristol, Bristol, UK
| | - Sian Cousins
- Bristol Medical School: Population Health Sciences, University of Bristol, Bristol, UK
| | | | - Jenny Donovan
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Rachael Heys
- Clinical Trials and Evaluation Unit, Bristol Trials Centre, University of Bristol, University of Bristol, Bristol, UK
| | - Robin A Wickens
- Clinical Trials and Evaluation Unit, Bristol Trials Centre, University of Bristol, University of Bristol, Bristol, UK
| | - Paul Wilkerson
- Division of Surgery, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Andrew Hollowood
- Division of Surgery, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Christopher Streets
- Division of Surgery, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Dan Titcomb
- Division of Surgery, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | | | - Tim Wheatley
- Upper GI Surgery, Derriford Hospital, Plymouth, UK
| | | | | | - Jamie Kelly
- Division of Surgery, University Hospital Southampton NHS Foundation Trust, Southampton, Hampshire, UK
| | - Fergus Noble
- Division of Surgery, University Hospital Southampton NHS Foundation Trust, Southampton, Hampshire, UK
| | - Graeme Couper
- General Surgery Department, Royal Infirmary of Edinburgh, Edinburgh, UK
| | | | - Chris Deans
- General Surgery Department, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Sukhbir Ubhi
- Department of Surgery, Leicester Royal Infirmary, Leicester, Leicester, UK
| | - Robert Williams
- Department of Surgery, Leicester Royal Infirmary, Leicester, Leicester, UK
| | - David Bowrey
- Department of Surgery, Leicester Royal Infirmary, Leicester, Leicester, UK
| | - David Exon
- Department of Surgery, Leicester Royal Infirmary, Leicester, Leicester, UK
| | - Paul Turner
- Department of Upper GI Surgery, Royal Preston Hospital, Preston, UK
| | | | - Ram Chaparala
- Department of Oesophago-Gastric Surgery, Salford Royal NHS Foundation Trust, Salford, UK
| | - Khurshid Akhtar
- Department of Oesophago-Gastric Surgery, Salford Royal NHS Foundation Trust, Salford, UK
| | - Naheed Farooq
- Department of Oesophago-Gastric Surgery, Salford Royal NHS Foundation Trust, Salford, UK
| | - Simon L Parsons
- Department of General Surgery, Nottingham City Hospital, Nottingham, UK
| | - Neil T Welch
- Department of General Surgery, Nottingham City Hospital, Nottingham, UK
| | - Rebecca J Houlihan
- Division of Surgery, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Joanne Smith
- Upper GI Surgery, Derriford Hospital, Plymouth, UK
| | - Rachel Schranz
- Division of Surgery, University Hospital Southampton NHS Foundation Trust, Southampton, Hampshire, UK
| | - Nicola Rea
- General Surgery Department, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Jill Cooke
- Department of Surgery, Leicester Royal Infirmary, Leicester, Leicester, UK
| | | | - Carolyn Hindmarsh
- Department of Oesophago-Gastric Surgery, Salford Royal NHS Foundation Trust, Salford, UK
| | - Sally Maitland
- Department of General Surgery, Nottingham City Hospital, Nottingham, UK
| | - Lucy Howie
- Gastroenterology Department, Royal United Hospital Bath NHS Trust, Bath, UK
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Baltin C, Kron F, Urbanski A, Zander T, Kron A, Berlth F, Kleinert R, Hallek M, Hoelscher AH, Chon SH. The economic burden of endoscopic treatment for anastomotic leaks following oncological Ivor Lewis esophagectomy. PLoS One 2019; 14:e0221406. [PMID: 31461487 PMCID: PMC6713440 DOI: 10.1371/journal.pone.0221406] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Accepted: 08/06/2019] [Indexed: 02/07/2023] Open
Abstract
Background Complications after surgery for esophageal cancer are associated with significant resource utilization. The aim of this study was to analyze the economic burden of two frequently used endoscopic treatments for anastomotic leak management after esophageal surgery: Treatment with a Self-expanding Metal Stent (SEMS) and Endoscopic Vacuum Therapy (EVT). Materials and methods Between January 2012 and December 2016, we identified 60 German-Diagnosis Related Group (G-DRG) cases of patients who received a SEMS and / or EVT for esophageal anastomotic leaks. Direct costs per case were analyzed according to the Institute for Remuneration System in Hospitals (InEK) cost-accounting approach by comparing DRG payments on the case level, including all extra fees per DRG catalogue. Results In total, 60 DRG cases were identified. Of these, 15 patients were excluded because they received a combination of SEMS and EVT. Another 6 cases could not be included due to incomplete DRG data. Finally, N = 39 DRG cases were analyzed from a profit-center perspective. A further analysis of the most frequent DRG code -G03- including InEK cost accounting, revealed almost twice the deficit for the EVT group (N = 13 cases, € - 9.282 per average case) compared to that for the SEMS group (N = 9 cases, € - 5.156 per average case). Conclusion Endoscopic treatments with SEMS and EVT for anastomotic leaks following oncological Ivor Lewis esophagectomies are not cost-efficient for German hospitals. Due to longer hospitalization and insufficient reimbursements, EVT is twice as costly as SEMS treatment. An adequate DRG cost compensation is needed for SEMS and EVT.
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Affiliation(s)
- Christoph Baltin
- Department of Orthopedics and Trauma Surgery, University Hospital of Cologne, Cologne, Germany
| | - Florian Kron
- FOM University of Applied Sciences, Essen, Germany
- Department of Internal Medicine Med I, University Hospital of Cologne, Cologne, Germany
| | - Alexander Urbanski
- Department of General, Visceral and Cancer Surgery, University Hospital of Cologne, Cologne, Germany
| | | | - Anna Kron
- FOM University of Applied Sciences, Essen, Germany
| | - Felix Berlth
- Department of General, Visceral and Transplant Surgery, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Robert Kleinert
- Department of General, Visceral and Cancer Surgery, University Hospital of Cologne, Cologne, Germany
| | - Michael Hallek
- Department of Internal Medicine Med I, University Hospital of Cologne, Cologne, Germany
| | | | - Seung-Hun Chon
- Department of General, Visceral and Cancer Surgery, University Hospital of Cologne, Cologne, Germany
- * E-mail:
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Wirsching A, Boshier PR, Krishnamoorthi R, Larsen MC, Irani S, Ross AS, Low DE. Endoscopic therapy and surveillance versus esophagectomy for early esophageal adenocarcinoma: A review of early outcomes and cost analysis. Am J Surg 2019; 218:164-169. [PMID: 30635212 DOI: 10.1016/j.amjsurg.2018.12.058] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Revised: 12/27/2018] [Accepted: 12/31/2018] [Indexed: 12/14/2022]
Abstract
BACKGROUND Endoscopic therapy is considered to be comparable to esophagectomy with respect to oncologic outcomes in early (cT1) esophageal adenocarcinoma (EC). The current study aims to compare early outcomes and financial costs, associated with endoscopic versus surgical therapy for early esophageal adenocarcinoma. METHODS Retrospective review of patients undergoing either endoscopic or surgical therapy for cT1 EC between 2010 and 2015. RESULTS Age, BMI, and Charlson Comorbidity Scores were similar in patients undergoing endoscopic therapy (N = 20) and esophagectomy (N = 23). For patients undergoing endoscopic therapy a median of 6 endoscopic interventions, were performed per patient (range 2-18). Esophagectomy was associated with a median hospital stay of 9 (8-13) days and greater procedure specific morbidity compared to endoscopic therapy. Costs related to endoscopic therapy were significantly lower compared to esophagectomy ($22,640 vs. $53,849, P < 0.001). CONCLUSIONS Endoscopic treatment is associated with decreased morbidity and financial costs when compared to esophagectomy.
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Affiliation(s)
- Andrea Wirsching
- Department of Thoracic Surgery and Thoracic Oncology, Virginia Mason Medical Center, 1100 Ninth Ave, Seattle, WA, 98111, USA.
| | - Piers R Boshier
- Department of Thoracic Surgery and Thoracic Oncology, Virginia Mason Medical Center, 1100 Ninth Ave, Seattle, WA, 98111, USA.
| | - Rajesh Krishnamoorthi
- Department of Gastroenterology and Hepatology, Virginia Mason Medical Center, Ninth Ave, Seattle, WA, 98111, USA.
| | - Michael C Larsen
- Department of Gastroenterology and Hepatology, Virginia Mason Medical Center, Ninth Ave, Seattle, WA, 98111, USA.
| | - Shayan Irani
- Department of Gastroenterology and Hepatology, Virginia Mason Medical Center, Ninth Ave, Seattle, WA, 98111, USA.
| | - Andrew S Ross
- Department of Gastroenterology and Hepatology, Virginia Mason Medical Center, Ninth Ave, Seattle, WA, 98111, USA.
| | - Donald E Low
- Department of Thoracic Surgery and Thoracic Oncology, Virginia Mason Medical Center, 1100 Ninth Ave, Seattle, WA, 98111, USA.
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Shin JH, Kunisawa S, Fushimi K, Imanaka Y. Effects of preoperative oral management by dentists on postoperative outcomes following esophagectomy: Multilevel propensity score matching and weighting analyses using the Japanese inpatient database. Medicine (Baltimore) 2019; 98:e15376. [PMID: 31027127 PMCID: PMC6831197 DOI: 10.1097/md.0000000000015376] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
The purpose of this study was to investigate the effects of preoperative oral management (POM) by dentists on the incidence of postoperative pulmonary complications (PPCs), length of hospital stay, medical costs, and days of antibiotics administration following both open and thoracoscopic esophagectomy.Dental plaque is an established risk factor for postoperative pneumonia, which could be reduced by POM. However, few clinical guidelines for cancer treatment, including those for esophageal cancer, recommend POM as routine perioperative care.We extracted data of esophagectomy cases from the Japanese Diagnosis Procedure Combination database. We subsequently conducted propensity score (PS) analyses for multilevel data, including matching, inverse probability of treatment weighting (IPTW), and standardized mortality ratio weighting (SMRW), to estimate the effect of POM by dentists on the outcomes of esophagectomy.We analyzed 3412 esophagectomy cases of which 812 were open, and 2600 were thoracoscopic surgery. In IPTW analysis to estimate the average treatment effect, the risk difference of postoperative aspiration pneumonia ranged from -2.49% to -2.02% between the POM and control groups of both open and thoracoscopic esophagectomy cases. IPTW analyses indicated that the total medical costs of thoracoscopic esophagectomy were reduced by 221,200 to 253,100 Japanese Yen (equivalent to about $2000-$2200). In PS matching and SMRW analyses to estimate average treatment effect on treated, there was no difference in outcomes between the POM and control groups.Our results suggested that in patients undergoing open or thoracoscopic esophagectomy, POM by dentists prevented the occurrence of postoperative aspiration pneumonia. It could also reduce the total medical costs of thoracoscopic esophagectomy. Thus, POM by dentists can be considered as a routine perioperative care for all patients undergoing esophagectomy, regardless of the expected risk for PPC.
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Affiliation(s)
- Jung-ho Shin
- Department of Healthcare Economics and Quality Management, Graduate School of Medicine, Kyoto University, Kyoto
| | - Susumu Kunisawa
- Department of Healthcare Economics and Quality Management, Graduate School of Medicine, Kyoto University, Kyoto
| | - Kiyohide Fushimi
- Department of Health Policy and Informatics, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Yuichi Imanaka
- Department of Healthcare Economics and Quality Management, Graduate School of Medicine, Kyoto University, Kyoto
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Schlottmann F, Strassle PD, Nayyar A, Herbella FAM, Cairns BA, Patti MG. Postoperative outcomes of esophagectomy for cancer in elderly patients. J Surg Res 2018; 229:9-14. [PMID: 29937021 DOI: 10.1016/j.jss.2018.03.050] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2018] [Revised: 02/09/2018] [Accepted: 03/20/2018] [Indexed: 12/22/2022]
Abstract
BACKGROUND The number of elderly patients with esophageal cancer is expected to increase. We aimed to determine the postoperative outcomes of esophagectomy for esophageal cancer in elderly patients. MATERIAL AND METHODS A retrospective, population-based analysis was performed using the National inpatient sample for the period 2000-2014. Adult patients ≥18 years old (yo) diagnosed with esophageal cancer who underwent esophagectomy during their inpatient hospitalization were included. Patients were categorized into <70 yo and ≥70 yo. Multivariable linear and logistic regressions were used to assess the potential effect of age on postoperative complications, inpatient mortality, and hospital charges. RESULTS Overall, 5243 patients were included, with 3699 (70.6%) <70 yo and 1544 (29.5%) ≥70 yo. The yearly rate of esophagectomies among patients ≥70 yo did not significantly changed during the study period (28.4% in 2000 and 26.3% in 2014, P = 0.76). Elderly patients were significantly more likely to have postoperative cardiac failure (odds ratio 1.59, 95% confidence interval [CI] 1.21, 2.09, P = 0.0009) and inpatient mortality (odds ratio 1.84, 95% CI 1.39, 2.45, P < 0.0001). Among the elderly patients, hospital charges were, on average, $16,320 greater (95% CI $3110, $29,530) than patients <70 yo (P = 0.02). The predicted probability of mortality increased consistently across age (1.5% in 40 yo, 2.5% in 50 yo, 3.6% in 60 yo, 5.4% in 70 yo, and 7.0% in 80 yo). CONCLUSIONS Elderly patients undergoing esophagectomy for cancer have a significantly higher risk of postoperative mortality and pose a higher financial burden on the health care system. Elderly patients with esophageal cancer should be carefully selected for surgery.
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Affiliation(s)
- Francisco Schlottmann
- Department of Surgery, University of North Carolina, Chapel Hill, North Carolina; Department of Surgery, Hospital Alemán of Buenos Aires, Buenos Aires, Argentina.
| | - Paula D Strassle
- Department of Surgery, University of North Carolina, Chapel Hill, North Carolina; Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Apoorve Nayyar
- Department of Surgery, University of North Carolina, Chapel Hill, North Carolina
| | - Fernando A M Herbella
- Department of Surgery, Escola Paulista de Medicina, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Bruce A Cairns
- Department of Surgery, University of North Carolina, Chapel Hill, North Carolina
| | - Marco G Patti
- Department of Surgery, University of North Carolina, Chapel Hill, North Carolina; Department of Medicine, University of North Carolina, Chapel Hill, North Carolina
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Liu Y, Li JJ, Zu P, Liu HX, Yu ZW, Ren Y. Two-step method for creating a gastric tube during laparoscopic-thoracoscopic Ivor-Lewis esophagectomy. World J Gastroenterol 2017; 23:8035-8043. [PMID: 29259379 PMCID: PMC5725298 DOI: 10.3748/wjg.v23.i45.8035] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Revised: 08/15/2017] [Accepted: 09/05/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To introduce a two-step method for creating a gastric tube during laparoscopic-thoracoscopic Ivor-Lewis esophagectomy and assess its clinical application.
METHODS One hundred and twenty-two patients with middle or lower esophageal cancer who underwent laparoscopic-thoracoscopic Ivor-Lewis esophagectomy at Liaoning Cancer Hospital and Institute from March 2014 to March 2016 were included in this study, and divided into two groups based on the procedure used for creating a gastric tube. One group used a two-step method for creating a gastric tube, and the other group used the conventional method. The two groups were compared regarding the operating time, surgical complications, and number of stapler cartridges used.
RESULTS The mean operating time was significantly shorter in the two-step method group than in the conventional method group [238 (179-293) min vs 272 (189-347) min, P < 0.01]. No postoperative death occurred in either group. There was no significant difference in the rate of complications [14 (21.9%) vs 13 (22.4%), P = 0.55] or mean number of stapler cartridges used [5 (4-6) vs 5.2 (5-6), P = 0.007] between the two groups.
CONCLUSION The two-step method for creating a gastric tube during laparoscopic-thoracoscopic Ivor-Lewis esophagectomy has the advantages of simple operation, minimal damage to the tubular stomach, and reduced use of stapler cartridges.
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Affiliation(s)
- Yu Liu
- Department of Thoracic Surgery, Cancer Hospital of China Medical University/Liaoning Cancer Hospital and Institute, Shenyang 110042, Liaoning Province, China
| | - Ji-Jia Li
- Department of Thoracic Surgery, Cancer Hospital of China Medical University/Liaoning Cancer Hospital and Institute, Shenyang 110042, Liaoning Province, China
| | - Peng Zu
- Department of Thoracic Surgery, Cancer Hospital of China Medical University/Liaoning Cancer Hospital and Institute, Shenyang 110042, Liaoning Province, China
| | - Hong-Xu Liu
- Department of Thoracic Surgery, Cancer Hospital of China Medical University/Liaoning Cancer Hospital and Institute, Shenyang 110042, Liaoning Province, China
| | - Zhan-Wu Yu
- Department of Thoracic Surgery, Cancer Hospital of China Medical University/Liaoning Cancer Hospital and Institute, Shenyang 110042, Liaoning Province, China
| | - Yi Ren
- Department of Thoracic Surgery, Cancer Hospital of China Medical University/Liaoning Cancer Hospital and Institute, Shenyang 110042, Liaoning Province, China
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Ho V, Short MN, Aloia TA. Can postoperative process of care utilization or complication rates explain the volume-cost relationship for cancer surgery? Surgery 2017; 162:418-428. [PMID: 28438333 DOI: 10.1016/j.surg.2017.03.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Revised: 02/27/2017] [Accepted: 03/04/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND Past studies identify an association between provider volume and outcomes, but less is known about the volume-cost relationship for cancer surgery. We analyze the volume-cost relationship for 6 cancer operations and explore whether it is influenced by the occurrence of complications and/or utilization of processes of care. METHODS Medicare hospital and inpatient claims for the years 2005 through 2009 were analyzed for 6 cancer resections: colectomy, rectal resection, pulmonary lobectomy, pneumonectomy, esophagectomy, and pancreatic resection. Regressions were first estimated to quantify the association of provider volume with costs, excluding measures of complications and processes of care as explanatory variables. Next, these variables were added to the regressions to test whether they weakened any previously observed volume-cost relationship. RESULTS Higher hospital volume is associated with lower patient costs for esophagectomy but not for other operations. Higher surgeon volume reduces costs for most procedures, but this result weakens when processes of care are added to the regressions. Processes of care that are frequently implemented in response to adverse events are associated with 14% to 34% higher costs. Utilization of these processes is more prevalent among low-volume versus high-volume surgeons. CONCLUSION Processes of care implemented when complications occur explain much of the surgeon volume-cost relationship. Given that surgeon volume is readily observed, better outcomes and lower costs may be achieved by referring patients to high-volume surgeons. Increasing patient access to surgeons with lower rates of complications may be the most effective strategy for avoiding costly processes of care, controlling expenditure growth.
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Affiliation(s)
- Vivian Ho
- Baker Institute for Public Policy, Rice University, Houston, TX; Department of Economics, Rice University, Houston, TX.
| | - Marah N Short
- Baker Institute for Public Policy, Rice University, Houston, TX
| | - Thomas A Aloia
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX
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8
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Cooke DT, Calhoun RF, Kuderer V, David EA. A Defined Esophagectomy Perioperative Clinical Care Process Can Improve Outcomes and Costs. Am Surg 2017; 83:103-111. [PMID: 28234134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Esophagectomy (EG) is a high-risk therapy for esophageal cancer and end-stage benign disease. This study compares the results of EG before and after implementation of a perioperative clinical care process including a health provider education program (EP) and institutional uncomplicated postoperative clinical pathway (POP) for purpose quality improvement. This is a single institution retrospective cohort study. The EP was provided to critical care and telemetry unit nurses and the POP was imbedded in the electronic health record. Patients undergoing elective EG with reconstruction with the stomach for benign disease or cancer were included from 2005 to 2011. Cohorts were pre- and postimplementation (PreI and PostI) of an EP and 8-day POP (August 2008). Patient, tumor and peri/postoperative-specific variables were compared between cohorts, as well as resource utilization and hospital costs. We identified 33 PreI and 41 PostI patients. Both cohorts had similar patient demographics, preoperative comorbidities, majority cancer diagnosis, and for cancer patients, majority adenocarcinoma and IIB/III pathologic stage. Both groups had one death and similar rate of discharge to home. The PostI cohort demonstrated reduced 30-day readmission rate (2.4% vs 24.2%); P < 0.05. In regard to clinical outcomes, the PostI group exhibited reduced deep venous thrombosis/pulmonary emboli (2.4% vs 18.2%); P < 0.05. The PostI group demonstrated significantly reduced radiographic test utilization and costs, as well as total overall 30-day readmission costs. A defined perioperative clinical process involving educating the patient care team and implementing a widely disseminated POP can reduce complications, 30-day readmission rates, and hospital costs after EG.
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Affiliation(s)
- David T Cooke
- Section of General Thoracic Surgery, University of California, Davis Medical Center, Sacramento, California, USA
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9
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Short MN, Ho V, Aloia TA. Impact of processes of care aimed at complication reduction on the cost of complex cancer surgery. J Surg Oncol 2015; 112:610-5. [PMID: 26391328 PMCID: PMC5396380 DOI: 10.1002/jso.24053] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2015] [Accepted: 09/13/2015] [Indexed: 12/27/2022]
Abstract
BACKGROUND AND OBJECTIVES Health care providers add multiple processes to the care of complex cancer patients, believing they prevent and/or ameliorate complications. However, the relationship between these processes, complication remediation, and expenditures is unknown. METHODS Data for patients with cancer diagnoses undergoing colectomy, rectal resection, pulmonary lobectomy, pneumonectomy, esophagectomy, and pancreatic resection were obtained from hospital and inpatient physician Medicare claims for the years 2005-2009. Risk-adjusted regression analyses measured the association between hospitalization costs and processes presumed to prevent and/or remedy complications common to high-risk procedures. RESULTS After controlling for comorbidities, analysis identified associations between increased costs and use of multiple processes, including arterial lines (4-12% higher; P < 0.001) and pulmonary artery catheters (23-33% higher; P < 0.001). Epidural analgesia was not associated with higher costs. Consultations were associated with 24-44% (P < 0.001) higher costs, and total parenteral nutrition was associated with 13-31% higher costs (P < 0.001). CONCLUSIONS Many frequently utilized processes and services presumed to avoid and/or ameliorate complications are associated with increased surgical oncology costs. This suggests that the patient-centered value of each process should be measured on a procedure-specific basis. Likewise, further attention should be focused on defining the efficacy of each of these costly, but frequently unproven, additions to perioperative care.
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Affiliation(s)
- Marah N. Short
- Baker Institute for Public Policy at Rice UniversityHoustonTexas
| | - Vivian Ho
- Baker Institute for Public Policy and Department of EconomicsRice UniversityHoustonTexas
- Department of MedicineBaylor College of MedicineHoustonTexas
| | - Thomas A. Aloia
- Department of Surgical OncologyUniversity of Texas MD Anderson Cancer CenterHoustonTexas
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Khullar OV, Jiang R, Force SD, Pickens A, Sancheti MS, Ward K, Gillespie T, Fernandez FG. Transthoracic versus transhiatal resection for esophageal adenocarcinoma of the lower esophagus: A value-based comparison. J Surg Oncol 2015; 112:517-23. [PMID: 26374192 PMCID: PMC4664447 DOI: 10.1002/jso.24024] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2015] [Accepted: 08/12/2015] [Indexed: 12/20/2022]
Abstract
BACKGROUND AND OBJECTIVE Our objective was to compare clinical outcomes, costs, and resource use based on operative approach, transthoracic (TT) or transhiatal (TH), for resection of esophageal cancer. METHODS This cohort analysis utilized the Surveillance, Epidemiology, and End Results--Medicare linked data from 2002 to 2009. Only adenocarcinomas of the lower esophagus were examined to minimize confounding. Medicare data was used to determine episode of care costs and resource use. Propensity score matching was used to control for identified confounders. Kaplan-Meier method and Cox-proportional hazard modeling were used to compare long-term survival. RESULTS 537 TT and 405 TH resections were identified. TT and TH esophagectomy had similar complication rates (46.7% vs. 50.8%), operative mortality (7.9% vs 7.1%), and 90 days readmission rates (30.5% vs. 32.5%). However, TH was associated with shorter length of stay (11.5 vs. 13.0 days, P = 0.006) and nearly $1,000 lower cost of initial hospitalization (P = 0.03). No difference in 5-year survival was identified (33.5% vs. 36%, P = 0.75). CONCLUSIONS TH esophagectomy was associated with lower costs and shorter length of stay in an elderly Medicare population, with similar clinical outcomes to TT. The TH approach to esophagectomy for distal esophageal adenocarcinoma may, therefore, provide greater value (quality/cost).
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Affiliation(s)
- Onkar V. Khullar
- Section of General Thoracic Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Renjian Jiang
- Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Seth D. Force
- Section of General Thoracic Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Allan Pickens
- Section of General Thoracic Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Manu S. Sancheti
- Section of General Thoracic Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Kevin Ward
- Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Theresa Gillespie
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
- Department of Hematology and Medical Oncology, Emory University School of Medicine, Atlanta, Georgia
| | - Felix G. Fernandez
- Section of General Thoracic Surgery, Emory University School of Medicine, Atlanta, Georgia
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11
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Shewale JB, Correa AM, Baker CM, Villafane-Ferriol N, Hofstetter WL, Jordan VS, Kehlet H, Lewis KM, Mehran RJ, Summers BL, Schaub D, Wilks SA, Swisher SG. Impact of a Fast-track Esophagectomy Protocol on Esophageal Cancer Patient Outcomes and Hospital Charges. Ann Surg 2015; 261:1114-23. [PMID: 25243545 PMCID: PMC4838458 DOI: 10.1097/sla.0000000000000971] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To evaluate the effects of a fast-track esophagectomy protocol (FTEP) on esophageal cancer patients' safety, length of hospital stay (LOS), and hospital charges. BACKGROUND FTEP involved transferring patients to the telemetry unit instead of the surgical intensive care unit (SICU) after esophagectomy. METHODS We retrospectively reviewed 708 consecutive patients who underwent esophagectomy for primary esophageal cancer during the 4 years before (group A; 322 patients) or 4 years after (group B; 386 patients) the institution of an FTEP. Postoperative morbidity and mortality, LOS, and hospital charges were reviewed. RESULTS Compared with group A, group B had significantly shorter median LOS (12 days vs 8 days; P < 0.001); lower mean numbers of SICU days (4.5 days vs 1.2 days; P < 0.001) and telemetry days (12.7 days vs 9.7 days; P < 0.001); and lower rates of atrial arrhythmia (27% vs 19%; P = 0.013) and pulmonary complications (27% vs 20%; P = 0.016). Multivariable analysis revealed FTEP to be associated with shorter LOS (P < 0.001) even after adjustment for predictors like tumor histology and location. FTEP was also associated with a lower rate of pulmonary complications (odds ratio = 0.655; 95% confidence interval = 0.456, 0.942; P = 0.022). In addition, the median hospital charges associated with primary admission and readmission within 90 days for group B ($65,649) were lower than that for group A ($79,117; P < 0.001). CONCLUSIONS These findings suggest that an FTEP reduces patients' LOS, perioperative morbidity, and hospital charges.
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Affiliation(s)
- Jitesh B. Shewale
- Department of Thoracic and Cardiovascular Surgery, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Arlene M. Correa
- Department of Thoracic and Cardiovascular Surgery, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Carla M. Baker
- Department of Thoracic and Cardiovascular Surgery, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | | | - Wayne L. Hofstetter
- Department of Thoracic and Cardiovascular Surgery, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Victoria S. Jordan
- Department of Thoracic and Cardiovascular Surgery, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Henrik Kehlet
- Section for Surgical Pathophysiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Katie M. Lewis
- Department of Thoracic and Cardiovascular Surgery, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Reza J. Mehran
- Department of Thoracic and Cardiovascular Surgery, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Barbara L. Summers
- Department of Thoracic and Cardiovascular Surgery, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Diane Schaub
- Department of Thoracic and Cardiovascular Surgery, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Sonia A. Wilks
- Department of Thoracic and Cardiovascular Surgery, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Stephen G. Swisher
- Department of Thoracic and Cardiovascular Surgery, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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Bhandari R, Hao YY. Implementation and Effectiveness of Early Chest Tube Removal during an Enhanced Recovery Programme after Oesophago-gastrectomy. JNMA J Nepal Med Assoc 2015; 53:24-27. [PMID: 26983043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023] Open
Abstract
INTRODUCTION Oesophageal resection were notoriously complicated and produces a cohort of patients prone to postoperative complications and here we would like to focus on the implementation and effectiveness of early chest tube removal in ERAS after oesophago-gastrectomy considering the various aspect like pleural effusion and reducing the length of hospital stay which ultimately lead to reducing the economic burden on patient. METHODS An ERAS programme was devised and implemented with the support of a dedicated in-hospital task-force. The patients underwent esophago-gastrectomy were randomly divided into two groups: the ERAS group and the control group (non-ERAS). The ERAS group was treated with early removal of the chest tube after surgery, and the control group was treated with traditional way and outcomes were compared between them. RESULTS The length of hospital stay and the cost of hospitalization in the ERAS group were significantly lower than those in the control group(p<0.05. However, there was no statistical significant difference in the incidences of pleural effusion between the two groups(p>0.05). CONCLUSIONS The introduction of early chest tube removal as an ERAS programme after oesophago-gastrectomy would not increase the risk of pleural effusion and would not increase the total length of stay and cost of hospitalisation without jeopardising patient safety or clinical outcomes.
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Affiliation(s)
- R Bhandari
- Yangtze University, Jingzhou, Hubei 434000, China
| | - Y Y Hao
- The Clinical Medical College of Yangtze University, Jingzhou, Hubei 434000, China
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13
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Bowrey DJ, Baker M, Halliday V, Thomas AL, Pulikottil-Jacob R, Smith K. Six weeks of home enteral nutrition versus standard care after esophagectomy or total gastrectomy for cancer: study protocol for a randomized controlled trial. Trials 2014; 15:187. [PMID: 24885032 PMCID: PMC4039309 DOI: 10.1186/1745-6215-15-187] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2014] [Accepted: 05/09/2014] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Each year approximately 3000 patients in the United Kingdom undergo surgery for esophagogastric cancer. Jejunostomy feeding tubes, placed at the time of surgery for early postoperative nutrition, have been shown to have a positive impact on clinical outcomes in the short term. Whether feeding out of hospital is of benefit is unknown. Local experience has identified that between 15 and 20% of patients required 'rescue' jejunostomy feeding for nutritional problems and weight loss while at home. This weight loss and poor nutrition may contribute to the detrimental effect on the overall quality of life (QoL) reported in these patients. METHODS/DESIGN This randomized pilot and feasibility study will provide preliminary information on the routine use of jejunostomy feeding after hospital discharge in terms of clinical benefits and QoL. Sixty participants undergoing esophagectomy or total gastrectomy will be randomized to receive either a planned program of six weeks of home jejunostomy feeding after discharge from hospital (intervention) or treatment-as-usual (control). The intention of this study is to inform a multi-centre randomized controlled trial. The primary outcome measures will be recruitment and retention rates at six weeks and six months. Secondary outcome measures will include disease specific and general QoL measures, nutritional parameters, total and oral nutritional intake, hospital readmission rates, and estimates of healthcare costs. Up to 20 participants will also be enrolled in a qualitative sub-study that will explore participants' and carers' experiences of home tube feeding.The results will be disseminated by presentation at surgical, gastroenterological and dietetic meetings and publication in appropriate peer review journals. A patient-friendly lay summary will be made available on the University of Leicester and the University Hospitals of Leicester NHS Trust websites. The study has full ethical and institutional approval and started recruitment in July 2012. TRIAL REGISTRATION UKClinical Research Network ID #12447 (Main study); UKCRN ID#13361 (Qualitative sub study); ClinicalTrials.gov #NCT01870817 (First registered 28 May 2013).
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Affiliation(s)
- David J Bowrey
- Department of Surgery, University Hospitals of Leicester NHS Trust, Level 6 Balmoral Building, Leicester Royal Infirmary, Leicester LE1 5WW, UK
| | - Melanie Baker
- Department of Surgery, University Hospitals of Leicester NHS Trust, Level 6 Balmoral Building, Leicester Royal Infirmary, Leicester LE1 5WW, UK
| | - Vanessa Halliday
- School of Health and Related Research, University of Sheffield, 30 Regent St, Sheffield S1 4DA, UK
| | - Anne L Thomas
- Department of Oncology, Clinical Sciences Building, University of Leicester, Leicester LE1 5WW, UK
| | - Ruth Pulikottil-Jacob
- Department of Health Economics, Room A101, University of Warwick, Warwick CV4 7AL, UK
| | - Karen Smith
- Department of Health Sciences, University of Leicester, 22-28 Princess Rd West, Leicester LE1 6TP, UK
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Abbas H, Rossidis G, Hochwald SN, Ben-David K. Robotic esophagectomy: new era of surgery. MINERVA CHIR 2013; 68:427-433. [PMID: 24101000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Esophagectomy is a surgical operation which requires technical expertise to decrease the morbidity and mortality frequently associated with this advance procedure. Various minimally invasive esophagectomy techniques have been developed to decrease the negative impact of esophageal resection. Recently, robotic assisted esophagectomies have been described with a wide variety in technique and outcome disparity. This article is a summation review of the current literature regarding the various techniques and surgical outcomes of robotic assisted esophagectomies.
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Affiliation(s)
- H Abbas
- Gastroesophageal Surgery, Department of Surgery University of Florida, Gainesville, FL, USA
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15
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van der Sluis PC, Ruurda JP, van der Horst S, Verhage RJJ, Besselink MGH, Prins MJD, Haverkamp L, Schippers C, Rinkes IHMB, Joore HCA, ten Kate FJW, Koffijberg H, Kroese CC, van Leeuwen MS, Lolkema MPJK, Reerink O, Schipper MEI, Steenhagen E, Vleggaar FP, Voest EE, Siersema PD, van Hillegersberg R. Robot-assisted minimally invasive thoraco-laparoscopic esophagectomy versus open transthoracic esophagectomy for resectable esophageal cancer, a randomized controlled trial (ROBOT trial). Trials 2012; 13:230. [PMID: 23199187 PMCID: PMC3564860 DOI: 10.1186/1745-6215-13-230] [Citation(s) in RCA: 126] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2012] [Accepted: 10/26/2012] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND For esophageal cancer patients, radical esophagolymphadenectomy is the cornerstone of multimodality treatment with curative intent. Transthoracic esophagectomy is the preferred surgical approach worldwide allowing for en-bloc resection of the tumor with the surrounding lymph nodes. However, the percentage of cardiopulmonary complications associated with the transthoracic approach is high (50 to 70%).Recent studies have shown that robot-assisted minimally invasive thoraco-laparoscopic esophagectomy (RATE) is at least equivalent to the open transthoracic approach for esophageal cancer in terms of short-term oncological outcomes. RATE was accompanied with reduced blood loss, shorter ICU stay and improved lymph node retrieval compared with open esophagectomy, and the pulmonary complication rate, hospital stay and perioperative mortality were comparable. The objective is to evaluate the efficacy, risks, quality of life and cost-effectiveness of RATE as an alternative to open transthoracic esophagectomy for treatment of esophageal cancer. METHODS/DESIGN This is an investigator-initiated and investigator-driven monocenter randomized controlled parallel-group, superiority trial. All adult patients (age ≥ 18 and ≤ 80 years) with histologically proven, surgically resectable (cT1-4a, N0-3, M0) esophageal carcinoma of the intrathoracic esophagus and with European Clinical Oncology Group performance status 0, 1 or 2 will be assessed for eligibility and included after obtaining informed consent. Patients (n = 112) with resectable esophageal cancer are randomized in the outpatient department to either RATE (n = 56) or open three-stage transthoracic esophageal resection (n = 56). The primary outcome of this study is the percentage of overall complications (grade 2 and higher) as stated by the modified Clavien-Dindo classification of surgical complications. DISCUSSION This is the first randomized controlled trial designed to compare RATE with open transthoracic esophagectomy as surgical treatment for resectable esophageal cancer. If our hypothesis is proven correct, RATE will result in a lower percentage of postoperative complications, lower blood loss, and shorter hospital stay, but with at least similar oncologic outcomes and better postoperative quality of life compared with open transthoracic esophagectomy. The study started in January 2012. Follow-up will be 5 years. Short-term results will be analyzed and published after discharge of the last randomized patient. TRIAL REGISTRATION Dutch trial register: NTR3291 ClinicalTrial.gov: NCT01544790.
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Affiliation(s)
- Pieter C van der Sluis
- Department of Surgery, G04.228, University Medical Center Utrecht, Heidelberglaan 100, Utrecht, CX, 3584, the Netherlands
| | - Jelle P Ruurda
- Department of Surgery, G04.228, University Medical Center Utrecht, Heidelberglaan 100, Utrecht, CX, 3584, the Netherlands
| | - Sylvia van der Horst
- Department of Surgery, G04.228, University Medical Center Utrecht, Heidelberglaan 100, Utrecht, CX, 3584, the Netherlands
| | - Roy JJ Verhage
- Department of Surgery, G04.228, University Medical Center Utrecht, Heidelberglaan 100, Utrecht, CX, 3584, the Netherlands
| | - Marc GH Besselink
- Department of Surgery, G04.228, University Medical Center Utrecht, Heidelberglaan 100, Utrecht, CX, 3584, the Netherlands
| | - Margriet JD Prins
- Department of Surgery, G04.228, University Medical Center Utrecht, Heidelberglaan 100, Utrecht, CX, 3584, the Netherlands
| | - Leonie Haverkamp
- Department of Surgery, G04.228, University Medical Center Utrecht, Heidelberglaan 100, Utrecht, CX, 3584, the Netherlands
| | - Carlo Schippers
- Department of Surgery, G04.228, University Medical Center Utrecht, Heidelberglaan 100, Utrecht, CX, 3584, the Netherlands
| | - Inne HM Borel Rinkes
- Department of Surgery, G04.228, University Medical Center Utrecht, Heidelberglaan 100, Utrecht, CX, 3584, the Netherlands
| | - Hans CA Joore
- Department of Intensive Care Medicine, University Medical Center Utrecht, Heidelberglaan 100, Utrecht, CX, 3584, the Netherlands
| | - Fiebo JW ten Kate
- Department of Pathology, University Medical Center Utrecht, Heidelberglaan 100, Utrecht, CX, 3584, the Netherlands
| | - Hendrik Koffijberg
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Heidelberglaan 100, Utrecht, CX, 3584, the Netherlands
| | - Christiaan C Kroese
- Department of Anesthesiology, University Medical Center Utrecht, Heidelberglaan 100, Utrecht, CX, 3584, the Netherlands
| | - Maarten S van Leeuwen
- Department of Radiology, University Medical Center Utrecht, Heidelberglaan 100, Utrecht, CX, 3584, the Netherlands
| | - Martijn PJK Lolkema
- Department of Medical Oncology, University Medical Center Utrecht, Heidelberglaan 100, Utrecht, CX, 3584, the Netherlands
| | - Onne Reerink
- Department of Radiotherapy, University Medical Center Utrecht, Heidelberglaan 100, Utrecht, CX, 3584, the Netherlands
| | - Marguerite EI Schipper
- Department of Pathology, University Medical Center Utrecht, Heidelberglaan 100, Utrecht, CX, 3584, the Netherlands
| | - Elles Steenhagen
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Heidelberglaan 100, Utrecht, CX, 3584, the Netherlands
| | - Frank P Vleggaar
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Heidelberglaan 100, Utrecht, CX, 3584, the Netherlands
| | - Emile E Voest
- Department of Medical Oncology, University Medical Center Utrecht, Heidelberglaan 100, Utrecht, CX, 3584, the Netherlands
| | - Peter D Siersema
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Heidelberglaan 100, Utrecht, CX, 3584, the Netherlands
| | - Richard van Hillegersberg
- Department of Surgery, G04.228, University Medical Center Utrecht, Heidelberglaan 100, Utrecht, CX, 3584, the Netherlands
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Gordon LG, Hirst NG, Mayne GC, Watson DI, Bright T, Cai W, Barbour AP, Smithers BM, Whiteman DC, Eckermann S. Modeling the cost-effectiveness of strategies for treating esophageal adenocarcinoma and high-grade dysplasia. J Gastrointest Surg 2012; 16:1451-61. [PMID: 22644445 DOI: 10.1007/s11605-012-1911-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2012] [Accepted: 05/07/2012] [Indexed: 01/31/2023]
Abstract
OBJECTIVE This study aims to synthesize cost and health outcomes for current treatment pathways for esophageal adenocarcinoma and high-grade dysplasia (HGD) and to model comparative net clinical and economic benefits of alternative management scenarios. METHODS A decision-analytic model of real-world practices for esophageal adenocarcinoma treatment by tumor stage was constructed and validated. The model synthesized treatment probabilities, survival, quality of life, and resource use extracted from epidemiological datasets, published literature, and expert opinion. Comparative analyses between current practice and five hypothetical scenarios for modified treatment were undertaken. RESULTS Over 5 years, outcomes across T stage ranged from 4.06 quality-adjusted life-years and costs of $3,179 for HGD to 1.62 quality-adjusted life-years and costs of $50,226 for stage T4. Greater use of endoscopic mucosal resection for stage T1 and measures to reduce esophagectomy mortality to 0-3 % produced modest gains, whereas a 20 % reduction in the proportion of patients presenting at stage T3 produced large incremental net benefits of $4,971 (95 % interval, $1,560-8,368). CONCLUSION These findings support measures that promote earlier diagnosis, such as developing risk assessment processes or endoscopic surveillance of Barrett's esophagus. Incremental net monetary benefits for other strategies are relatively small in comparison to predicted gains from early detection strategies.
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Affiliation(s)
- Louisa G Gordon
- Centre for Applied Health Economics, Griffith Health Institute, Griffith University, Logan Campus, University Drive, Meadowbrook, Queensland 4131, Australia.
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Bartha E, Rudin A, Flisberg P, Lundberg CJ, Carlsson P, Kalman S. Could benefits of epidural analgesia following oesophagectomy be measured by perceived perioperative patient workload? Acta Anaesthesiol Scand 2008; 52:1313-8. [PMID: 19025520 DOI: 10.1111/j.1399-6576.2008.01734.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND A controversy exists whether beneficial analgesic effects of epidural analgesia over intravenous analgesia influence the rate of post-operative complications and the length of hospital stay. There is some evidence that favours epidural analgesia following major surgery in high-risk patients. However, there is a controversy as to whether epidural analgesia reduces the intensive care resources following major surgery. In this study, we aimed at comparing the post-operative costs of intensive care in patients receiving epidural or intravenous analgesia. METHODS Clinical data and rates of post-operative complications were extracted from a previously reported trial following thoraco-abdominal oesophagectomy. Cost data for individual patients included in that trial were retrospectively obtained from administrative records. Two separate phases were defined: costs of pain treatment and the direct cost of intensive care. RESULTS Higher calculated costs of epidural vs. intravenous pain treatment, 1,037 vs. 410 Euros / patient, were outweighed by lower post-operative costs of intensive care 5,571 vs. 7,921 Euros / patient (NS). CONCLUSION Higher costs and better analgesic effects of epidural analgesia compared with intravenous analgesia do not reduce total costs for post-operative care following major surgery.
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Affiliation(s)
- E Bartha
- Department of Anaesthesiology and Intensive Care, Karolinska University Hospital, Huddinge, Sweden.
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Comay D, Blackhouse G, Goeree R, Armstrong D, Marshall JK. Photodynamic therapy for Barrett's esophagus with high-grade dysplasia: a cost-effectiveness analysis. Can J Gastroenterol 2007; 21:217-22. [PMID: 17431509 PMCID: PMC2657694 DOI: 10.1155/2007/791062] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVES To assess the cost-effectiveness of photodynamic therapy (PDT) and esophagectomy (ESO) relative to surveillance (SURV) for patients with Barrett's esophagus (BE) and high-grade dysplasia (HGD). METHODS A Markov decision tree was constructed to estimate costs and health outcomes of PDT, ESO and SURV in a hypothetical cohort of male patients, 50 years of age, with BE and HGD. Outcomes included unadjusted life-years (LYs) and quality-adjusted LYs (QALYs). Direct medical costs (2003 CDN$) were measured from the perspective of a provincial ministry of health. The time horizon for the model was five years (cycle length three months), and costs and outcomes were discounted at 3%. Model parameters were assigned unique distributions, and a probabilistic analysis with 10,000 Monte Carlo simulations was performed. RESULTS SURV was the least costly strategy, followed by PDT and ESO, but SURV was also the least effective. In terms of LYs, the incremental cost-effectiveness ratios were 814 dollars/LY for PDT versus SURV and 3,397 dollars/LY for ESO versus PDT. PDT dominated ESO for QALYs in the base-case. The incremental cost-effectiveness ratio of PDT versus SURV was 879 dollars/QALY. In probabilistic analysis, PDT was most likely to be cost-effective at willingness-to-pay (WTP) values between 100 dollars/LY and 3,500 dollars/LY, and ESO was most likely to be cost-effective for WTP values over 3500 dollars/LY. For quality-adjusted survival, PDT was most likely to be cost-effective for all WTP thresholds above 1,000 dollars/QALY. The likelihood that PDT was the most cost-effective strategy reached 0.99 at a WTP ceiling of 25,000 dollars/QALY. CONCLUSIONS In male patients with BE and HGD, PDT and ESO are cost-effective alternatives to SURV.
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Affiliation(s)
- Dan Comay
- Department of Medicine, Division of Gastroenterology, McMaster University, Hamilton, Ontario
| | - Gord Blackhouse
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario
- Centre for Evaluation of Medicines (St Joseph’s Hospital), McMaster University, Hamilton, Ontario
| | - Ron Goeree
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario
- Centre for Evaluation of Medicines (St Joseph’s Hospital), McMaster University, Hamilton, Ontario
| | - David Armstrong
- Department of Medicine, Division of Gastroenterology, McMaster University, Hamilton, Ontario
| | - John K Marshall
- Department of Medicine, Division of Gastroenterology, McMaster University, Hamilton, Ontario
- Centre for Evaluation of Medicines (St Joseph’s Hospital), McMaster University, Hamilton, Ontario
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Chappel AR, Zuckerman RS, Finlayson SRG. Small Rural Hospitals and High-Risk Operations: How Would Regionalization Affect Surgical Volume and Hospital Revenue? J Am Coll Surg 2006; 203:599-604. [PMID: 17084319 DOI: 10.1016/j.jamcollsurg.2006.07.009] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2006] [Revised: 06/28/2006] [Accepted: 07/10/2006] [Indexed: 10/24/2022]
Abstract
BACKGROUND Because higher hospital procedure volume is associated with better outcomes for many high-risk procedures, regionalization to higher-volume hospitals has been proposed as a way to improve quality of surgical care. The potential impact of such policies on small rural hospital volume and revenue is unknown. STUDY DESIGN We identified all hospitalizations in small rural hospitals (less than 50 beds) in New York State from 1998 to 2001 that included an ICD-9 procedure code for 1 of 9 procedures for which there is a documented volume-outcomes association: abdominal aortic aneurysm repair, aortic-valve replacement, carotid endarterectomy, colectomy, coronary artery bypass, cystectomy, esophagectomy, pancreatectomy, or pulmonary resection. Revenue from these procedures was estimated using gross charges and payor-specific reimbursement rates. We then compared these estimates with total hospital inpatient revenue for each rural hospital. RESULTS We identified 14 small rural hospitals where at least one of the nine procedures was performed. All included hospitalizations for colectomy. Aortic aneurysm repairs, cystectomies, and pancreatectomies were performed in three hospitals; carotid endarterectomy in two; and esophagectomy in one. In no hospitals were cardiac procedures or pulmonary resections performed. Estimated average contribution to hospital net revenue for all 9 procedures was approximately 2%, nearly all attributable to colectomy. CONCLUSIONS If all aortic aneurysm repairs, major cardiothoracic procedures, carotid endarterectomies, cystectomies, and pancreatectomies in New York State were regionalized to higher-volume hospitals, no small rural hospitals would experience substantial impact in terms of rural hospital procedure volume and revenue. Even regionalization of colectomy would have a small impact on inpatient volume and revenue.
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MESH Headings
- Aortic Aneurysm/surgery
- Coronary Artery Bypass/economics
- Coronary Artery Bypass/standards
- Coronary Artery Bypass/statistics & numerical data
- Current Procedural Terminology
- Endarterectomy, Carotid/economics
- Endarterectomy, Carotid/standards
- Endarterectomy, Carotid/statistics & numerical data
- Esophagectomy/economics
- Esophagectomy/standards
- Esophagectomy/statistics & numerical data
- Health Services Research
- Hospitals, Rural/economics
- Hospitals, Rural/organization & administration
- Hospitals, Rural/standards
- Hospitals, Rural/statistics & numerical data
- Humans
- Income/statistics & numerical data
- Income/trends
- New York
- Pancreatectomy/economics
- Pancreatectomy/standards
- Pancreatectomy/statistics & numerical data
- Pneumonectomy/economics
- Pneumonectomy/standards
- Pneumonectomy/statistics & numerical data
- Quality Assurance, Health Care/organization & administration
- Regional Medical Programs/economics
- Surgical Procedures, Operative/economics
- Surgical Procedures, Operative/standards
- Surgical Procedures, Operative/statistics & numerical data
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Affiliation(s)
- André R Chappel
- Department of Community and Preventive Medicine, University of Rochester Medical Center, Rochester, NY, and Mary Imogene Bassett Hospital and the Mithoefer Center for Rural Surgery, Cooperstown, NY, USA
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Abstract
BACKGROUND Multiple treatment strategies for subjects with high grade dysplasia (HGD) in Barrett's oesophagus (BO) have been suggested. However, it is unclear which of these strategies provides the greatest life expectancy, and the costs associated with the management strategies are unknown. AIM To compare the efficacy and cost effectiveness of competing management strategies for BO with HGD. METHODS We created a decision analysis model in Data 4.0 to assess possible treatment strategies for BO with HGD. The strategies included: (1) no preventative strategy, (2) elective surgical oesophagectomy, (3) endoscopic ablation, and (4) surveillance endoscopy. The base case was a healthy 50 year old White male with an initial diagnosis of BO with HGD. The model allowed for complications of surgery, including death. Ablative therapy could cause stricture or perforation. Pathological misinterpretation was allowed, and modelled after reported rates. Estimates were derived from the literature for the rate of progression of HGD to cancer and for complication rates for the various treatment modalities. The endoscopic ablation arm was modelled as photodynamic therapy. Sensitivity analyses were performed over a wide range of cancer incidences, complication rates, and procedure costs. RESULTS Endoscopic ablation was the most effective strategy, yielding 15.5 discounted quality adjusted life years (dQALY), compared with 15.0 for endoscopic surveillance and 14.9 for oesophagectomy. No preventative strategy was the most inexpensive option, yielding an average cost per quality adjusted life year of US dollars 54 (44) per dQALY, but resulted in high rates of cancer. Endoscopic surveillance dominated oesophagectomy, being both less costly and more effective. The condition of extended dominance occurred when comparing endoscopic ablation to endoscopic surveillance because, although the total costs of ablation were greater than those of surveillance, it was less expensive to buy an additional life year using endoscopic ablation than endoscopic surveillance. The incremental cost effectiveness ratio when moving from no therapy to ablative therapy was a reasonable US dollars 25 621/dQALY (21 009/dQALY). Sensitivity analysis demonstrated that when yearly rates of progression to cancer from HGD exceeded 30%, oesophagectomy became the most cost effective option. CONCLUSIONS A strategy of endoscopic ablation provided the longest quality adjusted life expectancy for BO with HGD. Although endoscopic surveillance was less expensive than endoscopic ablation, it was associated with shorter survival. Optimal utilisation of healthcare resources may be achieved with endoscopic ablative therapy for BO with HGD.
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Affiliation(s)
- N J Shaheen
- CB#7080, UNC-CH, Chapel Hill, NC 27599-7080, USA.
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22
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Abstract
BACKGROUND Photodynamic therapy appears to be effective in ablating high-grade dysplasia in Barrett's esophagus. Our aim was to identify the most effective and cost-effective strategy for managing high-grade dysplasia in Barrett's esophagus without associated endoscopically visible abnormalities. METHODS By using decision analysis, the lifetime costs and benefits of 4 strategies for which long-term data exist were estimated by us: esophagectomy, endoscopic surveillance, photodynamic therapy, followed by esophagectomy for residual high-grade dysplasia; and photodynamic therapy followed by endoscopic surveillance for residual high-grade dysplasia. It was assumed by us that there was a 30% prevalence of cancer in high-grade dysplasia patients and a 77% efficacy of photodynamic therapy for high-grade dysplasia and early cancer. RESULTS Esophagectomy cost 24,045 dollars, with life expectancy of 11.82 quality-adjusted life years. In comparison, photodynamic therapy followed by surveillance for residual high-grade dysplasia was the most effective strategy, with a quality-adjusted life expectancy of 12.31 quality-adjusted life years, but it also incurred the greatest lifetime cost (47,310 dollars) for an incremental cost-effectiveness of 47,410 dollars/quality-adjusted life years. The results were sensitive to post-surgical quality of life and survival, and to cancer prevalence if photodynamic therapy efficacy for cancer was less than 50%. CONCLUSIONS Photodynamic therapy followed by endoscopic surveillance for residual high-grade dysplasia appears to be cost effective compared with esophagectomy for patients diagnosed with high-grade dysplasia in Barrett's esophagus. Clinical trials directly comparing these strategies are warranted.
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Affiliation(s)
- Rohini Vij
- Division of Gastroenterology and Hepatology, Center for Primary Care and Outcomes Research, Department of Medicine, Stanford University School of Medicine, California, USA
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23
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Jensen LS, Dalsgaard J. [Cost-effectiveness of regionalization of esophageal resections in Denmark]. Ugeskr Laeger 2004; 166:2555-9. [PMID: 15285163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/30/2023]
Affiliation(s)
- Lone Susanne Jensen
- Arhus Universitetshospital, Arhus Sygehus, Kirurgisk Gastroenterologisk Afdeling L.
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24
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Abstract
OBJECTIVE To assess the effectiveness of high dependency unit (HDU) in the management of high-risk thoracic surgical cases at a single dedicated thoracic surgical unit. INTRODUCTION There is a strong drive to improve postoperative management in a cost-effective way. The number of high-risk thoracic surgical procedures undertaken is increasing rapidly. The HDU can be an effective weapon in the armoury of thoracic surgeons to treat these patients effectively without the need for managing in the extreme environment of expensive intensive care beds. METHOD Patients who had undergone lobectomy, pneumonectomy and oesophagectomy were included in the study, as they formed the bulk of the high risk thoracic surgical procedures undertaken by our unit. All data were collected retrospectively from case notes and computerised patient tracking system, for the period between April 2000 and March 2001. RESULT One hundred and ninety-one lobectomies (174 for malignancy), 86 pneumonectomies and 50 oesophagectomies were performed during the time period of the study. Of these, 189 (99%) lobectomies, 82 (95%) pneumonectomies and 47 (94%) oesophagectomies were electively admitted to HDU. The mean HDU stay was 21.8 h. Operation discharge time was 7.3 days for lung resections and 9.1 days for oesophagectomy. The overall 30-day mortality was 1.9% for lobectomy, 11% for pneumonectomy and 2% for oesophagectomy. Two oesophagectomies, one lobectomy and three pneumonectomies had to be transferred from HDU to ITU for either mechanical ventilation or more invasive monitoring. Four pneumonectomies, two lobectomies and two oesophagectomies had to be readmitted to HDU with respiratory failure or cardiac instability. Of all the readmitted patients, one pneumonectomy and one lobectomy died. The causes of death were myocardial infarction, pulmonary embolism, adult respiratory distress syndrome and septicaemia. DISCUSSION The above results clearly demonstrate that a well-equipped and properly manned HDU can greatly facilitate management of high-risk cases with favourable outcome. It provides excellent pain control facilities, detects complications early and avoids unnecessary ITU admissions. It also provides an excellent training opportunity for both medical and nursing staff.
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Affiliation(s)
- Shilajit Ghosh
- Birmingham Heartlands Hospital, Bordsley Green East, Birmingham B9 5SS, UK.
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25
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Abstract
The purpose of this study was to compare the effectiveness and cost-effectiveness of photodynamic therapy (PDT) versus surgical esophagectomy and intensive endoscopic surveillance for patients with Barrett's esophagus and high-grade dysplasia (HGD) who are operative candidates. The results of our Markov Monte Carlo model show that PDT increased life expectancy by 1.8 years and quality-adjusted life expectancy (QALE) by 1.65 years when compared to the surveillance strategy. Relative to the esophagectomy strategy, PDT resulted in a greater life expectancy by 0.8 years and 2.17 additional quality-adjusted life years (QALYs). Although PDT cost 20,400 dollars and 7,100 dollars more than surveillance and esophagectomy respectively, the resulting incremental cost-effective ratios (ICERs) of 12,400 dollars/QALY and 3,300 dollars/QALY are within commonly accepted values. These findings were sensitive to the value assigned to the quality of life after PDT, but only at unrealistic values. In conclusion, PDT increases life expectancy and is cost-effective when compared to endoscopic surveillance and surgical esophagectomy.
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Affiliation(s)
- Chin Hur
- Gastrointestinal Unit and Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts 02114, USA
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26
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Abstract
BACKGROUND Data on the relative clinical and economic impact of postoperative complications are needed in order to direct quality improvement efforts. STUDY DESIGN Patients undergoing two high-risk surgical procedures, hepatectomy (n = 569) and esophagectomy (n = 366), from 1994 to 1998 were included. Data were abstracted from the Maryland hospital discharge database. Relative resource use was determined using median regression, adjusting for patient comorbidities and other case-mix variables. RESULTS A total of 935 patients were studied. Overall in-hospital mortality was 6.1%; complication rate was 38.4%. Median cost for all patients was $14,527 (interquartile range $10,936-$21,412) and length of stay 9 days (interquartile range 7-13 days). Median hospital cost was increased for patients with complications ($16,868 versus $12,861; p < 0.001). In the multivariate analysis, several complications remained associated with increased cost. Acute renal failure ($25,219), septicemia ($18,852), and myocardial infarction ($9,573) were associated with the greatest increase in resource use. But because the incidence of each complication varies, the attributable fraction of total resource use was highest for acute renal failure (19%), septicemia (16%), and surgical complications (16%). CONCLUSIONS Complications are independently associated with increased resource use after high-risk surgery. Population-based studies may be valuable in determining the relative economic importance of postoperative complications. Quality improvement efforts for these complications should be prioritized based on both the incidence of the complication and its independent contribution to increased resource use.
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Affiliation(s)
- Justin B Dimick
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA
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27
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Hulscher JBF, van Sandick JW, de Boer AGEM, Wijnhoven BPL, Tijssen JGP, Fockens P, Stalmeier PFM, ten Kate FJW, van Dekken H, Obertop H, Tilanus HW, van Lanschot JJB. Extended transthoracic resection compared with limited transhiatal resection for adenocarcinoma of the esophagus. N Engl J Med 2002; 347:1662-9. [PMID: 12444180 DOI: 10.1056/nejmoa022343] [Citation(s) in RCA: 1281] [Impact Index Per Article: 58.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Controversy exists about the best surgical treatment for esophageal carcinoma. METHODS We randomly assigned 220 patients with adenocarcinoma of the mid-to-distal esophagus or adenocarcinoma of the gastric cardia involving the distal esophagus either to transhiatal esophagectomy or to transthoracic esophagectomy with extended en bloc lymphadenectomy. Principal end points were overall survival and disease-free survival. Early morbidity and mortality, the number of quality-adjusted life-years gained, and cost effectiveness were also determined. RESULTS A total of 106 patients were assigned to undergo transhiatal esophagectomy, and 114 to undergo transthoracic esophagectomy. Demographic characteristics and characteristics of the tumor were similar in the two groups. Perioperative morbidity was higher after transthoracic esophagectomy, but there was no significant difference in in-hospital mortality (P=0.45). After a median follow-up of 4.7 years, 142 patients had died--74 (70 percent) after transhiatal resection and 68 (60 percent) after transthoracic resection (P=0.12). Although the difference in survival was not statistically significant, there was a trend toward a survival benefit with the extended approach at five years: disease-free survival was 27 percent in the transhiatal-esophagectomy group, as compared with 39 percent in the transthoracic-esophagectomy group (95 percent confidence interval for the difference, -1 to 24 percent [the negative value indicates better survival with transhiatal resection]), whereas overall survival was 29 percent as compared with 39 percent (95 percent confidence interval for the difference, -3 to 23 percent). CONCLUSIONS Transhiatal esophagectomy was associated with lower morbidity than transthoracic esophagectomy with extended en bloc lymphadenectomy. Although median overall, disease-free, and quality-adjusted survival did not differ statistically between the groups, there was a trend toward improved long-term survival at five years with the extended transthoracic approach.
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Affiliation(s)
- Jan B F Hulscher
- Department of Surgery, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
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28
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Abstract
BACKGROUND Several complex surgical procedures had a reduction in mortality when they were performed at high volume centers. We hypothesized esophagectomy procedures for cancer performed at high volume hospitals in the state of Massachusetts would show a similar relationship. METHODS Data were obtained from the Massachusetts Health Data Consortium on discharge information for all acute care hospitals in Massachusetts regardless of payer from 1992 to 2000. The influence of hospital volume was related to days in the intensive care unit, length of stay, discharge disposition, hospital mortality, and total cost. Hospitals were stratified to low volume hospitals (< 6 cases per year) and high volume hospitals (> 6 cases per year). RESULTS One thousand one hundred ninety-three patients underwent esophagectomy during this 8-year study period in Massachusetts. Three high volume hospitals performed 56.5% of all resections (674 of 1,193). Sixty-one low volume hospitals performed 43.5% of the resections (519 of 1,193) with an average volume of only 1 case of esophagectomy per year. High volume hospitals were associated with a 2-day decrease in median length of stay (p < 0.001), a 3-day reduction in median intensive care unit stay (p < 0.001), an increased rate of home discharges (as opposed to rehabilitation hospitals) (p < 0.001), and a 3.7-fold decrease in hospital mortality (9.2% vs 2.5%; p < 0.001). The odds ratio of death at a low volume hospital was 4.3 (95% confidence interval, 2.3 to 7.7; p < 0.001). The median cost was $755 dollars greater at high volume hospitals (p = not significant). CONCLUSIONS Hospitals that perform a high volume of esophagectomies have better results with early clinical outcomes and marked reductions in mortality compared with low volume hospitals.
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Affiliation(s)
- E Y Kuo
- Division of General Thoracic Surgery, Massachusetts General Hospital, Boston 02114, USA
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29
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Dimick JB, Cattaneo SM, Lipsett PA, Pronovost PJ, Heitmiller RF. Hospital volume is related to clinical and economic outcomes of esophageal resection in Maryland. Ann Thorac Surg 2001; 72:334-9; discussion 339-41. [PMID: 11515862 DOI: 10.1016/s0003-4975(01)02781-3] [Citation(s) in RCA: 97] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Previous studies have documented a relationship between hospital volume and perioperative and economic outcomes. Our objective was to determine the effect of hospital volume on outcomes of esophageal resection. METHODS Statewide database was analyzed for patients who underwent esophageal resection in Maryland (n = 1,136 patients) from 1984 to 1999. Multivariate regression was used to determine the association of hospital volume with in-hospital mortality, length of stay, and charges after adjusting for case mix and time period. RESULTS Unadjusted in-hospital mortality rates were lower in high volume hospitals (2.7%) than medium (12.7%) and low (16%) volume hospitals (p < 0.001). High hospital volume was associated with (1) fivefold reduction in the risk of death (odds ratio, 0.21; 95% confidence interval, 0.10 to 0.42; p < 0.001); (2) a 6-day (95% confidence interval, 5 to 7 days; p < 0.001) reduction in length of stay; and (3) $11,673 (95% confidence interval, $9,504 to $12,841; p < 0.001) decrease in hospital charges. Conclusions. Hospitals that perform high volumes of esophageal resection have superior clinical and economic outcomes. By referring these patients to high volume centers, we may improve quality and reduce costs.
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Affiliation(s)
- J B Dimick
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland 21287-4605, USA
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Bousamra M. Optimizing results of esophageal resection for benign and malignant disease. J Ky Med Assoc 2001; 99:12-20. [PMID: 11201614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/19/2023]
Affiliation(s)
- M Bousamra
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Louisville School of Medicine, Louisville, KY 40292, USA.
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Amaravadi RK, Dimick JB, Pronovost PJ, Lipsett PA. ICU nurse-to-patient ratio is associated with complications and resource use after esophagectomy. Intensive Care Med 2000; 26:1857-62. [PMID: 11271096 DOI: 10.1007/s001340000720] [Citation(s) in RCA: 188] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To determine if having a night-time nurse-to-patient ratio (NNPR) of one nurse caring for one or two patients (> 1:2) versus one nurse caring for three or more patients (< 1:2) in the intensive care unit (ICU) is associated with clinical and economic outcomes following esophageal resection. DESIGN State-wide observational cohort study. Hospital discharge data was linked to a prospective survey of ICU organizational characteristics. Multivariate analysis adjusting for case-mix, hospital and surgeon volume was used to determine the association of NNPR with in-hospital mortality, length of stay (LOS), hospital cost and specific postoperative complications. SETTING Non-federal acute care hospitals (n = 35) in Maryland that performed esophageal resection. PATIENTS AND PARTICIPANTS Adult patients who had esophageal resection in Maryland, 1994 to 1998 (n = 366 patients). MEASUREMENTS AND RESULTS Two hundred twenty-five patients at nine hospitals had a NNPR > 1:2;128 patients in 23 hospitals had a NNPR < 1:2. No significant association between NNPR and in-hospital mortality was seen. A 39 % increase in median in-hospital LOS (4.3 days; 95% CI, (2, 5 days); p < 0.001), and a 32% increase in costs ($4,810; 95 % CI, ($2,094, $7,952) was associated with a NNPR < 1:2. Pneumonia (OR 2.4; 95 % CI (1.2, 4.7); p = 0.012), reintubation (OR 2.6; 95% CI(1.4, 4.5);p = 0.001), and septicemia (OR 3.6; 95 % CI(1.1, 12.5); p = 0.04), were specific complications associated with a NNPR < 1:2. CONCLUSIONS A nurse caring for more than two ICU patients at night increases the risk of several postoperative pulmonary and infectious complications and was associated with increased resource use in patients undergoing esophageal resection.
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Affiliation(s)
- R K Amaravadi
- Department of Surgery, The Johns Hopkins School of Medicine, Baltimore, MD 21287-4685, USA
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Abstract
OBJECTIVE Surveillance of Barrett's patients is recommended, to detect dysplasia and early cancer. The reported risk for developing cancer varies substantially, however. Our previous analysis used an average cancer incidence of 1/75 patient-years (PY). Recent reports suggest that the risk may range from 1/251 to 1/208 PY in combined series of patients with long segment Barrett's esophagus (LSBE, >3 cm), and short segment Barrett's esophagus (SSBE), and up to 1% annually in patients with SSBE. Our goal was to consider these new estimates of cancer risk in a cost-utility analysis of surveillance of patients with Barrett's esophagus. METHODS Using our previously published model, we incorporated an average of the recent estimates of cancer risk (0.4% annually, 1/227 PY), and our primary data on quality of life after esophagectomy. We included actual variable (direct) costs and used a discount rate of 5%. From the perspective of an HMO, the model evaluates surveillance every 1-5 yr and no surveillance, with esophagectomy performed if high grade dysplasia is diagnosed, and calculates the incremental cost-utility ratios for each strategy. RESULTS The results suggest that, at our baseline, annual cancer risk surveillance every 5 yr is the only viable strategy. More frequent surveillance costs more and yields a lower life expectancy. The incremental cost-utility ratio for surveillance every 5 yr is $98,000/quality-adjusted life year (QALY) gained, comparable to the incremental cost-effectiveness ratios of accepted practices (heart transplantation and screening for tuberculosis in selected populations, $160,000/LY gained and $216,000/LY gained, respectively). CONCLUSIONS Surveillance of Barrett's patients should extend life, with incremental cost-utility ratios that compare favorably with some accepted medical practices. Policy makers can compare the cost of surveillance to that of other accepted practices to determine their willingness to fund surveillance.
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Affiliation(s)
- D Provenzale
- Institute for Clinical and Epidemiological Research, Durham VAMC, North Carolina, USA
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Abstract
BACKGROUND Standardized clinical care pathways have been developed for postoperative management in an attempt to contain costs in an era of rising health care costs and limited resources. The purpose of this study was to assess the effect of these pathways on length of stay, hospital charges, and outcome for major thoracic surgical procedures. METHODS All anatomic lung (segmentectomy, lobectomy, and pneumonectomy) and partial and complete esophageal resections performed from July 1991 to July 1997 were retrospectively analyzed for length of stay, hospital charges, and outcome. A prospectively developed database was used. Clinical care pathways were introduced in March 1994. Comparisons were made between the procedures performed before (group I) and after (group II) pathway implementation. Common to both pathways are early mobilization and prudent x-ray and laboratory analysis. In addition, the pathway for esophagectomies emphasizes overnight intubation with 24-hour intensive care unit care, and staged diet advancement. The discharge goal was postoperative day 10. For lung resection the emphasis is early postoperative extubation with overnight intensive care unit management. The discharge goal was postoperative day 7. RESULTS Group I esophagectomies (n = 56) had significantly greater hospital charges compared with group II (n = 96) ($21,977 +/- $13,555 versus $17,919 +/- $5,321; p < 0.04, in actual dollars) and ($29,097 +/- $18,586 versus $19,260 +/- $6,000; p < 0.001, in dollars adjusted for inflation) and greater length of stay (13.6 +/- 6.9 versus 9.5 +/- 2.8 days; p < 0.001). Group I lung resections (n = 185) had a significantly greater length of stay compared with group II (n = 241) (8.0 +/- 6.2 versus 6.4 +/- 3.8 days; p < 0.002); although charges trended downward ($13,113 +/- $10,711 versus $12,404 +/- $7,189; not significant) in actual dollars, charges were significantly less in dollars adjusted for inflation ($17,103 +/- $13,211 versus $13,432 +/- $8,056; p < 0.01). The most significant decreases in charges for esophagectomies were in miscellaneous charges (61% in dollars adjusted for inflation), pharmaceuticals (60%), laboratory (42%) and radiologic (39%) tests, physical therapy charges (35%), and routine charges (34%). For lung resections the greatest savings occurred for pharmaceuticals (38%), supplies (34%), miscellaneous charges (25%), and routine charges (22%). Mortality was similar (esophagectomies: I, 3.6%; II, 0%; lung resections: I, 0.5%; II, 0.8%; not significant). CONCLUSIONS Introduction of standardized clinical pathways has resulted in a marked reduction of length of stay for all major thoracic surgical procedures. Total charges were reduced for both esophagectomies (34%) and lung resections (21%) with continued quality of outcome.
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Affiliation(s)
- K J Zehr
- Division of Thoracic Surgery, Johns Hopkins Hospital, Baltimore, Maryland 21287, USA
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34
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Hill AD, Walsh TN, Moraes D, Hennessy TP. Audit of an oesophageal unit. Ann R Coll Surg Engl 1992; 74:401-5. [PMID: 1471837 PMCID: PMC2497707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
We report an audit of 786 oesophageal procedures, including 53 oesophagectomies, performed during 1990 in a specialist oesophageal unit. Apart from assessing morbidity and mortality, audit allows a review of cost efficiency and justification for certain practices with regard to patient management. The data reported here may provide a framework against which individual surgeons may assess their own results and compare costs of procedures with a similar outcome.
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Affiliation(s)
- A D Hill
- Trinity College, Department of Surgery, St James's Hospital, Dublin, Ireland
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