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Basso et al. Mini-invasive distal pancreatectomy

were equally effective after distal pancreatectomy, but to different countries, because of variations in
the identification and suture of a transected pancreatic the different health systems’ reimbursements and
duct is the only technique able to reduce the incidence practices. A simplistic trade-off between operative
[12]
of POPF. [41,42] Our standardized technique and the use costs and LoS may lead to a rough estimate, resulting
of a stapled closure of the pancreatic remnant, despite in higher cost for the minimally invasive approach.
[45]
the low number of patients, has proven to be safe, Furthermore, technologic advances and availability
without significant morbidity or mortality, and with of new stapler and vessel-sealing devices, have
similar re-admission rates between groups. improved the minimally invasive approaches, but
simultaneously increased the costs of the procedure.
In our experience the LDP group showed reduced pain We found an additional cost of €537 for each minimally
intensity measured on the standard VAS scale (median invasive distal pancreatectomy, compared with a
4 vs. 6) during the first 2 postoperative days, allowing traditional open operation (see Results). However, in
reduced use of analgesics and earlier mobilization. their meta-analysis, Nigri et al. argued that devices
[46]
Similarly, resumption of bowel canalization (median are often equally used in LDP and ODP, but other
48 vs. 96 h) and solid oral feeding (median 2 vs. 3 practices or habits may influence results.A Korean
days) were shortened with LDP, compared with ODP. single-centre study found significantly higher total
costs for LDP, but LoS in this series was higher than
An ERAS protocol was applied in all patients, as any other published study (11.5 ± 4.1 days for LDP and
previously reported. These programs, introduced for 13.5 ± 4.9 days for ODP), reflecting the importance
[10]
colorectal surgery, have been progressively adopted of different practices. All subsequent studies found
[47]
by other surgical specialities, leading to a reduction that although the operative costs were higher for
of postoperative morbidity and a shortening of LoS. minimally invasive procedures, decreased LoS after
[43]
Pancreatic surgery is still a high risk procedure, but laparoscopic resection balanced, at least, overall
several non-randomized trials have demonstrated costs. [30,48] Rutz et al. found a mean operative cost
[7]
that ERAS in pancreatic resections is safe and of $4,900 for ODP and $5,756 for LDP, but calculated
feasible. In our study, the use of minimally invasive a mean total cost of care of $13,900 for the open
[44]
surgery together with recommendations of the ERAS procedure vs. $10,480 for the laparoscopic one. In this
programme have shown complementary roles,
speeding recovery and shortening LoS. study, we accurately evaluated the overall expenses of
the procedures, calculating device, equipment and all
Consistent with previous studies, the hospital LoS was disposable costs as electronically cataloged. Similar
significantly reduced in patients treated with minimally to other studies, we calculated the costs for a longer
invasive approach (median 8 vs. 11.5 days in LDP and LoS in ODP vs. LDP (median 11.5 vs. 8 days), and
ODP groups, respectively). Venkat et al. found a 4 we found an advantage of costs for the hospital stay
[14]
days reduction in LoS with LDP, whereas Cao et al. favoring the minimally invasive approach vs. the open
[12]
in a large population-based analysis, reported a mean technique (mean cost, €5,169 vs. €6,279.5).
LoS of 8.62 days in the laparoscopic group vs. 10.76
days in the open one. Pericleous et al. in their Undoubtedly, reduction of hospital stay impacts
[15]
meta-analysis of case-matched studies, reported a expenses, lowering the overall cost of postoperative
reduced LoS of 2.7 days, similar to other groups, management. Furthermore, the minimally invasive
who reported a reduction of LoS of 2.7 to 5 days for approach contributes to reduction of postoperative
LDP, compared with ODP. Very recently, a Cochrane pain and earlier ambulation, favouring an earlier
review found that mean LoS was shorter by 2.43 days discharge of patients. Consistent with our findings,
[39]
in the minimally invasive group compared with the Fox et al. found a shorter LoS and a reduction of total
open surgery group. Hospital stay is considered an hospital costs for LDP (n = 42), compared with ODP
[17]
important evaluation index in laparoscopic surgery. (n = 76), showing that LoS was directly proportional
[28]
Thus, our finding is interesting and probably related to total costs. Interestingly, Braga et al. suggested
to the implementation of ERAS protocol, with earlier that the cost-benefit analysis should consider not
weaning from i.v. analgesia and earlier canalization. only the hospital charges, but also the cosmesis
Interestingly, a significant relationship between LoS and quality of life of the patients to fully evaluate the
and age was found only in the ODP group. minimally invasive approach. Notably, in our study
the postoperative complications and readmission rate
[49]
Cost effectiveness of a procedure has become were similar. Ahmad et al. found that postoperative
important, given that resources are limited and cost complications and higher transfusion requirements, or
control is necessary, particularly in the Italian health the presence of chronic pancreatitis, had a significant
system. Unfortunately, our analysis is not generalizable impact on 30- and 90-day readmission rates.
Mini-invasive Surgery ¦ Volume 1 ¦ September 30 139