Etter Katherine, Davis Brad, Roy Sanjoy, Kalsekar Iftekhar, Yoo Andrew
Medical Device - Epidemiology, Johnson & Johnson, New Brunswick, New Jersey, USA.
CMC Surgery, Carolinas Medical Center, Charlotte, North Carolina, USA.
JSLS. 2017 Jul-Sep;21(3). doi: 10.4293/JSLS.2017.00036.
Studies have shown economic and clinical advantages of laparoscopic left-colon resections. Laparoscopic conversion to open is an important surgical outcome. We estimated conversion incidence, identified risk factors, and measured the clinical and economic impact.
In this retrospective study, we used the Premier Perspective database to analyze left-sided colectomies from 2009 to 2014. Operating room time (ORT), length of stay (LOS), total hospital cost (2014 U.S. dollars); along with incidence of in-hospital clinical outcomes (anastomotic leak surrogate [Leak], transfusion, and mortality) were evaluated. Multivariable models accounting for hospital clustering were used to identify conversion risk factors and analyze the effect of conversion on economic and clinical outcomes.
A total of 41,417 patients: 8,468 left hemicolectomy and 32,949 sigmoidectomy were identified. Lap-Conversion incidence was 13.3% (95% CI, 12.9-13.7). Adjusted mean LOS (±SE) days was significantly lower for the Lap-Successful group (4.9 compared with Lap-Conversion 6.8 and Open-Planned 7.0), but Lap-Conversion and Open-Planned had similar LOS. Adjusted mean cost was higher for Lap-Conversion $20,165 compared to Open-Planned $18,797; but this difference was smaller than the cost savings for Lap-Successful $16,206 ± $219. Open-Planned had lower odds of Leak compared to Lap-Conversion. Open-Planned and Lap-Conversion had similar odds of transfusion and mortality. Conversion risk factors included inflammatory bowel disease and left-hemicolectomy. Colorectal specialists were associated with 38% decreased odds of conversion.
Successful laparoscopic surgery was the most cost effective, with decreased LOS and odds of blood transfusion, leak surrogate, and mortality. Conversion was the most expensive and had increased odds of leak surrogate, but similar LOS compared to Open-Planned. The beneficial effect size of successful laparoscopic surgery was larger than the negative effect of conversion compared to Open-Planned.
研究显示腹腔镜左半结肠切除术具有经济和临床优势。腹腔镜中转开腹是一项重要的手术结果。我们估算了中转率，确定了风险因素，并评估了临床和经济影响。
在这项回顾性研究中，我们使用Premier Perspective数据库分析了2009年至2014年的左半结肠切除术。评估了手术室时间（ORT）、住院时间（LOS）、总住院费用（2014年美元）以及院内临床结局（吻合口漏替代指标[漏]、输血和死亡率）的发生率。采用考虑医院聚类的多变量模型来确定中转风险因素，并分析中转对经济和临床结局的影响。
共识别出41417例患者：8468例行左半结肠切除术，32949例行乙状结肠切除术。腹腔镜中转开腹率为13.3%（95%可信区间，12.9 - 13.7）。腹腔镜手术成功组的调整后平均住院时间（±标准误）天数显著更低（4.9天，而腹腔镜中转开腹组为6.8天，计划性开腹组为7.0天），但腹腔镜中转开腹组和计划性开腹组的住院时间相似。腹腔镜中转开腹组的调整后平均费用为20165美元，高于计划性开腹组的18797美元；但这一差异小于腹腔镜手术成功组节省的费用16206±219美元。计划性开腹组发生漏的几率低于腹腔镜中转开腹组。计划性开腹组和腹腔镜中转开腹组的输血和死亡率几率相似。中转风险因素包括炎症性肠病和左半结肠切除术。结直肠专科医生与中转几率降低38%相关。
成功的腹腔镜手术最具成本效益，住院时间缩短，输血、漏替代指标及死亡率几率降低。中转开腹是最昂贵的，漏替代指标几率增加，但与计划性开腹相比住院时间相似。与计划性开腹相比，成功的腹腔镜手术的有益效应大小大于中转开腹的负面影响。
