Hepatobiliary Surgery, IRCCS San Raffaele Hospital, Via Olgettina 60, 20132, Milan, Italy.
J Gastrointest Surg. 2019 Nov;23(11):2163-2173. doi: 10.1007/s11605-019-04112-4. Epub 2019 Feb 4.
Considering the increasing evidence on the feasibility of laparoscopic major hepatectomies (LMH), their clinical outcomes and associated costs were herein evaluated compared to open (OMH).
Major contributors of perioperative expenses were considered. With respect to the occurrence of conversion, a primary intention-to-treat analysis including conversions in the LMH group (ITT-A) was performed. An additional per-protocol analysis excluding conversions (PP-A) was undertaken, with calculation of additional costs of conversion analysis.
One hundred forty-five LMH and 61 OMH were included (14.5% conversion rate). At the ITT-A, LMH showed lower blood loss (p < 0.001) and morbidity (global p 0.037, moderate p 0.037), shorter hospital stay (p 0.035), and a lower need for intra- and postoperative red blood cells transfusions (p < 0.001), investigations (p 0.004), and antibiotics (p 0.002). The higher intraoperative expenses (+ 32.1%, p < 0.001) were offset by postoperative savings (- 27.2%, p 0.030), resulting in a global cost-neutrality of LMH (- 7.2%, p 0.807). At the PP-A, completed LMH showed also lower severe complications (p 0.042), interventional procedures (p 0.027), and readmission rates (p 0.031), and postoperative savings increased to - 71.3% (p 0.003) resulting in a 29.9% cost advantage of completed LMH (p 0.020). However, the mean additional cost of conversion was significant.
Completed LMH exhibit a high potential treatment effect compared to OMH and are associated to significant cost savings. Despite some of these benefits may be jeopardized by conversion, a program of LMH can still provide considerable clinical benefits without cost disadvantage and appears worth to be implemented in high-volume centers.
考虑到腹腔镜肝切除术（LMH）可行性的证据不断增加，本文评估了与开腹肝切除术（OMH）相比，LMH 的临床结果和相关成本。
考虑了围手术期费用的主要构成。对于转换的发生，进行了包括 LMH 组转换的主要意向治疗分析（ITT-A）。进行了排除转换的方案分析（PP-A），并计算了转换分析的额外成本。
共纳入 145 例 LMH 和 61 例 OMH（转换率为 14.5%）。在 ITT-A 中，LMH 显示出较低的出血量（p<0.001）和发病率（总体 p<0.037，中度 p<0.037），较短的住院时间（p<0.035），以及较低的围手术期内和术后红细胞输血需求（p<0.001）、检查（p<0.004）和抗生素（p<0.002）。较高的术中费用（+32.1%，p<0.001）被术后节省抵消（-27.2%，p<0.030），导致 LMH 的总体成本中性（-7.2%，p<0.807）。在 PP-A 中，完成的 LMH 还显示出较低的严重并发症（p<0.042）、介入治疗（p<0.027）和再入院率（p<0.031），术后节省增加到-71.3%（p<0.003），导致完成的 LMH 的成本优势为 29.9%（p<0.020）。然而，转换的平均额外成本是显著的。
与 OMH 相比，完成的 LMH 表现出较高的治疗效果，并与显著的成本节约相关。尽管一些这些好处可能会因转换而受到影响，但 LMH 计划仍可以在不增加成本劣势的情况下提供显著的临床获益，并且似乎值得在高容量中心实施。
