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Comparative Effectiveness of Minimally Invasive Surgery and Conventional Approaches to Major or Challenging Hepatectomies
S80
Scientific Forum Abstracts
Take Only What You Need? A Nationwide Analysis Revealing the Cost of Splenectomy in Distal Pancreatectomy Nicole Lopez, MD, Paula D Strassle, Shachar Laks, MD, Michael O Meyers, MD, Hong Jin Kim, MD, FACS, Jen Jen Yeh, MD, FACS University of North Carolina, Chapel Hill, NC INTRODUCTION: Despite the potential advantages of spleensparing distal pancreatectomy (SSDP), distal pancreatectomy with splenectomy (DPS) remains the standard procedure for conditions requiring resection of the pancreatic tail. Proponents of concurrent splenectomy cite technical ease and shorter operative times, while advocates of splenic preservation suggest possible immune benefits. Still, there is little evidence to support or refute splenic preservation in distal pancreatectomy. METHODS: The National Inpatient Sample database was used to evaluate adult patients who underwent nonemergent distal pancreatectomy with or without splenectomy between 2000 and 2013. Patients with malignancies were excluded. Surgical complications, length of stay (LOS), and total hospital charges were compared between DPS and SSDP procedures using multivariable logistic and linear regression, controlling for patient demographics, relevant comorbidities, and hospital characteristics. RESULTS: Of the 5,721 included patients, 4,336 (75.8%) underwent DPS, while 1,385 (24.2%) had SSDP. The proportion of SSDP procedures decreased during this time, p¼0.05 (Figure). On bivariate analysis, DPS resulted in increased rates of bleeding (p<0.0001), cardiac failure (p¼0.05), renal failure (p¼0.003), and overall complications (p<0.0001). Additionally, median LOS (7 days vs 6 days; p<0.0001) and median total charges ($52,951 vs $45,123; p<0.0001) were higher in DPS. After adjustment, bleeding (odds ratio [OR] 1.31; p¼0.004), overall complications (OR 1.31; p<0.001), LOS (0.64 day; p¼0.007), and total charges ($5,020; p¼0.05) remained greater with DPS.
J Am Coll Surg
complications, decreased LOS, and decreased total charges compared with DPS, highlighting the need to reconsider reflexive splenectomy when distal pancreatectomy is performed. Comparative Effectiveness of Minimally Invasive Surgery and Conventional Approaches to Major or Challenging Hepatectomies Lucas W Thornblade, MD, Xu Shi, Alex Ruiz, David R Flum, MD, FACS, James O Park, MD, FACS University of Washington Seattle, WA INTRODUCTION: The benefits of minimally invasive surgery (MIS) are well established, but in liver resection, they have been focused on patients undergoing lower-risk or minor resections. There is growing interest in MIS for major hepatectomy (MH) and in challenging resections; however, the comparative effectiveness against a conventional open approach has been limited to single-institution series. METHODS: Data were collected on 2,820 hepatectomy patients at 67 hospitals participating in NSQIP’s Hepatopancreaticobiliary Collaborative in 2014. We assessed serious morbidity or mortality (SMM) including organ-space infection, bleeds, and organ failure, as well as liver-specific complications (bile leak [BL], liver failure [LF]), reoperation or intervention (RI), and 30-day readmission for patients undergoing MH. We also evaluated all patients with characteristics reflecting a challenging resection (cirrhosis, 3 concurrent resections, morbid obesity, large tumors, and previous neoadjuvant chemotherapy). RESULTS: A total of 1,015 patients underwent MH (age 5714 years, 51.6% female, 13% MIS). Adjusting for clinical and operative factors, the risk of SMM was significantly lower in the MIS cohort (relative risk [RR] 0.46, 95% CI 0.22-0.95). There was no significant difference in the risk of BL, LF, RI, or readmission. Among all challenging resection groups, there was no significant difference in the risk of SMM between MIS and open operations (11% vs 23% for cirrhosis [RR 0.45, 95% CI 0.20-1.03], 26% vs 38% for large tumors [RR 0.79, 95% CI 0.31-2.00]). CONCLUSIONS: This is the largest multi-institution study on comparative outcomes of MIS in MH, and it found improved or equivalent safety outcomes. Although the decision to offer MIS may be influenced by factors not included in this evaluation, such as surgeon experience and other patient factors, these findings suggest its current use is safe and may even confer additional benefit.
Figure. Number of Elective DPS and SSDP Procedures among Adult Patients (18 years old) Each Year Between 2000 and 2013
CONCLUSIONS: Although spleen-sparing techniques may require specialized skill sets, SSDP is associated with fewer overall
Whipple Cost Calculator: A Novel Prediction Tool for Hospitalization Cost Based on Preoperative Variables Developed from a High-Volume, Single-Center Experience Russell C Kirks, Jr, MD, Allyson R Cochran, Keith Murphy, TE Barnes, MD, Erin H Baker, MD, John B Martine, MD, David A Iannitti, MD, FACS, Dionisios Vrochides, MD, PhD, FACS, FRCSC Carolinas Medical Center, Charlotte, NC
Scientific Forum Abstracts
Take Only What You Need? A Nationwide Analysis Revealing the Cost of Splenectomy in Distal Pancreatectomy Nicole Lopez, MD, Paula D Strassle, Shachar Laks, MD, Michael O Meyers, MD, Hong Jin Kim, MD, FACS, Jen Jen Yeh, MD, FACS University of North Carolina, Chapel Hill, NC INTRODUCTION: Despite the potential advantages of spleensparing distal pancreatectomy (SSDP), distal pancreatectomy with splenectomy (DPS) remains the standard procedure for conditions requiring resection of the pancreatic tail. Proponents of concurrent splenectomy cite technical ease and shorter operative times, while advocates of splenic preservation suggest possible immune benefits. Still, there is little evidence to support or refute splenic preservation in distal pancreatectomy. METHODS: The National Inpatient Sample database was used to evaluate adult patients who underwent nonemergent distal pancreatectomy with or without splenectomy between 2000 and 2013. Patients with malignancies were excluded. Surgical complications, length of stay (LOS), and total hospital charges were compared between DPS and SSDP procedures using multivariable logistic and linear regression, controlling for patient demographics, relevant comorbidities, and hospital characteristics. RESULTS: Of the 5,721 included patients, 4,336 (75.8%) underwent DPS, while 1,385 (24.2%) had SSDP. The proportion of SSDP procedures decreased during this time, p¼0.05 (Figure). On bivariate analysis, DPS resulted in increased rates of bleeding (p<0.0001), cardiac failure (p¼0.05), renal failure (p¼0.003), and overall complications (p<0.0001). Additionally, median LOS (7 days vs 6 days; p<0.0001) and median total charges ($52,951 vs $45,123; p<0.0001) were higher in DPS. After adjustment, bleeding (odds ratio [OR] 1.31; p¼0.004), overall complications (OR 1.31; p<0.001), LOS (0.64 day; p¼0.007), and total charges ($5,020; p¼0.05) remained greater with DPS.
J Am Coll Surg
complications, decreased LOS, and decreased total charges compared with DPS, highlighting the need to reconsider reflexive splenectomy when distal pancreatectomy is performed. Comparative Effectiveness of Minimally Invasive Surgery and Conventional Approaches to Major or Challenging Hepatectomies Lucas W Thornblade, MD, Xu Shi, Alex Ruiz, David R Flum, MD, FACS, James O Park, MD, FACS University of Washington Seattle, WA INTRODUCTION: The benefits of minimally invasive surgery (MIS) are well established, but in liver resection, they have been focused on patients undergoing lower-risk or minor resections. There is growing interest in MIS for major hepatectomy (MH) and in challenging resections; however, the comparative effectiveness against a conventional open approach has been limited to single-institution series. METHODS: Data were collected on 2,820 hepatectomy patients at 67 hospitals participating in NSQIP’s Hepatopancreaticobiliary Collaborative in 2014. We assessed serious morbidity or mortality (SMM) including organ-space infection, bleeds, and organ failure, as well as liver-specific complications (bile leak [BL], liver failure [LF]), reoperation or intervention (RI), and 30-day readmission for patients undergoing MH. We also evaluated all patients with characteristics reflecting a challenging resection (cirrhosis, 3 concurrent resections, morbid obesity, large tumors, and previous neoadjuvant chemotherapy). RESULTS: A total of 1,015 patients underwent MH (age 5714 years, 51.6% female, 13% MIS). Adjusting for clinical and operative factors, the risk of SMM was significantly lower in the MIS cohort (relative risk [RR] 0.46, 95% CI 0.22-0.95). There was no significant difference in the risk of BL, LF, RI, or readmission. Among all challenging resection groups, there was no significant difference in the risk of SMM between MIS and open operations (11% vs 23% for cirrhosis [RR 0.45, 95% CI 0.20-1.03], 26% vs 38% for large tumors [RR 0.79, 95% CI 0.31-2.00]). CONCLUSIONS: This is the largest multi-institution study on comparative outcomes of MIS in MH, and it found improved or equivalent safety outcomes. Although the decision to offer MIS may be influenced by factors not included in this evaluation, such as surgeon experience and other patient factors, these findings suggest its current use is safe and may even confer additional benefit.
Figure. Number of Elective DPS and SSDP Procedures among Adult Patients (18 years old) Each Year Between 2000 and 2013
CONCLUSIONS: Although spleen-sparing techniques may require specialized skill sets, SSDP is associated with fewer overall
Whipple Cost Calculator: A Novel Prediction Tool for Hospitalization Cost Based on Preoperative Variables Developed from a High-Volume, Single-Center Experience Russell C Kirks, Jr, MD, Allyson R Cochran, Keith Murphy, TE Barnes, MD, Erin H Baker, MD, John B Martine, MD, David A Iannitti, MD, FACS, Dionisios Vrochides, MD, PhD, FACS, FRCSC Carolinas Medical Center, Charlotte, NC