Cost implications and oncological outcomes for laparoscopic versus open surgery for right hemicolectomy

Abstract

Introduction

Recent studies have suggested that laparoscopic surgery for colorectal resection confers a cost benefit compared with open surgery. These studies have considered a wide range of colorectal operations together rather than focusing on a single procedure. Our study compared direct clinical costs for laparoscopic versus open right hemicolectomy.

Methods

Clinicopathological data and cost of treatment for all patients who underwent a right hemicolectomy between 2012 and 2013 were collected. The primary outcome was total cost of treatment. Secondary outcomes were length of stay, operative time and morbidity. The minimum follow-up duration was 12 months. Costs for laparoscopic and open surgery for elective resection alone were compared. Further analyses were performed comparing emergency cases with elective cases and cancer with non-cancer cases.

Results

There were 83 patients who underwent a right hemicolectomy during the study period and of these, 65 had an elective procedure. The total cost of a laparoscopic procedure was £3,998.12 compared with £3,427.50 for open surgery (p=0.039). The length of stay was shorter for laparoscopic surgery while the cost of an emergency right hemicolectomy was significantly greater than for elective surgery.

Conclusions

Although the length of stay for laparoscopic surgery was shorter, this did not translate to a reduction in cost. The cost benefit from a shorter length of stay was offset by a greater cost of consumables. Cost effectiveness analyses should be designed carefully, and they should consider individual operations separately when making healthcare management and funding decisions.

The laparoscopic approach for colectomy is used widely for both malignant and benign conditions.^1–3 There are several short-term benefits to the laparoscopic approach, including less pain and quicker recovery.^4,5 This approach is now well accepted, and initial concerns about technical difficulties and long-term outcomes have largely abated. However, the cost effectiveness of laparoscopic surgery has been questioned, and there are conflicting reports from studies investigating costs for open and laparoscopic surgery.^6–8 These studies are not easily comparable given the heterogeneity within them; the definition of a true cost of a procedure is not defined uniformly and most studies combined all colorectal operations rather than focusing on individual procedures. Our study compared the direct costs as well as short-term clinical and oncological outcomes for patients who underwent a laparoscopic right hemicolectomy over a one-year period with those for patients undergoing open procedures during the same period.

Methods

All patients who underwent a right hemicolectomy at our institution between January 2012 and January 2013 were identified from a prospectively maintained database of operations. Each set of case notes and computerised records for radiology and pathology were analysed to complete a database of procedures for all patients. The study was registered and had full approval from the local institution audit review board.

Patient demographics, pathology, urgency of surgery, operative approach (laparoscopic, open or laparoscopic converted to open), operative time, complications, length of stay, morbidity and mortality, and oncological outcomes (for cancer cases) were recorded. For each case, every piece of equipment used and every operating tray opened was also recorded, and the total cost per case was calculated. The total cost for a patient’s care was calculated as the cost of the consumables in theatre, the cost of their inpatient stay (including ward stay and days on the intensive care unit) and the cost of any postoperative interventions (reoperation), imaging during their postoperative stay and readmission over a 12-month follow-up period (Appendix 1 – available online).

Costs were calculated on an ‘intention-to-treat basis’ in that patients who had laparoscopic converted to open surgery were considered in the laparoscopic group for statistical analysis. Complications were recorded prospectively and included readmission or intervention within the 12-month follow-up period after primary surgery.

Patients who underwent a laparoscopic approach were compared with patients who had open surgery. No patients were excluded from the study although the choice between a laparoscopic approach and open surgery was at the discretion of the operating surgeon and was not randomised. In order to provide a true comparison, cost analyses were performed between similar groups (eg elective laparoscopic vs elective open). Analyses were also performed for emergency versus elective cases and cancer versus non-cancer cases to provide further information about the cost effectiveness of laparoscopic surgery in a variety of scenarios.

The laparoscopic and open surgery cohorts were compared for mortality and morbidity, length of stay, operative time, oncological outcomes and total cost. A chi-squared test was used to compare the groups and Student’s t-test was used to compare means. A p-value of <0.05 was considered statistically significant and SPSS^® version 20 (IBM, New York, US) was used for statistical analysis.

Results

Over the 1-year study period, 83 patients underwent a right hemicolectomy. The patient demographics, pathology, operative approach and urgency of surgery are detailed in Table 1. Overall, 43 cases (52%) were completed laparoscopically, 12 (14%) were commenced laparoscopically and were converted to open surgery, and 28 (34%) were wholly open procedures. There were 51 men (61%) and the median age was 72 years (interquartile range [IQR]: 64–79 years). The majority of cases were for colonic malignancy (n=69, 83%). Sixty-five procedures (78%) were performed on an elective (rather than emergency) basis.

Table 1.

Comparison between laparoscopic and open surgery for elective right hemicolectomy

	Laparoscopic (n=48)	Open (n=17)	p-value
Male patients	29 (60%)	11 (68%)	0.755
Median age	69.1 years	70.0 years	0.851
Cancer resections	41 (85%)	13 (76%)	0.398
Complications	10 (21%)	4 (24%)	0.730
In-hospital deaths	1 (2%)	1 (5%)	0.704
Mean operative time	178 minutes	114 minutes	0.001
Mean inpatient stay	6.0 days	7.8 minutes	0.612
Node yield	14	11	0.124
Mean cost	£3,998.12	£3,427.50	0.039

Laparoscopic vs open surgery for elective right hemicolectomy

There were 65 patients (40 male, 62%) who had an elective right hemicolectomy. Fifty-four patients (83%) had surgery for cancer. All of the remaining 11 patients had surgery for Crohn’s disease. There were 48 patients (74%) who had laparoscopic surgery. Eleven of these had conversion to open surgery. The remaining 17 patients (26%) had primary open surgery. The overall median age for elective right hemicolectomy patients was 72 years (IQR: 62.2–78.7 years).

The laparoscopic and open surgery groups were broadly similar in age, sex distribution and the proportion of patients who had a cancer resection as opposed to a benign resection. The length of stay was lower for patients who had laparoscopic surgery but this did not reach statistical significance. The operative time and cost of treatment were significantly higher for patients who underwent laparoscopic surgery than for those who had open surgery (Table 1).

Emergency vs elective surgery for right hemicolectomy

Of the 83 patients who had a right hemicolectomy, 65 (78%) underwent elective surgery. There were no significant differences between the two groups apart from a greater length of stay and total cost of treatment for patients who underwent emergency surgery (Table 2). The proportion of patients who had laparoscopic surgery in the elective group was much greater (58%) although almost 40% of patients who underwent emergency surgery had a laparoscopic operation.

Table 2.

Comparison between emergency and elective surgery for right hemicolectomy

	Emergency (n=18)	Elective (n=65)	p-value
Male patients	11 (61%)	40 (62%)	0.974
Median age	69.2 years	70.0 years	0.736
Cancer resections	15 (83%)	54 (83%)	0.979
Complications	5 (28%)	14 (22%)	0.732
In-hospital deaths	1 (5%)	2 (3%)	0.743
Mean operative time	187 minutes	161 minutes	0.184
Mean inpatient stay	11.1 days	6.9 days	0.048
Node yield	14	14	0.859
Mean cost	£5,510.62	£3,953.51	0.019

Right hemicolectomy for cancer vs non-cancer pathology

Of the 83 patients who underwent a right hemicolectomy, 69 (83%) had a cancer resection. There were no statistically significant differences between the cancer and non-cancer groups except for the fact that patients who had cancer resections were older (p=0.026) (Table 3).

Table 3.

Comparison between cancer and non-cancer pathology for right hemicolectomy

	Cancer (n=69)	Benign disease (n=14)	p-value
Male patients	41 (51%)	10 (71%)	0.400
Median age	70.8 years	63.1 years	0.026
Laparoscopic surgery	48 (70%)	7 (50%)	0.158
Complications	14 (20%)	5 (36%)	0.301
In-hospital deaths	2 (3%)	1 (7%)	0.332
Mean operative time	171 minutes	148 minutes	0.289
Mean inpatient stay	7.6 days	8.9 days	0.598
Mean cost	£4,214.53	£4,668.97	0.675

Discussion

This study demonstrates that oncological and short-term clinical outcomes between laparoscopic and open surgery for right hemicolectomy are broadly comparable. Although the length of stay was shorter for laparoscopic surgery, the cost benefit that a reduced inpatient stay confers⁸ was not offset by the overall cost of treatment and open surgery was significantly cheaper for patients who had an elective open right hemicolectomy. For patients who underwent laparoscopic surgery, the bulk of the increased cost was due to consumables and equipment. In this study, there were no significant reductions in complications in the laparoscopic group.

Many randomised controlled trials have demonstrated either equivalence or superiority of the laparoscopic approach over open surgery for laparoscopic colorectal cancer resection for a number of clinicopathological outcomes. The benefits include a lower risk of thromboembolism,⁹ a lower need for blood transfusion,¹⁰ less postoperative pain and a shorter length of stay.¹¹ However, there are few studies that have assessed the cost of laparoscopic surgery compared with that of open surgery. Most studies that have made cost–benefit analyses have shown an increased cost of laparoscopic surgery, and this has been attributed to increased operative time, less experience with laparoscopic surgery and a greater cost of consumables. Recent studies, with both crude measures of costs^8,11 and more advanced analysis of cost effectiveness,⁷ have suggested that laparoscopic surgery does confer a cost benefit over open surgery. These findings have also been reported in studies for liver and pancreatic surgery.^12,13

Our study was performed in a centre that has a high proportion of laparoscopic resections; even among emergency surgery cases, 40% of patients receive a laparoscopic operation. Despite this experience in laparoscopic surgery, the cost of a laparoscopic operation was greater than that of an open operation, which is in contrast to the findings in other recent publications. This may be because most studies comparing open and laparoscopic surgery for colorectal pathology included all resections although it is clear that a right hemicolectomy is very different to an anterior resection. Our study is among the first to perform a cost analysis for a specific operation and our findings are in line with those of previous studies that looked at laparoscopic versus open right hemicolectomy.¹⁴

On the other hand, there are a few caveats. First, the conversion rate for right hemicolectomy in our study was slightly higher than for previously reported studies (12/55, 23%).¹⁴ This may be related to the subtle difference in the level of experience of the operating surgeons, the difficulty of the procedure and other patient related factors. Conversion automatically increases the length of stay in the laparoscopic cohort owing to the intention-to-treat analysis policy.

Second, the enhanced recovery programme for laparoscopic and open surgical procedures was not fully enforced at the time of this study. Improved surgical expertise and experience in laparoscopic surgery, implementation of an enhanced recovery programme and better patient selection can mitigate these factors, leading to a reduction in the length of hospital stay. Given the cost of a single bed day in hospital (£225),¹⁵ a reduction in the inpatient stay of two days can make laparoscopic surgery cheaper than an open operation.

More disposable items are needed for laparoscopic right hemicolectomy than for open surgery. Fewer stapling devices are used for open procedures and the cost for disposables is lower for elective surgery compared with laparoscopic cases. However, for a pelvic operation, the stapling devices used for laparoscopic surgery are similar to those for open surgery and the difference in cost is not so pronounced. Unsurprisingly, the cost of emergency cases in this series was significantly greater than that of elective cases; this difference was mostly due to inpatient stay and imaging rather than consumables. Avoiding the use of stapling devices and clips, and using energy devices or handsewn techniques for pedicle ligation and anastomosis reduces the cost of consumables for laparoscopic right hemicolectomy further although this can lead to a marginal increase in the operative time, offsetting the saving slightly.

There are some limitations to this study. There was no randomisation in this series and the cost analysis performed was crude, with no measure of the cost of operative time, community costs or ‘non-surgical’ costs (eg the savings accrued from fewer analgesic requirements). Recent studies have assessed cost effectiveness through a more robust analysis (including costs of community care and quality of life data) and have suggested that laparoscopic surgery does remain cost effective compared with open surgery.^7,8 However, these studies included a wide range of colorectal operations and pathologies.

A further limitation in our series is that the outcomes for both elective and emergency cases were grouped together. Ideally, these should be analysed separately but this would have significantly reduced the overall numbers and made the data susceptible to statistical error.

One of the strengths of our study is that it considers a single operation in a centre with a high level of experience in laparoscopic surgery. As such, the potential problems encountered with learning curves and the introduction of a new technique should not apply here.

Although the clinical and operative equivalence of laparoscopic surgery with open surgery is now well established, these data suggest that cost effectiveness analyses should be more detailed than those performed previously. Grouping a widely heterogeneous collection of operations together does not give a realistic measure of the potential benefit of laparoscopic surgery over open surgery. Furthermore, elective procedures should be considered separately from emergency cases and it is not clear whether previous studies have stratified costs according to urgency (elective vs emergency) or nature of surgery.

Conclusions

The results of this study are different to those of recent studies that have reported lower costs for laparoscopic than for open resection for colorectal pathology. Instead, our data are more in keeping with earlier studies that compared the two approaches. Although there is a non-significant reduction in the length of stay for laparoscopic right hemicolectomy, the cost of consumables and inpatient care more than offset those benefits, resulting in a lower overall cost for open surgery. These data demonstrate the importance of ‘comparing like with like’ in terms of operations as well as careful consideration by both surgeons and managers in selecting the most appropriate approach for surgery.