Watch-and-Wait policy versus robotic surgery for locally advanced rectal cancer: A cost-effectiveness study (RECCOSTE).

INTRODUCTION: Complete surgical resection for locally advanced rectal cancer is the standard treatment after a clinical complete response following chemoradiotherapy. However, some novel clinical approaches could achieve better functional results, such as Robotic Resection, or avoiding surgical procedure and incrementing surveillance intensity, called Watch-and-Wait policy. We use computational techniques to compare these clinical approaches using quality adjusted life years (QALYs). METHODS: A Markov decision analytic model was used in order to perform a cost-utility analysis, comparing standard resection (SR), Robotic Rectal Resection (RRR) and Watch-and-Wait (WW) strategies, estimating the incremental cost-effectiveness ratio per QALY to be gained from patients reaching a clinical complete response to chemoradiotherapy. Model parameter estimates were informed by previously published studies comparing WW to SR and from our database of RRR versus SR. Lifetime incremental cost-utility ratio was calculated among approaches, and a sensitivity analysis were performed in order to estimate the model uncertainty. A willingness-to-pay of per one additional QALY gained was measured to determine which strategies would be most cost-effective. RESULTS: WW is a dominating option over SR ( -75,486. 75 € and +2.04 QALYs) and RRR ( -75,486. 75 € and +0.41 QALYs). The cost-effectiveness plane shows that WW does not always dominate over RRR or SR. WW saves costs in 99.98% of the simulations when compared with either SR or RRR but only 86.9% and 55.38% (respectively) of these fall within the SR quadrant. WW is only more effective than SR 55% of the time which implies a significant uncertainty due to the high utility value assigned to cCR after chemoradiotherapy in the RRR alternative. CONCLUSION: This study provides data of cost-effectiveness differences among Standard Surgery, Watch-and-Wait and Robotic Resection approaches in clinical complete response in locally advanced rectal cancer patients after neoadjuvant chemoradiotherapy, showing a benefit for Watch-and-Wait policy.

Quality of Life in Pediatric Minimally Invasive Surgery: Cost-Utility Analysis of Laparoscopic Versus Open Appendectomy.

Background: Economic evaluation in health care is becoming increasingly important. Laparoscopic appendectomy (LAp) is one of the most frequent minimally invasive procedures in the pediatric population. The increased costs of this approach in any indication could be justified by proving its cost-utility in terms of health-related quality of life (HRQoL). We aim to perform a cost-utility analysis between open and LAp (open appendectomy [OAp] and LAp). Materials and Methods: We included the data of children operated for acute noncomplicated appendicitis, who agreed to answer a validated quality of life (QoL) questionnaire. Costs were calculated for each patient. We established a threshold for cost-effectiveness (λ) of 20,000 to 30,000€ per quality adjusted life year (QALY) according to previous research. Results: A total of 53 patients were included. Overall mean costs in the OAp were 758.98€ and in the LAp 1525.50€. The incremental cost-effectiveness ratio was 18,000€/QALY, under the threshold of cost-effectiveness, therefore favoring the laparoscopic approach as it improves HRQoL despite the costs. Conclusions: Economic evaluation studies in Pediatric Surgery are scarce and rarely measure outcomes in terms of QoL. This information is important in the decision-making process for institutions and health-care professionals. Our results encourage the use of laparoscopy in pediatric appendectomy to improve HRQoL in our patients.

Robotic versus laparoscopic distal pancreatectomies: A systematic review and meta-analysis on costs and perioperative outcome.

AIM: The aim of this meta-analysis is to compare perioperative outcomes and costs of robotic and laparoscopic distal pancreatectomy (RDP and LDP). MATERIAL AND METHODS: In accordance with the PRISMA guidelines, we searched Medline, EMBASE, Cochrane and Web of Science for reports published before December 2020. RESULTS: The literature search identified 11 papers (1 187 patients). RDP showed a lower conversion rate (odds ratio: 2.56, 95% confidence intervals [CI]: 1.31 to 5.00) with no significant differences in bleeding and operative time, complications ≥ Clavien-Dindo grade III, pancreatic fistulas and length of stay. Despite RDP presenting higher costs in all included studies, none of these differences were significant. However, RDP showed higher total costs than LDP (standardized mean differences [SMD]: -1.18, 95% CI: -1.97 to -0.39). A subgroup analysis according to the continent of origin showed that studies coming from Asian research groups kept showing significant differences (SMD: -2.62, 95% CI: -3.38 to -1.85), while Western groups did not confirm these findings. CONCLUSION: Based on low-quality evidence, despite some potential technical advantages, RDP still seems to be costlier than LDP.

A cost-effectiveness analysis of robotic versus laparoscopic distal pancreatectomy.

AIM: There is no study in the literature that evaluates the cost-effectiveness of robotic distal pancreatectomy (RDP) over laparoscopic distal pancreatectomy (LDP). We performed a comparative study of RDP and LDP with the aim of evaluating clinical and cost-effective outcomes. MATERIAL AND METHODS: This is an observational, comparative prospective nonrandomized study. The primary end point was to compare the cost-effectiveness differences between both groups. A willingness to pay of €20 000 and €30 000 per quality-adjusted life year (QALY) was used as a threshold to recognize which treatment was most cost-effective. RESULTS: A total of 31 RDP and 28 LDP have been included. The overall mean total cost was similar in both groups (RDP: €9712.15 versus LDP: €9424.68; P > .5). Mean QALYs for RDP (0.652) was higher than that associated with LDP (0.59) (P > .5). CONCLUSION: This study seems to provide data of cost-effectiveness between RDP and LDP approaches, showing some benefits for RDP.

Venous Resection for Locally Advanced Pancreatic Cancer: Time Trend and Outcome Analysis of 65 Consecutive Resections at a High-Volume Center.

INTRODUCTION: Locally advanced pancreatic cancer (LAPC) is a highly malignant carcinoma with an extremely poor prognosis. Vascular venous invasion is a frequent finding in patients with pancreatic cancer. The aim of this study was to investigate the morbidity, mortality, and survival of patients with advanced pancreatic cancer. METHODS: We retrospectively reviewed our experience of 65 consecutive pancreatic surgeries with venous resection for pancreatic cancer in three hospitals: Ramon y Cajal (Madrid, Spain) from 2002 to 2004, Monteprincipe University Hospital (Madrid, Spain) from 2005 to 2006 and Sanchinarro University Hospital (Madrid, Spain) from 2007 to December 2017. Prognostic factors were analyzed by the log-rank test and a multivariate proportional hazard regression analysis. RESULTS: Major venous reconstruction was performed by primary lateral venorrhaphy in 11 patients (17%), primary end-to-end anastomosis in 46 (70.7%) and reconstruction with a Gore-Tex® patch (W.L. Gore & Associates, Inc., Flagstaff, AZ) in 8 (12.3%). In 58% of the patients, the pathological examination showed infiltration of the vascular specimen. About 85% of the procedures performed were R0. The perioperative morbidity rate with Dindo-Clavien classification = III was 21.5%. Tumor size and nodal status were the only prognostic variables, which significantly decreased survival by a multivariate analysis. CONCLUSIONS: Major vascular resection to achieve macroscopic tumor clearance can be performed safely with acceptable operative morbidity and mortality. Nevertheless, it is justified only in carefully selected cases.

Cost-effectiveness of Randomized Study of Laparoscopic Versus Open Bilateral Inguinal Hernia Repair.

OBJECTIVE: The aim of this study is to compare the clinical and cost-effective outcomes of the open Lichtenstein repair (OL) and laparoscopic trans-abdominal preperitoneal (TAPP) repair for bilateral inguinal hernias. SUMMARY BACKGROUND DATA: A cost-effective analysis of laparoscopic versus open inguinal hernia repair is still not well addressed, especially regarding bilateral hernia. METHODS: This is a clinical and cost-effectiveness analysis within a randomized prospective study conducted at Sanchinarro University Hospital.Cases of primary, reducible bilateral inguinal hernia were included and randomized using a simple randomization program.The outcome parameters included surgical and postoperative costs, quality adjusted life years (QALY), and incremental cost per QALY gained or the incremental cost effectiveness ratio. RESULTS: Between March 2013 and January 2017, 165 patients were enrolled in this study (81 of them underwent TAPP and 84 OL).The TAPP procedure had less early postoperative pain (P = 0.037), a shorter length of stay (P = 0.001), and fewer postoperative complications (P = 0.002) when compared with the OL approach. The overall cost of TAPP procedure was higher compared with the OL cost (1,683.93&OV0556; vs 1192.83&OV0556;, P = 0.027). The mean QALYs at 1 year for TAPP (0.8094) was higher than that associated with OL (0.6765) (P = 0.018). At a willingness-to-pay threshold of 20,000 &OV0556; and 30,000 &OV0556;, there was a 95.38% and 97.96% probability that TAPP was more cost-effective relative to OL. CONCLUSIONS: The TAPP procedure for bilateral inguinal hernia appears to be more cost-effective compared with OL.