Incidence of anastomotic leakage using powered circular staplers versus manual circular staplers for left colorectal anastomosis: a cost-effectiveness analysis.

BACKGROUND: Colorectal anastomotic leakage causes severe consequences for patients and healthcare system as it will lead to increased consumption of hospital resources and costs. Technological improvements in anastomotic devices could reduce the incidence of leakage and its economic impact. The aim of the present study was to assess if the use of a new powered circular stapler is cost-effective. METHOD: This observational study included patients undergoing left-sided circular stapled colorectal anastomosis between January 2018 and December 2021. Propensity score matching was carried out to create two comparable groups depending on whether the anastomosis was performed using a manual or powered circular device. The rate of anastomotic leakage, its severity, the consumption of hospital resources, and its cost were the main outcome measures. A cost-effectiveness analysis comparing the powered circular stapler versus manual circular staplers was performed. RESULTS: A total of 330 patients were included in the study, 165 in each group. Anastomotic leakage rates were significantly different (p = 0.012): 22 patients (13.3%) in the manual group versus 8 patients (4.8%) in the powered group. The effectiveness of the powered stapler and manual stapler was 98.27% and 93.69%, respectively. The average cost per patient in the powered group was €6238.38, compared with €9700.12 in the manual group. The incremental cost-effectiveness ratio was - €74,915.28 per patient without anastomotic complications. CONCLUSION: The incremental cost of powered circular stapler compared with manual devices was offset by the savings from lowered incidence and cost of management of anastomotic leaks.

A retrospective cohort study of intra-corporeal versus extra-corporeal anastomosis for right hemicolectomy with cost-effectiveness analysis.

BACKGROUND: We aimed to compare outcomes and cost effectiveness of extra-corporeal anastomosis (ECA) versus intra-corporeal anastomosis (ICA) for laparoscopic right hemicolectomy using the National Surgical Quality Improvement Programme data. METHODS: Patients who underwent elective laparoscopic right hemicolectomy for colon cancer from January 2018 to December 2022 were identified. Non-cancer diagnoses, emergency procedures or synchronous resection of other organs were excluded. Surgical characteristics, peri-operative outcomes, long-term survival and hospitalisation costs were compared. Incremental cost-effectiveness ratio (ICER) was used to evaluate cost-effectiveness. RESULTS: A total of 223 patients (175 ECA, 48 ICA) were included in the analysis. Both cohorts exhibited comparable baseline patient, comorbidity, and tumour characteristics. Distribution of pathological TMN stage, tumour largest dimension, total lymph node harvest and resection margin lengths were statistically similar. ICA was associated with a longer median operative duration compared with ECA (255 min vs. 220 min, P < 0.001). There was a quicker time to gastrointestinal recovery, with a shorter median hospital stay in the ICA group (4.0 versus 5.0 days, P = 0.001). Overall complication rates were comparable. ICA was associated with a higher surgical procedure cost (£6301.57 versus £4998.52, P < 0.001), but lower costs for ward accommodation (£1679.05 versus £2420.15, P = 0.001) and treatment (£3774.55 versus £4895.14, P = 0.009), with a 4.5% reduced overall cost compared with ECA. The ICER of -£3323.58 showed ICA to be more cost effective than ECA, across a range of willingness-to-pay thresholds. CONCLUSION: ICA in laparoscopic right hemicolectomy is associated with quicker post-operative recovery and may be more cost effective compared with ECA, despite increased operative costs.

Smartphone-Based DIY Home Microsurgical Training with 3D Printed Microvascular Clamps and Japanese Noodles.

We have recently incorporated simple modifications of the konjac flour noodle model to enable DIY home microsurgical training by (i) placing a smartphone on a mug to act as a microscope with at least ×3.5-5 magnification, and (ii) rather than cannulating with a 22G needle as described by others, we have found that cannulation with a 23G needle followed by a second pass with an 18G needle will create a lumen (approximately 0.83 mm) without an overly thick and unrealistic "vessel" wall. The current setup, however, did not allow realistic evaluation of anastomotic patency as the noodles became macerated after application of standard microvascular clamps, which also did not facilitate practice of back-wall anastomoses. In order to simulate the actual operative environment as much as possible, we introduced the use of 3D-printed microvascular clamps. These were modified from its previous iteration (suitable for use in silastic and chicken thigh vessels), and video recordings were submitted for internal validation by senior surgeons. A "wet" operative field where the konjac noodle lumen can be distended or collapsed, unlike other nonliving models, was noted by senior surgeons. With the 3D clamps, the noodle could now be flipped over for back-wall anastomosis and allowed patency testing upon completion as it did not become macerated, unlike that from clinical microvascular clamps. The perceived advantages of this model are numerous. Not only does it comply with the 3Rs of simulation-based training, but it can also reduce the associated costs of training by up to a hundred-fold or more when compared to a traditional rat course and potentially be extended to low-middle income countries without routine access to microsurgical training for capacity development. That it can be utilized remotely also bodes well with the current limitations on face-to-face training due to COVID restrictions and lockdowns.

The Efficiency of Laparoscopic Common Bile Duct Exploration in Endoscopic Retrograde-Cholangiopancreatography-Limited Setting in a Peripheral University Hospital.

Background: The aim of this study is to evaluate complications and costs in patients treated with laparoscopic and open method for common bile duct (CBD) stones. Secondary aim is to compare the effectiveness, safety, and outcomes of these methods. In addition, it is aimed to review the feasibility of laparoscopic method in rural areas. Methods: Seventy-one patients were analyzed retrospectively. Patients were divided into two groups as open and laparoscopic surgical method. These groups were analyzed comparatively in terms of complications and costs. Subgroups were formed from patients who underwent T-tube drainage, primary closure, and biliary anastomosis as choledochotomy management. As a secondary outcome, these three subgroups were investigated in terms of complications and cost. Results: The cost was lower in open method compared to laparoscopic method (484$, 707$, P = .002). There was no significant difference in postoperative complications between groups (P = .257). While the mean hospital stay was longer in the open group, the operation time was shorter (P = .002, P = .03). The mean length of hospital stay in the T-tube group was significantly higher than the primary closure (P = .001). The cost in the T-tube group was significantly higher than the primary closure and biliary anastomosis groups. Conclusion: Laparoscopic CBD exploration by experienced surgeons in endoscopic retrograde-cholangiopancreatography-limited settings is an effective and safe method in the treatment of choledocholithiasis. This procedure should not be limited to reference centers and should be performed safely in rural areas by well-trained surgeons.

Cost-effectiveness of sigmoid resection with primary anastomosis or end colostomy for perforated diverticulitis: an analysis of the randomized Ladies trial.

BACKGROUND: Several studies have been published favouring sigmoidectomy with primary anastomosis over Hartmann's procedure for perforated diverticulitis with purulent or faecal peritonitis (Hinchey grade III or IV), but cost-related outcomes were rarely reported. The present study aimed to evaluate costs and cost-effectiveness within the DIVA arm of the Ladies trial. METHODS: This was a cost-effectiveness analysis of the DIVA arm of the multicentre randomized Ladies trial, comparing primary anastomosis over Hartmann's procedure for Hinchey grade III or IV diverticulitis. During 12-month follow-up, data on resource use, indirect costs (Short Form Health and Labour Questionnaire) and quality of life (EuroQol Five Dimensions) were collected prospectively, and analysed according to the modified intention-to-treat principle. Main outcomes were incremental cost-effectiveness (ICER) and cost-utility (ICUR) ratios, expressed as the ratio of incremental costs and the incremental probability of being stoma-free or incremental quality-adjusted life-years respectively. RESULTS: Overall, 130 patients were included, of whom 64 were allocated to primary anastomosis (46 and 18 with Hinchey III and IV disease respectively) and 66 to Hartmann's procedure (46 and 20 respectively). Overall mean costs per patient were lower for primary anastomosis (€20 544, 95 per cent c.i. 19 569 to 21 519) than Hartmann's procedure (€28 670, 26 636 to 30 704), with a mean difference of €-8126 (-14 660 to -1592). The ICER was €-39 094 (95 per cent bias-corrected and accelerated (BCa) c.i. -1213 to -116), indicating primary anastomosis to be more cost-effective. The ICUR was €-101 435 (BCa c.i. -1 113 264 to 251 840). CONCLUSION: Primary anastomosis is more cost-effective than Hartmann's procedure for perforated diverticulitis with purulent or faecal peritonitis.

ANTECEDENTES: Se han publicado varios estudios en favor de la sigmoidectomía con anastomosis primaria (primary anastomosis, PA) sobre la intervención de Hartmann (Hartmann's procedure, HP) para la diverticulitis perforada con peritonitis purulenta o fecal (Hinchey grado III ó IV), pero apenas existe información de los resultados relacionados con el coste. Por lo tanto, el presente estudio tuvo como objetivo evaluar los costes y el coste efectividad del brazo DIVA en el ensayo clínico Ladies. MÉTODOS: Se realizó un análisis de coste-efectividad del brazo DIVA del ensayo clínico multicéntrico y aleatorizado Ladies, que comparó PA y HP para la diverticulitis Hinchey de grado III ó IV. Durante un seguimiento de 12 meses, se recogieron datos prospectivamente del uso de recursos, costes indirectos (SF-HLQ) y calidad de vida (EQ-5D), y se analizaron de acuerdo con una modificación del principio por intención de tratar. Los resultados principales fueron la relación coste-efectividad incremental (incremental cost-effectiveness ratio, ICER) y la relación coste-utilidad incremental (incremental cost-utility ratio, ICUR), expresados como la razón del incremento de costes y el incremento en la probabilidad de no requerir estoma o años de vida ajustados por calidad, respectivamente. RESULTADOS: En total, se incluyeron 130 pacientes, 64 de los cuales fueron asignados a PA (Hinchey III/IV: 46/20) y 66 a HP (Hinchey III/IV: 46/18). Los costes medios globales por paciente fueron más bajos para la PA (€20.544 (i.c. del 95%: 19.569 a 21.519)) en comparación con HP (€ 28.670 (i.c. del 95%: 26.636 a 30.704)), con una diferencia media de €−8.126 (i.c. del 95% −14.660 a −1.592)). Además, se observó un ICER de € −39.094 (95% bias-corrected and accelerated boodstrap confidence interval, BCaCI −1.213 a −116), lo que indica que PA es más coste efectiva. El ICUR fue € −101.435 (BCaCI del 95%: −1.113.264 a 251.840). CONCLUSIÓN: La anastomosis primaria es más rentable que el procedimiento de Hartmann para la diverticulitis perforada con peritonitis purulenta o fecal.

An economic analysis of prophylactic lymphovenous anastomosis among breast cancer patients receiving mastectomy with axillary lymph node dissection.

BACKGROUND AND OBJECTIVES: Prophylactic lymphovenous anastomosis (LVA) has been shown to decrease the incidence of postoperative lymphedema among patients receiving mastectomy with axillary lymph node dissection (ALND). However, the economic impact of this intervention on overall healthcare costs has not been adequately studied and insurance reimbursement for lymphedema treatment is limited resulting in substantial out-of-pocket patient expenses. METHODS: We performed a cost-minimization decision analysis from the societal perspective to assess two different patient scenarios: (a) mastectomy with ALND alone, (b) mastectomy with ALND and prophylactic LVA. RESULTS: The annual cost of lymphedema-related care is estimated to be $5,691.88 ($3,160.52 direct, $2,531.36 indirect). If all patients undergoing mastectomy with ALND undergo prophylactic LVA, the average expected lifetime cost per patient in the entire population (whether or not they develop lymphedema) is approximately $6,295.61, compared to $13,942.26 if no patients in the same population receive prophylactic LVA. CONCLUSIONS: Prophylactic LVA is economically preferred over mastectomy and ALND alone from a cost minimization perspective, and results in an average of $7,646.65 (45.2%) cost saving per patient over the course of their lifetime.

Extracorporeal versus intracorporeal anastomosis after laparoscopic right hemicolectomy: cost-effectiveness analysis.

AIM: The cost effectiveness of the laparoscopic right hemicolectomy is still debated, and the current literature does not allow to be drawn certain conclusion. Our study compared direct clinical costs and outcomes for laparoscopic right hemicolectomy with the two most used type of anastomosis, such as ExtraCorporeal Anastomosis (ECA) and IntraCorporeal Anastomosis (ICA). MATERIAL AND METHODS: In this retrospective study, all patients who underwent laparoscopic right hemicolectomy with intracorporeal and extracorporeal anastomosis between January 2016 and April 2018 were evaluated. Patients were divided into two groups according to the type of anastomosis: ECA or ICA. RESULTS: Thirty ECA and twenty-nine ICA patients were included in the study. Operative time was significantly longer in ICA group than ECA group (p < 0.001). No significant differences between the groups were seen in terms of timeto- first flatus, postoperative complications and re-admission rate. ICA group showed a shorter hospitalization (5 vs 6; p < 0.022). In the ICA group, considering only the surgical tools were more expensive than in ECA (1435.6 € vs 72 €). Nevertheless, the total cost of the two procedures in similar (14451.36 € in ECA group vs 14631.04 € in ICA group). CONCLUSION: ECA and ICA are comparable in terms of postoperative outcomes. ICA requires much more expensive charges, compared to a minor hospitalization. The ECA seems to be less expensive in terms of surgical supplies but the longer recovery determines an increase in the total cost resulting in a non-inferiority of one compared to the other technique. KEY WORDS: Cost-analysis, ExtraCorporeal Anastomosis, IntraCorporeal Anastomosis, Laparoscopy, Right Hemicolectomy.

Economics of Lymphovenous Bypass.

BACKGROUND: The objective of this study was to compare the economic impact of complete decongestive therapy and lymphovenous bypass in the management of upper extremity lymphedema. METHODS: Economics were modeled for a patient with breast cancer-related lymphedema undergoing three different clinical pathways: (1) complete decongestive therapy alone; (2) lymphovenous bypass no longer requiring ongoing complete decongestive therapy; or (3) lymphovenous bypass requiring ongoing complete decongestive therapy. Activity-based cost analysis identified costs incurred with complete decongestive therapy and lymphovenous bypass. Costs were retrieved from supplier price lists, physician fee schedules, lymphedema therapists, and literature reviews. The net present value of all costs incurred for each clinical pathway were calculated. RESULTS: The estimated net present value of all costs for a patient with breast cancer-related lymphedema undergoing treatment were as follows: (1) complete decongestive therapy alone ($30,400); (2) lymphovenous bypass no longer requiring ongoing complete decongestive therapy ($15,000); or (3) lymphovenous bypass requiring ongoing complete decongestive therapy ($42,100). The expected net present value of all costs for lymphovenous bypass was $26,800, which was comparable to that of complete decongestive therapy alone. Sensitivity analysis demonstrated that the expected net present value of lymphovenous bypass was dependent on the patient's life expectancy, number of bypass anastomoses, and likelihood of discontinuing complete decongestive therapy. CONCLUSIONS: Lymphedema has substantial ongoing costs irrespective of the treatment modality. The cost of lymphovenous bypass appears comparable to that of complete decongestive therapy alone-the surgical costs of lymphovenous bypass are offset by the savings from discontinued ongoing therapy. Despite its limitations as a theoretical economic model, this study provides insight into the potential economic impact of lymphovenous bypass.

Ileostomy versus fecal diversion device to protect anastomosis after rectal surgery: a randomized clinical trial.

PURPOSE: Patients with rectal anastomosis commonly experience various ileostomy-related complications. This study aimed to elucidate the usefulness of a fecal diversion device (FDD) as an alternative to ileostomy for protecting rectal anastomosis. METHODS: Patients with rectal anastomosis were randomly assigned to the ileostomy and FDD groups except in cases of emergency surgery. The primary endpoint was the clinical safety and effectiveness of FDD. The mean operation time, delay of diet advancement, length of hospital stay, FDD and stoma durations, and anastomotic leakage (AL) management methods were compared. RESULTS: A total of 54 patients were enrolled in this study. No cases of mortality occurred. Overall morbidity was similar between groups (P = 0.551). Six patients (22.2%) in the FDD group and nine (29.0%) in the stoma group (P = 0.555) had AL. The mean total hospital stay was 16.4 ± 6.7 and 23.4 ± 8.7 days in the FDD and stoma groups, respectively (P = 0.002). The mean total hospital cost was 12,726.8 ± 3422.8 USD and 17,954.9 ± 9040.3 USD in the FDD and stoma groups, respectively (P = 0.008). The mean FDD and stoma durations were 21.6 ± 6.1 days and 114.9 ± 41.3 days, respectively (P < 0.0001). CONCLUSIONS: This study demonstrated FDD safety and effectiveness. We identified the possibility of FDD as an alternative technique to conventional stoma procedures.

Design and Validation of a Low-Cost, High-Fidelity Model for Urethrovesical Anastomosis in Radical Prostatectomy.

OBJECTIVE: We sought to develop and validate a low-cost, high-fidelity robotic surgical model for the urethrovesical anastomosis component of the robot-assisted laparoscopic radical prostatectomy. MATERIALS AND METHODS: A novel simulation model was constructed using a 3D-printed model of the male bony pelvis from CT scan data and silicone molds to recreate the soft tissue aspects. Using a da Vinci Si surgical robot, urology faculty and trainees performed simulated urethrovesical anastomosis. Each participant was given 12 minutes to complete the simulation. A survey established face validity, content validity, and acceptability. Simulation runs were evaluated by three blinded reviewers. The anastomosis was graded by two reviewers for suture placement accuracy and anastomosis quality. These factors were compared with robotic experience to establish construct validity. RESULTS: Twenty participants took part in the initial validation of this model. Groups were defined as experts (surgical faculty), intermediate (fellows and chief residents), and novices (junior residents). Likert scores (1-5 scale, top score 5) examining face validity, content validity, and acceptability were 3.49 ± 0.43, 4.15 ± 0.23, and 4.02 ± 0.19, respectively. Construct validity was excellent based on the model's ability to stratify groups. All evaluated metrics were statistically different between the three levels of training. Total material cost was $2.50 per model. CONCLUSIONS: We developed a novel low-cost robotic simulation of the urethrovesical anastomosis for robot-assisted radical prostatectomy. The model discerns robotic skill level across all levels of training and was found favorable by participants showing excellent face, content, and construct validities.

Operative management of non-iatrogenic pediatric and adolescence peripheral arterial trauma: An experience from a resource challenged setting.

OBJECTIVES: To evaluates the management and outcome of non-iatrogenic pediatric and adolescence extremity arterial injuries in a resource-challenged setting. METHODS: A retrospective study of the surgical management for non-iatrogenic extremity arterial trauma in pediatric and adolescence during the period from January 2008 to December 2015. This study was performed in two different countries at tertiary referral university and teaching hospitals having a specialized emergency and trauma centers. A thorough study of each patient record was collected from these centers including, the original demographic data and their clinical presentations. Operative data of each patient was also reported. RESULTS: During the 8-year period of the study, 149 pediatric and adolescent extremity arterial trauma patients were treated. They were 93.3% male, and 6.7% female, respectively. The age ranged from 2 to 18 years with a mean of 10.25 ± 4.05 years. Lower extremity arterial trauma was recorded in 51%, while 49% were having upper extremity injuries. Primary repair with end-to-end vascular anastomosis was performed in 51.7%, while an interposition reversed saphenous vein graft was performed in 48.3%. The operative procedures were performed by an experienced vascular surgeon and well-trained pediatric surgeons and general surgeons. Pseudoaneurysms was recorded in 9% of cases. Fasciotomy was performed in 15% of cases. CONCLUSION: Treatment of pediatric and adolescent extremity arterial injuries with primary end-to-end vascular anastomoses or with the use of an interposition reversed saphenous vein graft is a reliable, feasible, and more cost-effectiveness technique with good results. Moreover, it should be adopted for all vascular trauma patients, whenever possible.

Safety and Feasibility of a Lower-Cost Stapler in Bariatric Surgery.

BACKGROUND: Laparoscopic staplers are integral to bariatric surgery. Their pricing significantly impacts the overall cost of procedures. An independent device company has designed a stapler handle and single-use reloads for cross-compatibility and equivalency with existing manufacturers, at a lower cost. OBJECTIVES: We aim to demonstrate non-inferior function and cross-compatibility of a newly introduced stapler handle and reloads compared to our institution's current stapling system in a large animal survival study. SETTING: University-affiliated animal research facility, USA. METHODS: Matched small bowel anastomoses were created in four pigs, one with each stapler (a total of two per animal). After 14 days, investigators blinded to stapler type evaluated the anastomoses grossly and microscopically. Each anastomosis was scored on multiple measures of healing. Individual parameters were added for a global "healing score." RESULTS: Clinical stapler function and gross quality of anastomoses were similar between stapler groups. Individual scores for anastomotic ulceration, reepithelialization, granulation tissue, mural healing, eosinophilic infiltration, serosal inflammation, and microscopic adherences were also statistically similar. The mean "healing scores" were equal. While this study was underpowered for subtle differences, safe and reliable performance in large animals still supports the feasibility of introducing new devices into human use. CONCLUSIONS: The new stapler system delivers a similar technical performance and is cross-compatible with currently marketed stapling devices. An equivalent quality device at a lower price point should enable case cost reduction, helping to maintain hospital case margin and procedure value in the face of potentially declining reimbursement. This device may provide a safe and functional alternative to currently used laparoscopic surgical staplers.

Application of Microanastomosis Techniques in Vascular Neurosurgery Training and Innovation of Future Surgical Strategies for Giant Aneurysms.

BACKGROUND: With the development of endovascular neurosurgery, fewer patients have been requiring surgery, and those who do require surgery have more complex cases. Thus, neurosurgeons better trained in microneurosurgery and clipping skills are needed. METHODS: From 2014 to 2017, we built 296 aneurysms models from vessels harvested from chicken wings. The aneurysm models were created by anastomosing segments of arteries and veins with the same aneurysmal geometry and vascular relationships as in actual cases, using 3-dimensional computed tomography angiography. The models were injected with saline using a continuous infusion system, and different clipping techniques were attempted by different neurosurgeons. We have also described new technical solution for treatment of giant aneurysms, a surgical method that excludes them from flux using microsurgical endovascular bypass. RESULTS: We have described, in detail, the design for building middle cerebral artery, posterior communicating artery, anterior communicating artery, and basilar tip aneurysm models. All aneurysm models were patent, with no leakage points and with a good resemblance to the 3-dimensional computed tomography angiographic images that had served as the basis for the models. The aneurysm models were successfully clipped using different techniques. The neurosurgeons that trained on the aneurysm model before surgery found this experience useful. CONCLUSIONS: Aneurysm models respecting the real-case aneurysmal geometry provide a good training method for learning and preparing for surgery.

Outcome and Cost Analysis of Hand-Sewn and Stapled Anastomoses in the Reversal of Loop Ileostomy.

Diverting loop ileostomies are common procedures for protecting high-risk anastomoses. There is little consensus on the most ideal technique both in terms of cost efficiency and outcome. Data for this study were collected from 101 patients who underwent loop ileostomy reversal between 2009 and 2014 at Morristown Medical Center. Of the 101 patients included in the review, 57 received a hand-sewn anastomosis (HS-A) and 44 received a stapled anastomosis (S-A). Average total hospital charges for stapled anastomoses were significantly greater than that for hand-sewn anastomoses, as were total operating room supply costs. When the total cost of the operation itself was considered, S-A cases were still found to be significantly greater than HS-A cases. Hospital room charges, total lab charges, pathology charges, and EKG/ECG charges were all greater for S-A cases than HS-A cases. Overall costs were greater for S-As than hand-sewn anastomoses and because of a lack of difference in procedure length, stapler supply costs were not offset. Complication rates and length of stay were also similar between the techniques. We found S-A cases to be more costly and have a greater cost/hour than HS-A cases.

Economic Comparison of Hand-Sutured and Coupler-Assisted Microvascular Anastomoses.

BACKGROUND: Compared with hand-sewn anastomoses, microvascular anastomotic coupling devices (MACDs) provide equivalent flap survival and reduced operative time. To date, an economic analysis of MACDs has not been reported. The objective of this study was to evaluate the economics of a venous anastomosis performed using a coupling device compared with a hand-sewn anastomosis. METHODS: Economics were modeled for a single free tissue transfer (FTT) requiring one venous anastomosis performed with either hand-sewn sutures or with a coupler-assisted anastomosis using the GEM COUPLER. Fixed and variable costs incurred with each anastomotic technique were identified with an activity-based cost analysis. Price lists were retrieved from suppliers to quantify disposable costs and capital expenditures. Two literature reviews were executed to identify microsurgical operating room (OR) costs and operating time reductions with coupler-assisted anastomoses. RESULTS: For each venous anastomosis, the use of the anastomotic coupler increased disposable costs by $284.40 compared with a hand-sutured anastomosis. Total fixed and variable OR costs were $30.82 per minute. Operating time was reduced by a mean of 16.9 minutes with a coupler-assisted anastomosis, decreasing OR costs by $519.29. Total savings of $234.89 were generated for each coupler-assisted anastomosis, recuperating the device's capital expenditure after 13 uses. CONCLUSION: Compared with a hand-sewn venous anastomosis, an MACD produces savings with each case and quickly recoups the device's capital expenditure. Despite its limitations and simplicity, this study provides a practical economic analysis that can help inform purchasing decisions, particularly for smaller volume centers where the economic rationale may be less clear.

Complications and Cost Analysis of Intraoperative Arterial Complications in Head and Neck Free Flap Reconstruction.

Background Microvascular anastomotic patency is fundamental to head and neck free flap reconstructive success. The aims of this study were to identify factors associated with intraoperative arterial anastomotic issues and analyze the impact on subsequent complications and cost in head and neck reconstruction. Methods A retrospective review was performed on all head and neck free flap reconstructions from 2005 to 2013. Patients with intraoperative, arterial anastomotic difficulties were compared with patients without. Postoperative outcomes and costs were analyzed to determine factors associated with microvascular arterial complications. A regression analysis was performed to control for confounders. Results Total 438 head and neck free flaps were performed, with 24 (5.5%) having intraoperative arterial complications. Patient groups and flap survival between the two groups were similar. Free flaps with arterial issues had higher rates of unplanned reoperations (p < 0.001), emergent take-backs (p = 0.034), and major surgical (p = 0.002) and respiratory (p = 0.036) complications. The overall cost of reconstruction was nearly double in patients with arterial issues (p = 0.001). Regression analysis revealed that African American race (OR = 5.5, p < 0.009), use of vasopressors (OR = 6.0, p = 0.024), end-to-side venous anastomosis (OR = 4.0, p = 0.009), and use of internal fixation hardware (OR =3.5, p = 0.013) were significantly associated with arterial complications. Conclusion Intraoperative arterial complications may impact complications and overall cost of free flap head and neck reconstruction. Although some factors are nonmodifiable or unavoidable, microsurgeons should nonetheless be aware of the risk association. We recommend optimizing preoperative comorbidities and avoiding use of vasopressors in head and neck free flap cases to the extent possible.

A Low-Cost High-Definition Video System for Microsurgical Hindlimb Replantation in Rats.

Background The surgical microscope is still essential for microsurgery, but several alternatives that show promising results are currently under development, such as endoscopes and laparoscopes with video systems; however, as yet, these have only been used for arterial anastomoses. The aim of this study was to evaluate the use of a low-cost video-assisted magnification system in replantation of the hindlimbs of rats. Methods Thirty Wistar rats were randomly divided into two matched groups according to the magnification system used: the microscope group, with hindlimb replantation performed under a microscope with an image magnification of 40× and the video group, with the procedures performed under a video system composed of a high-definition camcorder, macrolenses, a 42-in television, and a digital HDMI cable. The camera was set to 50× magnification. We analyzed weight, arterial and venous caliber, total surgery time, arterial and venous anastomosis time, patency immediately and 7 days postoperatively, the number of stitches, and survival rate. Results There were no significant differences between the groups in weight, arterial or venous caliber, or the number of stitches. Replantation under the video system took longer (p < 0.05). Patency rates were similar between groups, both immediately and 7 days postoperatively. Conclusion It is possible to perform a hindlimb replantation in rats through video system magnification, with a satisfactory success rate comparable with that for procedures performed under surgical microscopes.

An Effective New Intestinal Anastomosis Method.

BACKGROUND This study aimed to establish an easy, safe, and cost-saving intestinal anastomotic method. MATERIAL AND METHODS Between January 2014 and February 2016, a total of 150 patients with gastric cancer who underwent surgery in the Department of General Surgery of Xuzhou Medical University Affiliated Hospital were divided into 2 groups: the treatment group (80) using new hand-sewn anastomoses, and the control group (70) using stapled anastomoses. Briefly, a new hand-sewn anastomosis of continuous suture without inversion was performed, with the first layer encompassing the entire layer of the intestinal wall. The edge was about 5 mm, and the stitch spacing was about 6 mm. Continuous suturing was performed only in the seromuscular layer of intestinal wall for the second layer, with the same edge and stitch spacing as the first layer. All 70 patients in the control group underwent intestinal stapled anastomoses. Surgical anastomotic time and cost, postoperative anastomotic bleeding, leakage, and stricture were recorded and analyzed. RESULTS The surgical anastomotic time using the new method was relatively short compared with the control group (8±1.6 min vs. 9±2.8 min), and the cost of anastomosis using the new method was significantly lower compared to the control group ($30±6.8 vs. $1000±106.2). The new method exhibited lower anastomotic bleeding (0/80 vs. 2/70) and anastomotic leakage (0/80 vs. 1/70), but similar anastomotic stricture (0/80 vs. 0/70). CONCLUSIONS Our results suggest the new hand-sewn intestinal anastomosis is a safe, easy-to-learn, cost-saving, and time-saving method that also avoids some of the drawbacks of the stapled anastomoses.

Hospital costs of colorectal cancer surgery for the oldest old: A Dutch population-based study.

Background Due to increasing healthcare costs, discussions regarding increased hospital costs when operating on high-risk patients is rising. Therefore, the aim of this study was to analyze if oldest-old colorectal cancer patients have a greater impact on hospital costs than their younger counterparts. METHODS: All colorectal cancer procedures performed in 29 Dutch hospitals between 2010 and 2012 and listed in the Dutch Surgical Colorectal Audit were analyzed. Oldest-old patients (≥85 years) were compared to patients <85 years. Ninety-day hospital costs were measured uniformly in all hospitals based on time-driven activity-based costs. RESULTS: Compared to <85-year-old patients (n = 9130), the oldest old (n = 783) had longer hospital stays (LOS) (11.3 vs. 13.2, P < 0.001), more severe complications (21.8% vs. 29.0%, P < 0.001), more failure to rescue (13.9% vs. 37.0%, P < 0.001) and higher mortality (3.0% vs. 10.7%, P < 0.001). Deceased oldest-old patients had significantly less LOS and less LOS ICU. Total hospital costs were 3% lower for oldest-old patients (€13,168) than for <85-year-old patients (€13,644, P < 0.001). In cases of severe complications or death, hospital costs for the oldest old were 25% and 31% lower than those of <85-year-old patients (both P < 0.001). CONCLUSION: Although frequently assumed to be more expensive, operating on oldest-old patients with colorectal cancer does not increase hospital costs compared to younger patients. This was most likely due to faster deterioration or less aggressive treatment of oldest-old patients when (severe) complications occurred. J. Surg. Oncol. 2016;114:1009-1015. © 2016 Wiley Periodicals, Inc.

Colectomy with Permanent End Ileostomy Is More Cost-Effective than Ileal Pouch-Anal Anastomosis for Crohn's Colitis.

BACKGROUND: Much of the economic burden of Crohn's disease (CD) is related to surgery. Twenty percent of patients with CD have isolated colonic disease. While permanent end ileostomy (EI) is generally the procedure of choice for patients with refractory CD colitis, single-center experiences suggest that restorative proctocolectomy (IPAA) is durable in select patients. AIMS: We assessed the cost-effectiveness of total colectomy with permanent EI versus IPAA in medically refractory colonic CD. METHODS: We used a lifetime Markov model with 6-month cycles to simulate quality-adjusted life years (QALYs) and cost. In each of the EI and IPAA strategies, patients could transition between multiple health states. One-way and multivariable sensitivity analysis and tornado analysis were performed to identify thresholds for factors influencing cost-effectiveness. RESULTS: IPAA was more effective than EI surgery with an incremental cost-effectiveness ratio of $70,715 per QALY gained. We identified the following variables of importance in our model: (1) the cost of the EI surgery, (2) the cost of infliximab, and (3) the cost of gastroenterology ambulatory visit and labs. Threshold analysis revealed that if the costs associated with EI surgery exceeded $20,167 or if the utility of IPAA with CD remission without medical therapy exceeded 0.37, IPAA became the more cost-effective strategy. CONCLUSIONS: In patients with medically refractory CD isolated to the colon, colectomy with permanent EI is more cost-effective than IPAA unless the costs associated with the EI surgery exceed $20,167 or if the utility associated with IPAA and CD remission exceeds 0.37.