Factors Associated with Postoperative Prolonged Mechanical Ventilation in Pediatric Liver Transplant Recipients.

INTRODUCTION: Almost all pediatric orthotopic liver transplant (OLT) recipients require mechanical ventilation in the early postoperative period. Prolonged postoperative mechanical ventilation (PPMV) may be a marker of severe disease and may be associated with morbidity and mortality. We determined the incidence and risk factors for PPMV in children who underwent OLT. METHODS: This was a retrospective analysis of data collected on 128 pediatric OLT recipients. PPMV was defined as postoperative ventilation ≥ 4 days. Perioperative characteristics were compared between cases and control groups. Multivariable logistic regression analysis was used to calculate odds ratios for PPMV after controlling for relevant cofactors. RESULTS: An estimated 25% (95% CI, 17.4%-32.6%) required PPMV. The overall incidence of PPMV varied significantly by age group with the highest incidence among infants. PPMV was associated with higher postoperative mortality (p = 0.004) and longer intensive care unit (p < 0.001) and hospital length of stay (p < 0.001). Multivariable analysis identified young patient age, preoperative hypocalcemia, and increasing duration of surgery as independent predictors of PPMV following OLT. CONCLUSION: The incidence of PPMV is high and it was associated with prolonged ICU and hospital LOS and higher posttransplant mortality. Surgery duration appears to be the only modifiable predictor of PPMV.

Cost analysis of robotic versus open radical cystectomy for bladder cancer.

PURPOSE: Recently robotic approaches to cystectomy have been reported, and while clinical and oncological efficacy continues to be evaluated, potential financial costs have not been clearly evaluated. In this study we present a financial analysis using current cost structures and clinical outcomes for robotic and open cystectomy for bladder cancer. MATERIALS AND METHODS: The financial costs of robotic and open radical cystectomy were categorized into operating room and hospital components, and further divided into fixed and variable costs for each. Fixed operating room costs for open cases involved base cost as well as disposable equipment costs while robotic fixed costs included the amortized machine cost as well as equipment and maintenance. Variable operating room costs were directly related to length of surgery. Variable hospital costs were directly related to transfusion requirement and length of stay. The means of the prior 20 cases of robotic and open cystectomy were used to perform a comparative cost analysis. RESULTS: Mean fixed operating room costs for robotic cases were $1,634 higher than for open cases. Operating room variable costs were also higher by a difference of $570, directly related to increased operating room time. Hospital costs were nearly identical for the fixed component while variable costs were $564 higher for the open approach secondary to higher transfusion costs and longer mean length of stay. Based on these findings robotic cystectomy is associated with an overall higher financial cost of $1,640 (robotic $16,248 vs open $14,608). Cost calculators were constructed based on these fixed and variable costs for each surgical approach to demonstrate the expected total costs based on varying operating room time and length of stay. CONCLUSIONS: Robotic assisted laparoscopic radical cystectomy is associated with a higher financial cost (+$1,640) than the open approach in the perioperative setting. However, this analysis is limited by its single institution design and a multicenter followup study is required to provide a more comprehensive analysis.