Cost Analysis of Laparoscopic Splenectomy for Liver Cirrhotic Patients with Massive Splenomegaly Based On the Learning Curve

Mingjun Wang, PhD, Jin Zhou, PhD, Zhong Wu, PhD, Xin Wang, PhD, Bing Peng, PhD. Department of Hepatopancreatobiliary Surgery, West China Hospital, No. 37, Guoxue Alley, Chengdu, Sichuan, 610041, China.

 Introduction: Compared with open splenectomy (OS), laparoscopic splenectomy (LS) is increasingly seen as a superior technique for liver cirrhotic patients with massive splenomegaly. On the other hand, surgeons need a steep learning curve period to be adept in laparoscopic surgeries. During the early stage of the learning curve, longer operation time, greater consumption of disposable equipment and higher rate of conversions may contribute to the higher hospital charges. The aim of this study is to compare the hospital resource consumption connected to different laparoscopic and open methods of splenectomy for cirrhotic patients with massive splenomegaly at different learning curve periods.

Methods and procedures: An institutional database was reviewed to identify liver cirrhotic patients with massive splenomegaly who underwent splenectomy from 2008 to 2011. All patients receiving LS (n=45) were divided into Group 1 (n=24), in which patients’ LS were conducted during the early stage of the learning curve, and Group 2 (n=21), in which patients were treated with LS after the learning curve phase was achieved. An additional 24 patients underwent OS from 2008 to 2011 were included as Group 3. In addition to clinical data and outcomes, a cost analysis including overall, operating theatre, anesthesia, and wards costs was performed.

Results: With respect to the clinical data and outcomes, no significant differences were found regarding the preoperative variables (age, gender, Child-Pugh class, ASA, and splenic length) among the three groups. Compared with patients in Group 2, patients in Group 1 required longer operative time (239±32 min vs. 177±41 min, P<0.001) and postoperative hospital stay (8.1±1.7 days vs. 6.2±0.7 days, P<0.001), and the other intraoperative and postoperative variables (blood loss, postoperative complications, time of returning to the first oral intake, transfusion rate, and conversion rate) were comparable. Compared with patients in Group 2, patients in Group 3 required similar operative time (169±61 min vs. 177±41 min, P=0.60), longer postoperative stay (10.7±3.5 days vs. 6.2±0.7 days, P<0.001) as well as longer time of returning to the first oral intake (3.3±0.7 days vs. 1.8±0.1 days, P<0.001), and suffered more intraoperative blood loss (153.5±65.7 mL vs. 440.7±215.8 mL, P<0.001) as well as more postoperative surgical complications. In regard to the cost analysis, after the learning curve phase was achieved (Group 2), compared with OS, LS was associated with significantly higher operating theater cost mainly due to the greater consumption of disposable equipment (13000±2155 RMB vs. 5144±2492 RMB, P<0.001), which was balanced by decreased postoperative wards cost (12927±2307 RMB vs. 19251±6408 RMB, P<0.001). The overall cost was similar between Group 2 and Group 3 (29691±4599 RMB vs. 27967±8286 RMB, P=0.403), while the overall cost in Group 1 (42402±5876 RMB) was higher than that in Group 2 (29691±4599 RMB, P<0.001) and Group 3 (27967±8286 RMB, P<0.001).

Conclusion: In an experienced surgeon’s hand, LS, with better surgical outcomes and equivalent overall cost, is a superior choice for liver cirrhotic patients with massive splenomegaly compared with OS.

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