Outcomes and Costs of Laparoscopic Distal Pancreatectomy: Comparison to Open Resection in a Single Centre

Adrian M Fox, Dr, Kristen B Pitzul, Faizal D Bhojani, Dr, Max Kaplan, Carol-anne Moulton, Dr, Alice Wei, Dr, Sean P Cleary, Dr, Allan Okrainec. Division Of General Surgery, Toronto General Hospital, University Health Network, Toronto, ONTARIO; Division Of General Surgery, Toronto Western Hospital, University Health Network, Toronto, ONTARIO

Introduction: Surgical resection for distal pancreatic lesions, especially of low or indeterminate malignant potential, is increasingly performed laparoscopically. Laparoscopic distal pancreatectomy (LDP) is technically challenging, but may have such benefits as decreased post operative morbidity, shorter OR time, and shorter length of stay (LOS). Previous evidence suggests that laparoscopic surgery is more expensive than open surgery due to an increase in operative costs, however a detailed breakdown of hospital expenditures has yet to be completed.The purpose of this study is to compare the short-term clinical outcomes and hospital expenditures associated with laparoscopic or open distal pancreatectomy.

Methods and Procedures: We evaluated all distal pancreatic resections performed at our center between January 2004 and March 2010. Cases were found through a prospectively compiled Hepatobiliary database and correlated with operating room data and cost center information. The hospital’s cost center tabulates detailed accounting for all expenses accrued throughout a specific patients admission. Non-parametric statistical analysis was used to compare oncologic and surgical outcomes.

Results: A total of 133 cases were identified, 50 laparoscopic (including 10 converted cases), and 83 open resections. Demographic characteristics were similar between groups other than a significant predominance of females in the laparoscopic group: 68% females (n=16) LDP and 50.6% (n=41) open (P=0.05) . Indication for operation differed by a paucity of malignant tumours being approached laparoscopically: 2.04% (n=1) LDP and 24.1% (n=20) open. Intraoperatively, there were no differences in estimated blood loss, OR time, or transfusion requirement. 10 cases were converted to open (20%); 5 for technical factors, 2 for inability to localise tumour, 1 for bleeding, 1 for large tumour size, and 1 for anatomical uncertainty. Significantly larger tumours were approached by open resection. Median tumour size was 2.6cm (range 1.5-4.25cm; n=49) in the LDP group and 3.5cm (range 2.48-5.98cm; n=82) for open (P=0.028). Median length of stay (LOS) for the LDP cohort was 5 days (range 4-7 days) and that for the open cohort was 7 days (range 6-9 days) (P<0.001). Post operative pancreatic fistulae occurred in 26 patients, with a significantly higher proportion observed in the LDP group at 28.57% (n=14) compared to the open group 14.46% (n=12) (P=0.049). However, pancreatic fistulae were all Grade A except one Grade B in the LDP group. Median OR cost was $3843 for LDP and $3239 for open (P=0.57). Median total cost (CAD, adjusted for inflation) was $11855.70 (9887.99-14423.29; n-47) for the LDP and $14331.44 (12275.99-18112.08; n = 79) for the open resection group (P=0.001)

Conclusion: LDP is both a cost effective and safe approach for lesions that are benign or of low malignant potential. This series has shown shorter LOS and equivalent post operative outcomes for the two groups. The trend to a more expensive OR cost for LDP is offset by a significant saving when total admission costs are combined.