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Economic Analysis of Minimally Invasive Liver Resection

This systematic review/meta-analysis compares open, laparoscopic, and robotic hepatectomy to assess economic viability. Findings indicate laparoscopic resection is cost-effective, while robotic resection may be in high-volume centers.

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Economic Analysis of Minimally Invasive Liver Resection

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  1. Economic Analysis of Open Versus Laparoscopic Versus Robotic Hepatectomy: A Systematic Review and Meta-Analysis Ioannis A. Ziogas, Alexandros P. Evangeliou, Konstantinos S. Mylonas, Dimitrios I. Athanasiadis, Panagiotis Cherouveim, David A. Geller, Richard D. Schulick, Sophoclis P. Alexopoulos, Georgios Tsoulfas

  2. Introduction • Application of minimally-invasive surgery in complex procedures (i.e. liver surgery) • International consensuses (Louisville 2008 & Morioka 2014) • Safe and efficient in appropriately selected patients • Concerns about economic viability of minimally-invasive hepatectomy

  3. Rationale & Aim • Current reimbursement models pose a barrier in the broader adoption of minimally-invasive liver resection • Previous systematic reviews provided thorough overview of qualitative economic comparisons • No quantitative comparison (Meta-analysis) • Aim: Meta-analysis of open vs. laparoscopic vs. robotic hepatectomy to assess if minimally-invasive procedures are cost-prohibitive

  4. Methods • PRISMA guidelines and protocol registration (reviewregistry704) • PubMed and Cochrane bibliographical databases (end-of-search date: March 16th, 2019) • Search and data extraction by 3 independent researchers and discrepancies resolved by 4th • Reference lists of included studies and previous systematic reviews hand-searched for missed studies (snowball technique)

  5. Methods (cont.) • Quality assessment • Modified Jadad scale for randomized controlled trials (RCTs) • Newcastle–Ottawa scale (NOS) non-randomized studies • Brisbane 2000 nomenclature definition for major and minor liver resections (Morioka 2014) • Minor:  2 Couinaud segments • Major:  3 Couinaud segments • Cost in variable units (United States Dollar [USD], Euro, Chinese Yuan, etc.) • all units into USD as per official exchange rates publicly available at the time each individual study was conducted

  6. Methods (cont.) • Meta-analyses of operative, hospitalization, and total economic costs: • OLR vs. LLR • LLR vs. robotic liver resection [RLR] • OLR vs. RLR • Subgroup analyses: (i) major hepatectomy series, and (ii) minor hepatectomy series • Cochran Q statistic and by estimating I2: between-study heterogeneity • Sensitivity analyses: origin of potential heterogeneity • Funnel plots and the Egger’s formal statistical test: publication bias

  7. Results • 28 eligible studies • 2 RCTs • 26 non-randomized (3 prospective, 23 retrospective) • Quality assessment • Modified Jadad scale: 4.5 ± 2.1 • NOS: 7.8 ± 0.7

  8. Indication for hepatectomy

  9. 1. Open vs. Laparoscopic A) Operative costs

  10. 1. Open vs. Laparoscopic B) Hospitalization costs

  11. 1. Open vs. Laparoscopic C) Total costs

  12. 2. Laparoscopic vs. Robotic • Operative & B) Hospitalization costs • Paucity of data C) Total costs

  13. 3. Open vs. Robotic • Lack of data  no economic meta-analysis • Qualitative synthesis (4 studies comparing OLR vs. RLR): A) Operative costs: OLR < RLR B) Hospitalization costs: OLR > RLR C) Total costs: OLR ≃ RLR (mixed results, East vs. West re-imbursement models) • Quality of life: OLR < RLR

  14. Additional costs of the robot • Fixed capital costs ($2,600,000) • Longevity ~ 10 years • 2,600,000 ➗ 10 = $260,000 per annum • Annual maintenance costs ($175,000) • Total ~ $435,000 annual costs just for the robot • If high-volume center (2 cases/day  500/year): $870 per case • If low-volume center (2 cases/week  100/year): $4,350 per case

  15. Limitations • Only two RCTs • Confounders (institutions’/surgeons’ experience) impossible to evaluate • Differences in economic costs over the years (patients operated on from 1997 to 2017), and among countries (Eastern versus Western countries) • Lack of either SD or other measures of variance were not reported (18/28 studies in meta-analysis) • Paucity of economic data regarding the comparison of open and robotic hepatectomy

  16. Conclusions • Laparoscopic Hepatectomy • Major: total costs OLR ≃ LLR • Minor: total costs OLR > LLR • Not cost-prohibitive • Robotic Hepatectomy • Total costs: RLR > LLR and RLR > OLR • Not cost prohibitive only in high-volume institutions • Future well-powered RCTs are needed (awaiting results of The ORANGE II PLUS - Trial [NCT01441856]) • Greater experience  overcome learning curve  decrease in operative time and instrumentation use  better economic profiles

  17. Thank you!

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