title: Cost-effectiveness of diagnostic laparoscopy for assessing resectability in pancreatic and periampullary cancer.
abstract: BACKGROUND
  Surgical resection is the only curative treatment for pancreatic and periampullary cancer, but many patients undergo unnecessary laparotomy because tumours can be understaged by computerised tomography (CT). A recent Cochrane review found diagnostic laparoscopy can decrease unnecessary laparotomy. We compared the cost-effectiveness of diagnostic laparoscopy prior to laparotomy versus direct laparotomy in patients with pancreatic and periampullary cancer with resectable disease based on CT scanning.
  
  
  METHODS
  Model based cost-utility analysis estimating mean costs and quality-adjusted life years (QALYs) per patient from the perspective of the UK National Health Service. A decision tree model was constructed using probabilities, outcomes and cost data from published sources. One-way and probabilistic sensitivity analyses were undertaken.
  
  
  RESULTS
  When laparotomy following diagnostic laparoscopy occurred in a subsequent admission, diagnostic laparoscopy incurred similar mean costs per patient to direct laparotomy (£7470 versus £7480); diagnostic laparoscopy costs (£995) were offset by avoiding unnecessary laparotomy costs. Diagnostic laparoscopy produced significantly more mean QALYs per patient than direct laparotomy (0.346 versus 0.337). Results were sensitive to the accuracy of diagnostic laparoscopy and the probability that disease was unresectable. Diagnostic laparoscopy had 63 to 66% probability of being cost-effective at a maximum willingness to pay for a QALY of £20 000 to £30 000. When laparotomy was undertaken in the same admission as diagnostic laparoscopy the mean cost per patient of diagnostic laparoscopy increased to £8224.
  
  
  CONCLUSIONS
  Diagnostic laparoscopy prior to laparotomy in patients with CT-resectable cancer appears to be cost-effective in pancreatic cancer (but not in periampullary cancer), when laparotomy following diagnostic laparoscopy occurs in a subsequent admission.
authors.affiliation: Department of Applied Health Research, University College London, Gower Street, 1-19 Torrington Place, London, WC1E 7HB, UK. steve.morris@ucl.ac.uk.
authors.forename: Stephen
authors.initials: S
authors.lastname: Morris
authors.affiliation: University College London Medical School, 9th Floor, Royal Free Hospital, Rowland Hill Street, London, UK. k.gurusamy@ucl.ac.uk.
authors.forename: Kurinchi S
authors.initials: KS
authors.lastname: Gurusamy
authors.affiliation: Department of Applied Health Research, University College London, Gower Street, 1-19 Torrington Place, London, WC1E 7HB, UK. j.sheringham@ucl.ac.uk.
authors.forename: Jessica
authors.initials: J
authors.lastname: Sheringham
authors.affiliation: University College London Medical School, 9th Floor, Royal Free Hospital, Rowland Hill Street, London, UK. b.davidson@ucl.ac.uk.
authors.forename: Brian R
authors.initials: BR
authors.lastname: Davidson
mesh_terms: D014670:Ampulla of Vater; D003138:Common Bile Duct Neoplasms / Q000000981:diagnostic imaging / Q000473:pathology* / Q000601:surgery; D003362:Cost-Benefit Analysis; D003663:Decision Trees; D003949:Diagnostic Techniques, Surgical / Q000191:economics*; D004180:Direct Service Costs; D006801:Humans; D010535:Laparoscopy / Q000191:economics*; D009367:Neoplasm Staging; D010190:Pancreatic Neoplasms / Q000000981:diagnostic imaging / Q000473:pathology* / Q000601:surgery; D011336:Probability; D019057:Quality-Adjusted Life Years; D014057:Tomography, X-Ray Computed