title: Outcome and costs of laparoscopic pancreaticoduodenectomy during the initial learning curve vs laparotomy.
abstract: OBJECTIVE
  To compare laparoscopic pancreaticoduodenectomy (TLPD) during the initial learning curve with open pancreaticoduodenectomy in terms of outcome and costs.
  
  
  METHODS
  This is a retrospective review of the consecutive patients who underwent TLPD between December 2009 and April 2014 at our institution. The experiences of the initial 15 consecutive TLPD cases, considered as the initial learning curve of each surgeon, were compared with the same number of consecutive laparotomy cases with the same spectrum of diseases in terms of outcome and costs. Laparoscopic patients with conversion to open surgery were excluded. Preoperative demographic and comorbidity data were obtained. Postoperative data on intestinal movement, pain score, mortality, complications, and costs were obtained for analysis. Complications related to surgery included pneumonia, intra-abdominal abscess, postpancreatectomy hemorrhage, biliary leak, pancreatic fistula, delayed gastric emptying, and multiple organ dysfunction syndrome. The total costs consisted of cost of surgery, anesthesia, and admission examination.
  
  
  RESULTS
  A total of 60 patients, including 30 consecutive laparoscopic cases and 30 consecutive open cases, were enrolled for review. Demographic and comorbidity characteristics of the two groups were similar. TLPD required a significantly longer operative time (513.17 ± 56.13 min vs 371.67 ± 85.53 min, P < 0.001). The TLPD group had significantly fewer mean numbers of days until bowel sounds returned (2.03 ± 0.55 d vs 3.83 ± 0.59 d, P < 0.001) and exhaustion (4.17 ± 0.75 d vs 5.37 ± 0.81 d, P < 0.001). The mean visual analogue score on postoperative day 4 was less in the TLPD group (3.5 ± 9.7 vs 4.47 ± 1.11, P < 0.05). No differences in surgery-related morbidities and mortality were observed between the two groups. Patients in the TLPD group recovered more quickly and required a shorter hospital stay after surgery (9.97 ± 3.74 d vs 11.87 ± 4.72 d, P < 0.05). A significant difference in the total cost was found between the two groups (TLPD 81317.43 ± 2027.60 RMB vs laparotomy 78433.23 ± 5788.12 RMB, P < 0.05). TLPD had a statistically higher cost for both surgery (24732.13 ± 929.28 RMB vs 19317.53 ± 795.94 RMB, P < 0.001) and anesthesia (6192.37 ± 272.77 RMB vs 5184.10 ± 146.93 RMB, P < 0.001), but a reduced cost for admission examination (50392.93 ± 1761.22 RMB vs 53931.60 ± 5556.94 RMB, P < 0.05).
  
  
  CONCLUSIONS
  TLPD is safe when performed by experienced pancreatobiliary surgeons during the initial learning curve, but has a higher cost than open pancreaticoduodenectomy.
authors.affiliation: Chun-Lu Tan, Hao Zhang, Bing Peng, Ke-Zhou Li, Department of Pancreatic Surgery, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China.
authors.forename: Chun-Lu
authors.initials: CL
authors.lastname: Tan
authors.affiliation: Chun-Lu Tan, Hao Zhang, Bing Peng, Ke-Zhou Li, Department of Pancreatic Surgery, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China.
authors.forename: Hao
authors.initials: H
authors.lastname: Zhang
authors.affiliation: Chun-Lu Tan, Hao Zhang, Bing Peng, Ke-Zhou Li, Department of Pancreatic Surgery, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China.
authors.forename: Bing
authors.initials: B
authors.lastname: Peng
authors.affiliation: Chun-Lu Tan, Hao Zhang, Bing Peng, Ke-Zhou Li, Department of Pancreatic Surgery, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China.
authors.forename: Ke-Zhou
authors.initials: KZ
authors.lastname: Li
mesh_terms: D000328:Adult; D000368:Aged; D002983:Clinical Competence / Q000191:economics*; D003362:Cost-Benefit Analysis; D005260:Female; D017721:Hospital Costs; D006801:Humans; D010535:Laparoscopy / Q000009:adverse effects / Q000191:economics*; D007813:Laparotomy / Q000009:adverse effects / Q000191:economics*; D059032:Learning Curve; D007902:Length of Stay / Q000191:economics; D008297:Male; D008875:Middle Aged; D061646:Operative Time; D016577:Pancreaticoduodenectomy / Q000009:adverse effects / Q000191:economics* / Q000379:methods; D011183:Postoperative Complications / Q000191:economics; D013997:Time Factors; D016896:Treatment Outcome
keywords: Cost; Initial learning curve; Laparoscopic surgery; Pancreaticoduodenectomy; Postoperative event