The First Decade of Laparoscopic Pancreaticoduodenectomy in the United States: Costs and Outcomes Using the Nationwide Inpatient Sample.
BACKGROUND
Minimally invasive pancreaticoduodenectomy (PD) remains an uncommon procedure, and the safety and efficacy remain uncertain beyond single institution case series. The aim of this study is to compare outcomes and costs between laparoscopic (LPD) and open PD (OPD) using a large population-based database.


METHODS
The Nationwide Inpatient Sample database (a sample of approximately 20 % of all hospital discharges) was analyzed to identify patients who underwent PD from 2000 to 2010. Patient demographics, comorbidities, hospital characteristics, inflation-adjusted total charges, and complications were evaluated using univariate and multivariate logistic regression. Hospitals were categorized as high-volume hospitals (HVH) if more than 20 PD (open and laparoscopic) were performed annually, while those performing fewer than 20 PD were classified as low-volume hospitals.


RESULTS
Of the 15,574 PD identified, 681 cases were LPD (4.4 %). Compared to OPD, patients who underwent LPD were slightly older (65 vs. 67 years; p = 0.001) and were more commonly treated at HVH (56.6 vs. 66.1 %; p < 0.001). Higher rates of complications were observed in OPD than LPD (46 vs. 39.4 %; p = 0.001), though mortality rates were comparable (5 vs. 3.8 %, p = 0.27). Inflation-adjusted median hospital charges were similar between OPD and LPD ($87,577 vs. $81,833, p = 0.199). However, hospital stay was slightly longer in the OPD group compared to LPD group (12 vs. 11 days, p < 0.001). Stratifying outcomes by hospital volume, LPD at HVH resulted in shorter hospital stays (9 vs. 13 days, p < 0.001), which translated into significantly lower median hospital charges ($76,572 vs. $106,367, p < 0.001).


CONCLUSIONS
Contrary to fears regarding the potential for compromised outcomes early in the learning curve, LPD morbidity in its first decade is modestly reduced, while hospital costs are comparable to OPD. In high-volume pancreatic hospitals, LPD is associated with a reduction in length of stay and hospital costs.
Department of Surgery, Stanford University School of Medicine, 300 Pasteur Drive, Suite H3680D, Stanford, CA, 94305, USA.
Thuy B
TB
Tran
Department of Surgery, Stanford University School of Medicine, 300 Pasteur Drive, Suite H3680D, Stanford, CA, 94305, USA.
Monica M
MM
Dua
Department of Surgery, Stanford University School of Medicine, 300 Pasteur Drive, Suite H3680D, Stanford, CA, 94305, USA.
David J
DJ
Worhunsky
Department of Surgery, Stanford University School of Medicine, 300 Pasteur Drive, Suite H3680D, Stanford, CA, 94305, USA.
George A
GA
Poultsides
Department of Surgery, Stanford University School of Medicine, 300 Pasteur Drive, Suite H3680D, Stanford, CA, 94305, USA.
Jeffrey A
JA
Norton
Department of Surgery, Stanford University School of Medicine, 300 Pasteur Drive, Suite H3680D, Stanford, CA, 94305, USA. bvisser@stanford.edu.
Brendan C
BC
Visser
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D016208:Databases, Factual; D005260:Female; D017722:Hospital Charges / Q000706:statistics & numerical data*; D061847:Hospitals, High-Volume; D061846:Hospitals, Low-Volume; D006801:Humans; D010535:Laparoscopy / Q000191:economics; D059032:Learning Curve; D007902:Length of Stay / Q000191:economics; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D017063:Outcome Assessment, Health Care; D016577:Pancreaticoduodenectomy / Q000191:economics / Q000379:methods*; D011183:Postoperative Complications / Q000453:epidemiology / Q000209:etiology*; D012189:Retrospective Studies; D014481:United States
Costs analysis; Laparoscopic; Nationwide Inpatient Sample; Pancreaticoduodenectomy