Cost-effectiveness of Laparoscopic vs Open Gastrectomy for Gastric Cancer

Abstract

ImportanceLaparoscopic gastrectomy is rapidly being adopted worldwide as an alternative to open gastrectomy to treat gastric cancer. However, laparoscopic gastrectomy might be more expensive as a result of longer operating times and more expensive surgical materials. To date, the cost-effectiveness of both procedures has not been prospectively evaluated in a randomized clinical trial.ObjectiveTo evaluate the cost-effectiveness of laparoscopic compared with open gastrectomy.Design, Setting, and ParticipantsIn this multicenter randomized clinical trial of patients undergoing total or distal gastrectomy in 10 Dutch tertiary referral centers, cost-effectiveness data were collected alongside a multicenter randomized clinical trial on laparoscopic vs open gastrectomy for resectable gastric adenocarcinoma (cT1-4aN0-3bM0). A modified societal perspective and 1-year time horizon were used. Costs were calculated on the individual patient level by using hospital registry data and medical consumption and productivity loss questionnaires. The unit costs of laparoscopic and open gastrectomy were calculated bottom-up. Quality-adjusted life-years (QALYs) were calculated with the EuroQol 5-dimension questionnaire, in which a value of 0 indicates death and 1 indicates perfect health. Missing questionnaire data were imputed with multiple imputation. Bootstrapping was performed to estimate the uncertainty surrounding the cost-effectiveness. The study was conducted from March 17, 2015, to August 20, 2018. Data analyses were performed between September 1, 2020, and November 17, 2021.InterventionsLaparoscopic vs open gastrectomy.Main Outcomes and MeasuresEvaluations in this cost-effectiveness analysis included total costs and QALYs.ResultsBetween 2015 and 2018, 227 patients were included. Mean (SD) age was 67.5 (11.7) years, and 140 were male (61.7%). Unit costs for initial surgery were calculated to be €8124 (US $8087) for laparoscopic total gastrectomy, €7353 (US $7320) for laparoscopic distal gastrectomy, €6584 (US $6554) for open total gastrectomy, and €5893 (US $5866) for open distal gastrectomy. Mean total costs after 1-year follow-up were €26 084 (US $25 965) in the laparoscopic group and €25 332 (US $25 216) in the open group (difference, €752 [US $749; 3.0%]). Mean (SD) QALY contributions during 1 year were 0.665 (0.298) in the laparoscopic group and 0.686 (0.288) in the open group (difference, −0.021). Bootstrapping showed that these differences between treatment groups were relatively small compared with the uncertainty of the analysis.Conclusions and RelevanceAlthough the laparoscopic gastrectomy itself was more expensive, after 1-year follow-up, results suggest that differences in both total costs and effectiveness were limited between laparoscopic and open gastrectomy. These results support centers’ choosing, based on their own preference, whether to (de)implement laparoscopic gastrectomy as an alternative to open gastrectomy.

Impact of 18FFDG-PET/CT and Laparoscopy in Staging of Locally Advanced Gastric Cancer: A Cost Analysis in the Prospective Multicenter PLASTIC-Study

“… Percentages may not add up to 100% due to rounding a Unit prices of D2-gastrectomy in a previous prospective multicenter include the use of operating room, disposable and reusable materials, surgical instruments, and laparoscopic equipment, as reported by Van der Veen et al 8 b The surgical approach (open or laparoscopic) was missing for 36 patients (12%) c The costs of surgical re-interventions were calculated by multiplying the duration of surgery (this could be retrieved for 32% of reoperations) by the €22 minute price of the operating room as previously reported by Bolkenstein et al 20 As 14% of operated patients underwent surgical re-intervention (€2478), the average cost per patient totaled €349 d Surgical re-interventions were recorded until 30 days after surgery …”

“…a Unit prices of D2-gastrectomy in a previous prospective multicenter include the use of operating room, disposable and reusable materials, surgical instruments, and laparoscopic equipment, as reported by Van der Veen et al 8 …”

“…Surgery costs were based on a previous bottom-up calculation for D2-gastrectomy in the Dutch prospective LOGICA-trial, which included costs of the operating room, personnel salary, surgical instruments, laparoscopic equipment, disposable materials, and epidural placement in ten hospitals. 8 …”

Assessing Cost-effectiveness From the LOGICA Trial—Is Laparoscopic Gastrectomy Worth the Cost?

“…In this issue of JAMA Surgery, van der Veen et al publish a detailed cost analysis of the LOGICA trial, comparing quality-adjusted life-years (QALYs) and patient costs up to 1 year postoperatively, and ultimately demonstrate that there is no difference in cost or QALYs between laparoscopic and open approaches. The total cost in the laparoscopic group was 3.0% higher than that in the open group (€26 084 [US $25 965] vs €25 332 [US $25 216]; difference, €752 [US $749]), driven primarily by longer operative times and use of disposable surgical materials with laparoscopy.…”

“…This study shows that the potential postoperative benefits of minimally invasive gastrectomy match the increased costs of longer operative time and more expensive materials. Laparoscopic gastrectomy continues to emerge as a feasible alternative to open gastrectomy for gastric cancer resection, and van der Veen et al suggest that laparoscopic gastrectomy is on par not only with an open approach regarding oncologic outcomes but also financially.…”