MIAMI BEACH – For patients with colorectal cancer and liver metastasis, one-stage surgery cuts hospital time and expense.
Compared to a staged approach, resecting both the primary and metastatic cancers shaved almost $28,000 off total hospital charges. Most of the savings came from the shortened hospital stay – an average of 6 fewer days than for patients with staged procedures, Dr. Aslam Ejaz said at the annual meeting of the Americas Hepato-Pancreato-Biliary Association.
"The main driving factor [of costs] was the increasing length of stay," said Dr. Ejaz, a research fellow in surgical oncology at Johns Hopkins Hospital, Baltimore. "Each additional day resulted in a mean increase of $3,600."
Most studies have found similar clinical outcomes for such patients, regardless of whether their surgical treatment is staged or simultaneous. But there are few data comparing the techniques’ economic impact.
For the study, Dr. Ejaz used a Johns Hopkins database to examine the staged vs. the one-stage approach. His cohort included 224 patients who, from 1990 to 2012, underwent a liver resection with curative intent for synchronous colorectal liver metastasis. They had a simultaneous procedure (111) or a staged procedure (113).
Most of the patients were in their 50s. Preoperative chemotherapy was significantly more common among those who had staged surgery with liver resection first. Primary rectal cancers were significantly more common among patients who had staged surgery.
The overall hepatectomy-related morbidity rate was similar: 25% in the simultaneous surgery group and 27% in the staged surgery group. Major complications after hepatectomy occurred in 18% of the simultaneous and 13% of the staged group – not significantly different.
Clear margins were obtained in 85% of the simultaneous surgery group and 88% of the staged surgery group. Mortality was similar (1% vs. 2%). The total length of stay was significantly longer in the staged surgery group (13 vs. 7 days.).
When categorized into minor and major hepatectomies, the overall complication rate was similar. For minor hepatectomies, it was 25% in the simultaneous surgery group and 29% in the staged group. For major hepatectomies, the rates were 27% and 28%, respectively.
There were no deaths in the minor hepatectomy group. Among those who had major hepatectomy, 4% of each surgical group died.
The median overall survival was 33 months. In both groups, 5-year survival was about 28%. The median recurrence-free survival was 26 months. The median 5-year recurrence-free survival was 20% in both groups.
A multivariate analysis examined factors associated with complications. There were no significant associations with simultaneous resection, major hepatectomy, rectal tumor, bilateral hepatic disease, or extrahepatic metastasis. However, concurrent resection and ablation doubled the risk of a complication (odds ratio, 2.02).
Patients who had a simultaneous procedure had significantly shorter hospital stays than did those who underwent a staged procedure. Most who had simultaneous surgery went home in 6 days or less (48) or in 6-9 days (38). Just 12 stayed 9-11 days; 13 stayed for 11 or more days.
Among those who had staged procedures, none went home in 6 or fewer days, and only 7 went home in 6-9 days. All other staged surgery patients stayed longer: 26 stayed 9-11 days, 39 stayed 11-13 days, and 41 stayed more than 13 days.
This extra time translated into extra money, Dr. Ejaz said, with each hospital day costing a mean of $3,581. To tease out cost associations, he stratified patients by operative factors and disease-related characteristics.
Charges for patents with unilateral or bilateral disease were significantly different ($48,000 vs. $53,000). There also were significantly different charges for those who had resection only compared to resection plus ablation ($45,500 vs. $57,000), and minor hepatic surgery compared to major hepatic surgery ($44,300 vs. $54,500).
Surgery timing also significantly affected price. The mean total cost for those who had simultaneous surgery was $34,000, while it was $62,000 for those who had staged surgery – a 55% difference amounting to $28,000.
Since clinical outcomes were so similar, the study shows that patients with resectable synchronous colorectal liver metastasis can be safely managed with either simultaneous or staged approach, Dr. Ejaz said. "But a simultaneous approach results in fewer hospital days and overall lower hospital charges, and should be the preferred approach when it’s clinically appropriate and technically feasible."
Dr. Timothy Pawlik – Dr. Ejaz’s preceptor – said that the findings are useful to both patients and systems.
"This study can be used to explain to patients how a simultaneous operation is generally safe," he said in an interview. "It may, in fact, be more beneficial to surgeons and hospitals or health care systems, as it shows that a simultaneous operation can be performed safely and save on health care costs."