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Evaluation of the Clinical and Economic Impacts of both Preoperative Portal Vein Embolization and the Laparoscopic Approach in Extended Hepatectomies
*Lindsay Hollander, *Jeffrey Pollack, Ronald Salem, Charles Cha
Yale University School of Medicine, New Haven, CT

Objective:
The purpose of this study is to compare the clinical and economic impacts of preoperative PVE versus no PVE and laparoscopic versus open extended hepatectomies.
Design:
Retrospective review of a prospectively-maintained database with a cost-benefit analysis.
Setting:
Tertiary referral hospital.
Patients:
All patients who underwent extended hepatectomies between 8/2007 and 6/2014 at Yale University New Haven Hospital (YNNH) were reviewed. Of 36 patients, 15 (42%) underwent preoperative PVE and 18 (50%) were resected laparoscopically.
Interventions:
PVE is performed approximately 6 weeks prior to the hepatectomy, usually in an ipsilateral approach with polyvinyl alcohol microparticles. A laparoscopic hepatectomy is performed similarly to an open hepatectomy while adhering to standard laparoscopic principles.
Main Outcome Measures:
Major surgical complications, ICU days, and overall length of stay (LOS).
Results:
PVE and laparoscopy compared favorably with no PVE and the open approach, respectively, from both a clinical and economic standpoint. The PVE group tended to have fewer ICU days, overall LOS, postoperative complications (27% vs. 52%, P =0.03) than no PVE, with lower postoperative peak bilirubin levels (1.4 vs 5.9, p=0.05). Laparoscopy also led to a reduction in ICU days (1.8 vs. 6.6, P = .006), overall LOS (7.2 vs. 17.6 days, P = .02), postoperative morbidity (28% vs. 64%, P = .04), and peak bilirubin levels (1.7 vs 7.7, p=0.008) compared to open. PVE revealed an average cost savings of US\,000-\,000 per patient, and laparoscopy saved approximately US\,000-\,000 per patient when compared with no PVE and the open approach, respectively.
Conclusions:
Our study illustrates the safety and clinical benefit of preoperative PVEs and the laparoscopic approach and suggests an economic cost advantage for these techniques in extended hepatectomies.


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