Department of Surgery, Central Hospital of Central Finland, Jyväskylä, Finland 2

Transcription

1 557016SJS / Fst-trck colorectl surgerya. Ehrlich, et l. reserch-rticle2014 ORIGINAL ARTICLE Comprison of lproscopic nd colonic resection within fst-trck nd trditionl periopertive cre pthwys: Clinicl outcomes nd in-hospitl costs Scndinvin Journl of Surgery 2015, Vol. 104(4) The Finnish Surgicl Society 2014 Reprints nd permissions: sgepub.co.uk/journlspermissions.nv DOI: / sjs.sgepub.com A. Ehrlich 1, S. Kellokumpu 2, B. Wgner 3, H. Kutiinen 4,5, I. Kellokumpu 1 1 Deprtment of Surgery, Centrl Hospitl of Centrl Finlnd, Jyväskylä, Finlnd 2 Jyväskylä University School of Business nd Economics, Jyväskylä, Finlnd 3 Deprtment of Anesthesiology, Centrl Hospitl of Centrl Finlnd, Jyväskylä, Finlnd 4 Deprtment of Generl Prctice, Primry Helth Cre Unit, Turku University Hospitl, Turku, Finlnd 5 Unit of Primry Helth Cre, Helsinki University Hospitl, Helsinki, Finlnd Abstrct Bckground: This study exmined short-term clinicl outcomes nd in-hospitl costs of lproscopic nd colonic resection within fst-trck nd trditionl cre pthwys. Mteril nd Methods: A cse control study ws performed. From 2007 to 2009, 116 ptients underwent lproscopic or colonic resection for benign or mlignnt disese within fst-trck cre pthwy. The control group consisted of 116 ge-, sex-, comorbidity-, type of surgery, nd dignosis-mtched ptients who received trditionl periopertive cre from 2000 to The min mesures of outcome were postopertive hospitl sty nd in-hospitl costs, with 30-dy mortlity, morbidity, reopertion, nd redmission rtes s secondry outcomes. Results: The study groups were well blnced for bseline chrcteristics. Postopertive hospitl sty ws shorter in the fst-trck thn in the control group: lproscopic resection medin 3 versus 5 dys (p < 0.001) nd resection 4 versus 7 dys (p < 0.001). In multivrite nlysis fst-trck cre, lproscopic surgery nd complictions were independent determinnts ffecting the length of hospitl sty. Overll, there ws trend towrd lower in-hospitl costs in the fst-trck group compred with the trditionl cre group, but the difference ws not sttisticlly significnt. Open surgery within fst-trck cre ws the lest costly option compred to lproscopic or surgery within trditionl cre but not significntly so when compred with lproscopy within fst-trck cre. Intke of solid food nd bowel function recovered 1 dy erlier in the fst-trck group Correspondence: Ilmo Kellokumpu Deprtment of Surgery Centrl Hospitl of Centrl Finlnd Keskussirlntie Jyväskylä Finlnd Emil: ilmo.kellokumpu@ksshp.fi

2 212 A. Ehrlich, et l. thn in the control group (p < 0.001). Complictions were more frequent fter surgery thn fter lproscopic surgery (23.3% vs 11.0%, p = 0.012). Reopertion nd redmission rtes were similr between the study groups. Conclusion: Lproscopy improves the efficiency of fst-trck periopertive cre without significntly incresing in-hospitl costs. Key words: Lproscopy; colon; fst-trck Introduction Rndomized trils nd met-nlyses hve now demonstrted the sfety nd efficcy of fst-trck periopertive cre in colorectl surgery, not only in reducing postopertive hospitl sty nd morbidity but lso in improving ptient convlescence nd stisfction when compred with trditionl cre (1 10). The concept is bsed on multimodl evidence-bsed cre pltform nd includes preopertive eduction nd optimiztion of ptients, ttenution of surgicl stress response, optimized pin control, nd postopertive rehbilittion with enforced orl nutrition nd erly mbultion (11, 12). The role of lproscopy in the fst-trck setting hs been controversil. Severl rndomized trils compring lproscopic versus resection for colon cncer within trditionl periopertive cre hve shown tht the lproscopic method cn provide n equivlent oncologic outcome, fster short-term recovery, nd shorter hospitl sty thn the method (13 15). A recent rndomized tril (16) showed tht lproscopic colonic surgery within fst-trck cre resulted in fster recovery nd shorter hospitl sty thn surgery without incresing in-hospitl costs in contrst to nother study demonstrting no such difference (7). At present, level 1 evidence is missing to show tht there is n dditive effect by combining lproscopic surgery nd fst-trck periopertive cre (2). It is lso uncertin whether lproscopic colonic surgery improves the economic efficiency of fst-trck periopertive cre in comprison with surgery, despite the fct tht the cost-effectiveness of enhnced recovery pthwys for colorectl surgery is supported by recent met-nlysis (17). The objectives of this study were to compre short-term clinicl outcomes nd in-hospitl costs between lproscopic or colonic resection within either fst-trck or trditionl periopertive cre pthwys. Determinnts ffecting the length of postopertive hospitl sty were lso exmined. Mteril nd methods Ptients nd study design A non-rndomized cse control study ws performed. The fst-trck group included 116 ptients who underwent lproscopic (N = 73) or (N = 43) colonic resection for benign or mlignnt disese from 2007 to Included were ptients with good mentl nd physicl performnce sttus hving n ttending person t home nd the Americn Society of Anesthesiologists (ASA) score I III. Elderly ptients fulfilling the predefined criteri were lso included. Excluded were ptients who underwent emergency surgery or mjor multiorgn resection. Body mss index >35 kg/m 2 nd ptients with significnt crdic/pulmonry comorbidity in whom prolonged lproscopic surgery would hve been potentilly hrmful were reltive contrindictions to lproscopy. Dt on ptients who underwent or lproscopic surgery in the fst-trck setting were collected prospectively. The control group consisted of 116 ge-, sex-, comorbidity-, type of surgery, nd dignosis-mtched ptients who received lproscopic or colonic resection within trditionl periopertive cre from 2000 to Dt on surgery were collected retrospectively, wheres lproscopic dt were retrieved from prospective colorectl dtbse. Hospitl records were reviewed regrding periopertive dt nd instrument use. All ptients were followed up for 30 dys to ssess morbidity nd redmissions. The study ws pproved by the ethics committee of the hospitl. Fst-trck nd trditionl periopertive cre protocols In ccordnce with recent interntionl consensus review (12), the fst-trck protocol included 20 evidence-bsed fst-trck elements (Tble 1). Briefly, extensive preopertive counseling, orl crbohydrtes until 2 h before surgery, totlly intrvenous nesthesi (TIVA) using short-cting nesthetics (propofol remifentnil nd cis-trcurium for muscle relxtion) insted of trditionl inhltion nesthesi (oxygen-sevoflurne nd cis-trcurium for muscle relxtion), short durtion of postopertive opioid-spring nlgesi (ropivcine nd fentnyl) with epidurl ctheter nd single-use pump scheduled to be removed on the second postopertive dy, orl prcetmol nd nonsteroidl ntiinflmmtory drug (NSAID) strted 2 dys fter surgery, nd use of opioids only for brekthrough pin were the min differences between fst-trck nd trditionl cre. Furthermore, fst-trck recovery ws protocol driven with discontinution of intrvenous (IV) fluids s soon s possible, erly postopertive feeding, removl of urinry ctheter on the first postopertive dy, nd erly mobiliztion. Prophylctic dexmethsone ws not routinely used for postopertive nuse nd vomiting during the study period. In both study groups, ptients were dischrged when they were febrile, fully mobilized, tolerted three mels per dy, hd dequte pin control on orl nlgesics, nd dequte home support.

3 Fst-trck colorectl surgery 213 Tble 1 Comprison of fst-trck nd trditionl cre elements. Fst-trck group Control group p-vlue N = 116 N = 116 Preopertive Extensive informtion nd counseling 116 (100.0) 0 (0) <0.001 Fsting guidelines/crbohydrte loding 116 (100.0) 0 (0) <0.001 No mechnicl bowel preprtion 114 (98.2) 59 (50.9) <0.001 No sedtive prenesthetic mediction 116 (100.0) 7 (6.0) <0.001 Prophylxis ginst thromboembolism 116 (100.0) 116 (100.0) 1.00 Antimicrobil prophylxis 116 (100) 116 (100) 1.00 Intropertive Stndrdized intrvenous nesthesi 116 (100.0) 0 (0) <0.001 Prevention of hypothermi 116 (100.0) 87 (75.0) <0.001 Lproscopic resection 73 (62.9) 73 (62.9) 1.00 Restrictive to moderte periopertive fluid regimen 71 (61.2) 5 (4.3) <0.001 ( 40 ml/kg/24 h) Postopertive No routine use of nsogstric tubes 116 (100.0) 40 (34.5) <0.001 Periopertive high O 2 concentrtions 116 (100.0) 116 (100.0) 1.00 Avoidnce of drins 116 (100.0) 87 (75.0) <0.001 Epidurl nlgesi, epidurl ctheter removed POD 2 102/112 (87.9) 84/98 (85.7) 0.22 Routine use of opioids for pin 0 (0) 87 (75.0) <0.001 Use of ntiemetics on demnd 41 (35.3) 45 (38.8) 0.59 Use of lxtives (Milk of Mgnesi) 116 (100) 39 (33.6) <0.001 Urinry ctheter removed POD 1 95 (81.9) 9 (7.8) <0.001 Enhnced mobiliztion Mobilized on the dy of surgery 93 (80.2) 0 (0) <0.001 Mobilized 6 8 h/dy within POD 2 91 (78.4) 58 (50.0) <0.001 Enhnced postopertive feeding Orl liquids on the dy of surgery 107 (92.2) 0 (0) <0.001 Liquid food/protein drinks >1000 ml, POD (95.7) 50 (43.0) <0.001 Norml food, POD 2 96 (95.7) 6 (5.2) <0.001 POD: postopertive dy. Ptients who underwent subtotl colectomy hd mechnicl bowel preprtion (Colonsteril ) strted t home 2 dys before surgery. Surgicl technique The opertions were performed by senior stff surgeons with the prticiption of residents in trining. The decision to do lproscopic or surgery within the inclusion criteri ws left to the discretion of the operting surgeon. Lproscopic colonic resection ws performed using the five-trocr technique for right nd left hemicolectomies. Specimens were extrcted through Pfnnenstiel incision (left hemicolectomy) or peri-umbilicl incision (smll bowel nd ileocolic resection, right hemicolectomy). In the fst-trck group, surgery ws performed using trnsverse incision for right hemicolectomies nd midline incision for left hemicolectomies, wheres in the control group, surgery ws performed using midline incisions. Definitions Conversion to surgery ws defined s necessity to interrupt the lproscopic procedure nd to proceed using conventionl technique. Prlytic ileus ws defined s the bsence of bowel function for 5 dys or the need for reinsertion of nsogstric tube fter strting orl diet in the bsence of mechnicl bowel obstruction. Complictions were clssified ccording to the Dindo Clvien (18) clssifiction. Postopertive hospitl sty during index dmission ws defined s dys spent in the hospitl fter surgery. Length of totl hospitl sty included preopertive, postopertive, nd redmission-relted dys spent in the hospitl. Cost evlution All costs were clculted ccording to the yer 2010 prices ( ). Pre-existing dt on some mjor resources nd their llocted costs in 2010 were obtined from the hospitl dministrtion (Tble 2). Costs of operting room resources (bsic costs, nesthesi nd nurses, surgicl tem, instrument use) nd recovery room services were clculted ccording to the time spent in the operting nd recovery rooms, durtion of surgery, nd the level of trining required. The costs of disposble instruments including circulr nd liner stplers for nd lproscopic surgery, trocrs, lproscopic dithermy scissors, Hrmonic scissors, nd bipolr vessel selers were clculted ccording

4 214 A. Ehrlich, et l. Tble 2 Mjor resources nd their llocted costs. Unit costs ( ) Preopertive costs Lbortory investigtions (PVK, N, K, Kre, electrocrdiogrm) Chest X-ry 49.8 Thorcobdominl CT Double-contrst brium enem Ultrsound-guided dringe of bscess Colonoscopy Fiberosigmoidoscopy Outptient physicin consulttion (surgeon, nesthesiologist) Preopertive fst-trck visit (operting surgeon, FT nurse) Operting room costs Bsic costs (clening, electricity, steriliztion, etc.) Operting room time (nesthesiologist, per min nurses) Surgicl tem Recovery room time 0.36 per min Use of disposble instruments (liner nd circulr stplers, lproscopic instruments) per ptient Postopertive costs Abdominl surgicl deprtment, elective per dy cre (bsic costs, phrmcy, IV fluids nd lbortory costs, nursing stff) Outptient visit, emergency cre per dy Emergency cre deprtment per dy Intensive cre unit per dy Pthology, histopthologicl exmintion CT: computed tomogrphy; FT: fst-trck; IV: intrvenous. Cpitl costs of reusble instruments, lproscopic optics, nd bsic lproscopic equipment (two monitors, insuffltor, etc.) nd dministrtion costs re excluded from the nlysis. The operting time chrges vry by the mount of tem members nd expertise. to the use. Excluded were cpitl costs of reusble instruments nd stndrd lproscopic equipment, dministrtion nd trveling costs, nd costs of different djuvnt chemotherpy tretments for stge III colon cncer. Sttisticl nlysis The dt were nlyzed on n intention-to-tret bsis considering lproscopic nd converted lproscopic resections together. Results re given s men (stndrd devition, SD) or medin (interqurtile rnge, IQR). The comprison between groups ws mde using nlysis of vrince (ANOVA), Kruskl Wllis, or chi-squre test. Becuse the cost dt in this study were very skewed, bootstrp-type nlysis (10,000 repetitions) ws used. Anlysis of determinnts ffecting postopertive hospitl sty ws done using univrite nd multivrite zero-truncted Poisson regression models with robust stndrd errors or negtive binomil regression (zero-truncted) models, when overdispersion is present. The length of hospitl sty (LOS) rtio ws expressed s the rtio of men hospitl dys. Vribles with p < 0.20 t univrite nlysis were entered in the multivrite nlysis. All sttisticl tests were two-sided. A p-vlue less thn 0.05 ws considered significnt. STATA (SttCorp Stt relese 12, Sttisticl Softwre. SttCorp LP, College Sttion, TX) ws used for sttisticl nlysis. Results Differences between fst-trck nd trditionl cre elements s well s the degree of dherence to the 20 predefined fst-trck elements re shown in Tble 1. Bseline chrcteristics did not differ significntly between the study groups (Tble 3). Colon cncers nd benign diseses (minly denoms nd diverticulr disese) were evenly distributed in the study groups. A totl of 73 ptients underwent lproscopic nd 43 resection in the fst-trck nd control groups, respectively. Conversion to surgery occurred in 6.8% nd 5.5% of lproscopiclly operted ptients within fst-trck nd trditionl periopertive cre groups due to severe dhesions from previous surgeries or diverticulitis. Min mesures of outcome Postopertive hospitl sty ws shorter fter lproscopic thn surgery both in the fst-trck group nd in the control cre group (Tble 4): lproscopic resection within fst-trck cre medin 3 (IQR 3 4) dys versus trditionl cre 5 (IQR 4.5 6) dys (p < 0.001) nd resection within fst-trck cre medin 4 (IQR 3 6) dys versus trditionl cre 7 (IQR 6 9) dys (p < 0.001). Using univrite nd multivrite regression nlysis, trditionl periopertive cre (LOS rtio 1.56 (95% confidence intervl (CI): ), p < 0.001), surgery (1.17 ( ), p = 0.009), generl (1.73 ( ), p < 0.001), surgicl (1.85 ( ), p < 0.001) complictions, nd severity of complictions (Dindo Clvien grde ( ), p < 0.001) were fctors incresing the LOS. Overll, there ws trend towrd lower in-hospitl costs in the fst-trck group compred with the trditionl cre group (Fig. 1; Tble 5). Open surgery within fst-trck cre ws the lest costly option compred to lproscopic or resection within trditionl cre but not significntly so when compred to lproscopy within fst-trck cre. Preopertive costs between the study groups were similr becuse the fst-trck group included only one extr dditionl preopertive visit for informtion nd counseling. The perptient operting room costs were higher in the lproscopic thn in the surgery group minly due to n incresed use of disposble instruments (men difference 678 (95% CI: ), p = 0.001). The per-ptient postopertive expenses were lower in the lproscopic thn in the group, the min reson being shorter sty in the elective bdominl wrd (men difference 922 ( 1576 to 329), p = ).

5 Fst-trck colorectl surgery 215 Tble 3 Bseline clinicl chrcteristics. Fst-trck lproscopy Fst-trck Trditionl lproscopy Trditionl p-vlue N = 73 N = 43 N = 73 N = 43 Age, men (SD) 62.8 (12.2) 60.8 (12.0) 64.1 (12.1) 61.7 (12.9) 0.51 Mle sex, n (%) 27 (37.0) 18 (41.9) 28 (38.4) 18 (41.9) 0.94 BMI, men (SD) 25.9 (3.5) 28.5 (5.3) 25.9 (3.3) 26.8 (4.4) ASA I nd II, n (%) 55 (75.3) 29 (67.4) 45 (61.6) 24 (55.8) 0.14 Comorbidity, no. of ptients (%) 44 (60.3) 29 (67.4) 44 (60.3) 29 (67.4) 0.76 Crdic Hypertension Pulmonry Dibetes Hypothyreosis Other Mlignnt disese, n (%) 40 (54.8) 21 (48.8) 44 (60.3) 27 (62.8) 0.53 Type of resection, n (%) 0.10 Ileocolic resection 6 (8.2) 1 (2.4) 7 (9.6) 0 (0) Right/trnsverse colon 32 (43.8) 15 (34.9) 30 (41.1) 15 (34.9) Left/sigmoid colon 33 (45.2) 27 (62.8) 34 (46.6) 28 (65.1) Subtotl colectomy 2 (2.7) 0 (0) 2 (2.7) 0 (0) SD: stndrd devition; BMI: body mss index; ASA: Americn Society of Anesthesiologists. Figures in the columns re not dditive becuse some ptients hd more thn one comorbid condition. Tble 4 30-dy surgicl outcome. Fst-trck lproscopy Fst-trck Trditionl lproscopy Trditionl p-vlue N = 73 N = 43 N = 73 N = 43 Opertion time, medin (IQR) min 135 ( ) 143 ( ) 125 ( ) 101 (89 130) Bleeding, medin (IQR) ml 50 (10 100) 150 ( ) 40 (20 100) 200 ( ) <0.001 Conversion rte (%) 5 (6.8) 4 (5.5) 0.57 Orl liquids >1 L, medin (IQR) dys 1 (0 1) 1 (0 1) 1 (1 2) 2 (1 4) <0.001 Solid food, medin (IQR) dys 2 (2 2) 2 (2 2) 3 (3 4) 4 (3 6) <0.001 Fltus, medin (IQR) dys 1 (1 2) 1 (1 2) 2 (2 3) 3 (2 4) <0.001 Fully mobilized POD 2, n (%) 59 (80.8) 32 (74.4) 41 (56.2) 17 (39.5) < dy mortlity, n (%) 0 (0) 0 (0) 0 (0) 1 (2.3) 0.54 Overll 30-dy morbidity, n (%) 7 (9.6) 9 (20.9) 9 (12.3) 11 (25.6) 0.08 Surgicl morbidity, n (%) 4 (5.5) 9 (20.9) 5 (6.8) 9 (20.9) Anstomotic lek 3 (4.1) 0 (0) 2 (2.7) 4 (9.3) Prlytic ileus 1 (1.4) 4 (9.3) 2 (2.7) 1 (2.3) Wound infection 0 (0) 3 (7.0) 0 (0) 3 (7.0) Other 0 (0) 4 (9.3) 1 (1.4) 2 (4.7) Generl morbidity, n (%) 4 (5.5) 0 (0) 4 (5.5) 2 (4.7) 0.40 Fever, unknown etiology 4 (5.5) 0 (0) 0 (0) 1 (2.3) Pneumoni 0 (0) 0 (0) 2 (2.7) 1 (2.3) Pulmonry embolism 0 (0) 0 (0) 1 (1.4) 0 (0) Hert infrction 0 (0) 0 (0) 1 (1.4) 0 (0) Dindo Clvien grde 3-5, n (%) 3 (4.1) 4 (9.3) 5 (6.8) 6 (14.0) 0.27 Reopertions (%) 2 (2.7) 2 (4.7) 2 (2.7) 4 (9.3) 0.32 Redmissions, n (%) 5 (6.8) 3 (7.0) 1 (1.4) 6 (14.0) 0.07 Postopertive sty, medin (IQR) dys 3 (3 4) 4 (3 6) 5 (5 6) 7 (6 9) <0.001 Totl sty, medin (IQR) dys b 5 (5 7) 6 (5 8) 8 (7 8) 9 (8 12) <0.001 IQR: interqurtile rnge; POD: postopertive dy. Figures in the columns re not dditive becuse some ptients hd more thn one compliction. b Totl hospitl sty: totl sty during index dmission nd redmission-relted dys.

6 216 A. Ehrlich, et l. Fig. 1. Men (95% CI) differences in in-hospitl costs ccording to tretment strtegy. FT: fst-trck. Tble 5 Men in-hospitl costs (95% CI). Fst-trck lproscopy Fst-trck Trditionl lproscopy Trditionl N = 73 N = 43 N = 73 N = 43 Totl costs, ,273 (95% CI) ( ,912) ( ) ( ,228) ( ,569) Preopertive costs, (95% CI) ( ) ( ) ( ) ( ) Opertive costs, (95% CI) ( ) ( ) ( ) ( ) Postopertive costs, (95% CI) ( ) ( ) ( ) ( ) CI: confidence intervl. Totl costs include costs of index dmission nd redmission-relted costs. Secondry outcomes Intke of solid food nd bowel function recovered 1 dy erlier in the fst-trck thn in the control group (p < 0.001) (Tble 4). One ptient in the stndrd group died of hert infrction nd postopertive pneumoni. Overll 30-dy morbidity ws similr between the four study groups. However, complictions were more frequent fter surgery thn fter lproscopic surgery either within fst-trck or trditionl cre (23.3% vs 11.0%, p = 0.012). Reopertion rtes were similr between the study groups. After dischrge from hospitl, 8 ptients (7.4%) in the fst-trck group nd 16 (13.8%) in the control group were sent to generl prctitioner guided nursing fcility, wheres other ptients went home. Redmission rtes did not differ significntly between fst-trck nd trditionl study groups. Discussion The role of lproscopy in improving postopertive outcome within fst-trck periopertive cre pthwy hs been controversil, but recent rndomized study (16) nd met-nlysis (2) concluded tht lproscopic colorectl surgery within fst-trck multimodl mngement hs shorter postopertive nd overll hospitl sty thn surgery within fsttrck cre. Here, while iming t the rtionliztion of periopertive cre in dily clinicl prctice, we show tht lproscopic colonic resection within fst-trck periopertive cre in comprison with trditionl cre pthwy significntly reduced the LOS without compromising ptient sfety or incresing hospitl costs, nd could be done with reltively high rte of protocol complince. Fst-trck cre nd lproscopic surgery were independent determinnts reducing the length of postopertive hospitl sty, wheres complictions dversely ffected the length of postopertive hospitl sty. A recent rndomized tril reported shorter postopertive hospitl sty fter lproscopic thn colonic surgery (5 vs 6 dys) in the fst-trck setting (16). In line with tht, the postopertive hospitl sty fter colonic resections in our study ws 3 dys fter lproscopic nd 4 dys fter surgery within fst-trck cre compred to 5 nd 7 dys

7 Fst-trck colorectl surgery 217 within trditionl cre. Although postopertive hospitl sty of 2 dys hs been reported fter fsttrck colonic surgery, Andersen et l. (19) showed tht the redmission rte ws round 10% insted of 20% by plnning dischrge 3 dys insted of 2 dys fter surgery within fst-trck cre. Accordingly, our redmission rte in the fst-trck group ws well below 10%. Overll, the development of complictions hd the strongest dverse impct on the length of postopertive sty. Efforts to improve the qulity of cre re therefore importnt. From helth economics point of view, systemtic review of the costs of lproscopic colorectl surgery within trditionl periopertive cre reported similr totl costs for lproscopic surgery thn surgery despite greter operting room costs (20). Previous met-nlyses of rndomized trils compring fsttrck nd trditionl cre pthwys in colorectl surgery (1 3), nd recent systemtic review (17) lso tend to support the cost-effectiveness of enhnced recovery pthwys for colorectl surgery s result of shorter postopertive hospitl sty nd slightly reduced postopertive morbidity (1, 2). However, the qulity of the current evidence is limited (17). A recent rndomized tril showed no sttisticlly significnt differences in in-hospitl costs between lproscopic or colonic resection within fst-trck or trditionl cre (16). Another rndomized study reported lower costs fter surgery within fst-trck cre thn within trditionl cre (21). This study shows tht despite trend towrd lower costs in the fsttrck thn in the trditionl cre group, the difference ws not sttisticlly significnt. Open surgery within fst-trck cre ws the lest costly option compred to lproscopic or surgery within trditionl cre but not significntly so when compred with lproscopy within fst-trck cre. Becuse lproscopic colonic resection within fst-trck cre resulted in shorter hospitl sty nd lower compliction rte thn surgery without significntly incresing in-hospitl costs, the combintion of lproscopic surgery nd fst-trck cre seems to be the optiml strtegy for elective colonic surgery. In our study, greter operting room costs in lproscopic surgery were minly due to the incresed use of disposble instruments nd prtly counterblnced by shorter hospitl sty. With respect to postopertive hospitl costs, the min determinnt incresing costs ws the length of sty in the hospitl. In multivrite nlysis, postopertive complictions were the mjor determinnt prolonging the LOS. It is well known tht the clinicl outcome nd costs of colorectl surgery re dependent on surgeon s experience nd the qulity of surgery. The sfety of lproscopic colonic surgery, in terms of short-term results, hs been demonstrted in mny rndomized trils (13 15). Short-term outcomes in this study were comprble to those reported by other studies (13 15), suggesting tht the qulity of surgery in this cohort of ptients ws s good s elsewhere. A smll proportion of ptients developed complictions incresing the length of postopertive hospitl sty or led to reopertions, unplnned intensive cre unit (ICU) dmissions, or redmissions to hospitl, thereby incresing in-hospitl costs. Overll postopertive morbidity in our study ws significntly lower in ptients who underwent lproscopic colonic resection insted of resection. This is in contrst to rndomized trils which filed to demonstrte decrese in morbidity fter lproscopic or colonic surgery in the fst-trck setting (16, 21). A mjor chllenge with this study ws the lck of rndomiztion which my hve cused some selection bis. Historicl controls operted on before the implementtion of fst-trck cre were used for comprison to void the contmintion of the trditionl cre elements with more modern fst-trck elements if more recently operted ptients were included. Cpitl costs of lproscopic equipment were excluded becuse lproscopic equipment is nowdys considered stndrd operting theter equipment. Moreover, in our hospitl, lproscopic equipment is used not only for colorectl surgery but lso for mny different kinds of procedures, including gllbldder nd common bile duct stone removl; fundoplictions; herni surgery; colorectl, liver nd pncretic surgery; drenl glnd surgery; esophgel resections; thorcic surgery; nd stging, mking the cpitl costing very difficult. Another limittion ws tht the reserch ws conducted in one hospitl nd included the lerning curve when implementing the fst-trck pthwy. However, senior surgeons hd lrge experience in lproscopic nd colorectl surgery. Also, the dherence with different fst-trck elements ws higher thn usully reported. Conclusion Lproscopic colonic resection within fst-trck periopertive cre is sfe, improves postopertive recovery, is not significntly more costly thn surgery, nd results in shorter hospitl sty, thereby improving the efficiency of fst-trck periopertive cre. Acknowledgements This study ws pproved by the ethics committee of the hospitl. Declrtion of conflicting interests The uthors hve no conflicts of interest to declre. Funding This study ws funded by the locl EVO (Erityisvltionosuus) funding of Centrl Hospitl of Centrl Finlnd. References 1. Spnjersberg WR, Reurings J, Keus F et l: Fst trck surgery versus conventionl recovery strtegies for colorectl surgery. Cochrne Dtbse Syst Rev 2011;CD Li MZ, Xio LB, Wu WH et l: Met-nlysis of lproscopic versus colorectl surgery within fst-trck periopertive cre. 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