S. Lombardo1, J. S. Rosenberg1, S. Erdene2, J. Kim1, E. Sandang2, J. Nellermore1, R. Price1 1University Of Utah,Center For Global Surgery,Salt Lake City, UT, USA 2Mongolian National University Of Medical Sciences,Department Of Surgery,Ulaanbaatar, ULAANBAATAR, Mongolia
Introduction: Laparoscopic cholecystectomy (LC) is the surgical standard of care for operable uncomplicated biliary disease in developed countries, with shorter hospital length of stay (HLOS), reduced pain, and earlier return to work when compared to open surgery (OC). Use of LC in resource-limited, low and middle income (LMIC) countries, such as Mongolia, is increasingly common. This prospective, observational study evaluates costs, clinical outcomes, and quality of life (QoL) associated with LC vs OC in Mongolia.
Methods: Patient surveys and chart review were used to capture patient demographics, clinical outcomes, and out-of-pocket and insurance costs associated with cholecystectomy. QoL was assessed pre-operatively and at 30 days post-operatively using the 5-level EuroQol (ED-QL-5D) questionnaire. Patient demographics, intra- and post-operative complications, surgical and hospital fees, and QoL results were collected by researchers through verbal interview and chart review from March 2016 through February 2017. Four of the seven participating sites were tertiary centers in Ulaanbaatar; the remaining three were rural secondary level facilities. Student T-test and Chi-squared tests were used for univariate analysis. Multivariate logistic and linear regressions were generated using variables with p-value 0.2 or less on univariate analysis. Outcomes were analyzed on the basis of intent-to-treat.
Results: In total, 215 cholecystectomies were captured, with 122 (56.7%) starting laparoscopically. Two converted to OC (1.6%). Patients undergoing LC were more likely to have attended college and have insurance, though overall insurance rates were low (10.3%). Pre-operative symptoms were comparable between groups. No deaths were reported. Total complication rate was 21.8% with no difference between groups, however LC patients were less likely to have superficial infections (Table 1). Mean HLOS and mean days to return to work (DRTW) were significantly shorter for LC. QoL was significantly improved after surgery for both groups, with no difference between groups. Mean total costs (out-of-pocket + insurance) were higher for LC, but this was not significant (555,000 vs. 477,000 Tugriks, p-value 0.126). After adjustment, LC was associated with significantly lower rates of complication, shorter HLOS, fewer DRTW, greater improvement in QoL scores, and no increase in cost when compared to OC (Table 1).
Conclusion: LC is a safe surgical treatment for patients with biliary disease in Mongolia. LC is comparative in expense to OC and is associated with improved outcomes. Reduced HLOS, shorter time off work, fewer complications, and improved QoL after LC are likely associated with greater cost-savings, but further investigation is required.
