Lung volume reduction surgery: a micro-costing analysis from a national tertiary referral centre.

OBJECTIVES: Lung volume reduction surgery (LVRS) is a clinically effective palliation procedure for patients with chronic obstructive pulmonary disease. LVRS has recently been commissioned by the NHS England. In this study, a costing model was developed to analyse cost and resource implications of different LVRS procedures. METHODS: Three pathways were defined by their surgical procedures: bronchoscopic endobronchial valve insertion (EBV-LVRS), video-assisted thoracic surgery LVRS and robotic-assisted thoracic surgery LVRS. The costing model considered use of hospital resources from the LVRS decision until 90 days after hospital admission. The model was calibrated with data obtained from an observational study, electronic health records and expert opinion. Unit costs were obtained from the hospital finance department and reported in 2021 Euros. RESULTS: Video-assisted thoracic surgery LVRS was associated with the lowest cost at €12 896 per patient. This compares to the costs of EBV-LVRS at €15 598 per patient and €13 305 per patient for robotic-assisted thoracic surgery LVRS. A large component of EBV-LVRS costs were accrued secondary to complications, including revision EBV-LVRS. CONCLUSIONS: This study presents a comprehensive model framework for the analysis of hospital-related resource use and costs for the 3 surgical modalities. In the future, service commissioning agencies, hospital management and clinicians can use this framework to determine their modifiable resource use (composition of surgical teams, use of staff and consumables, planned length of stay and revision rates for EBV-LVRS) and to assess the potential cost implications of changes in these parameters.

Escalated grades of complications correlate with incremental costs of video-assisted thoracoscopic surgery major lung resection for lung cancer in China.

OBJECTIVE: Few studies have focused on factors associated with the incremental cost of video-assisted thoracoscopic surgery (VATS) in China. We aim to systematically classify the complications after VATS major lung resection and explore their correlation with hospital costs. METHODS: Patients with pathologically stage I-III lung cancer who underwent VATS major lung resections from January 2007 to December 2018 were included. The Thoracic Mortality and Morbidity (TM&M) Classification system was used to evaluate postoperative complications. Grade I and II complications, defined as minor complications, require no therapy or pharmacologic intervention only. Grade III and IV complications, defined as major complications, require surgical intervention or life support. Grade V results in death. A generalized linear model was used to explore the correlation of incremental hospital costs and complications, as well as other clinicopathologic parameters between 2013 and 2016. RESULTS: A total of 2881 patients were enrolled in the first part, and the minor and major complications rates were 24.3% (703 patients) and 8.3% (228 patients), respectively. Six hundred and eighty-two patients were enrolled in the second part. The complications grade II (odds ratio [OR] 1.12, 95% confidence interval [CI] 1.05-1.2, p = 0.0005), grade III (OR 1.55, 95% CI 1.26-1.9, p < 0.0001), grades IV and V (OR 1.09, 95% CI 1.04-1.13, p = 0.0002), diffusion capacity of carbon dioxide (OR 0.998, 95% CI 0.997-1.000, p = 0.004), and duration of chest drainage (OR 1.03, 95% CI 1.02-1.04, p < 0.001) and were independent risk factors for the increase in in-hospital costs of VATS major lung resections. CONCLUSIONS: The severity of complications graded by the TM&M system was an independent risk factor for increased in-hospital costs.

Single-Port vs Conventional Three-Port Video-Assisted Thoracoscopic Pulmonary Wedge Resection: Comparison of Postoperative Pain and Surgical Costs.

PURPOSE: Single-port video-assisted thoracoscopic (VATS) pulmonary wedge resection was reported in 2004. We started using single-port VATS (SPVATS) pulmonary wedge resection in 2017 and compared results between conventional three-port VATS (VATS group) and SPVATS (SPVATS group). METHODS: We identified 145 consecutive patients with VATS group and SPVATS group. Perioperative characteristics including pain and the number of stapler cartridges used were examined as the surgical outcomes, retrospectively. RESULTS: In all, 66 cases of SPVATS group and 79 cases of VATS group pulmonary wedge resection were compared. The rate of epidural anesthesia (p <0.0001) was significantly higher and operative time (p <0.0001) was significantly longer with VATS group than with SPVATS group. The number of stapler cartridges used, duration of drain insertion, and rate of postoperative complications did not differ significantly between groups. Average numerical rating scale (NRS) score on postoperative day 1 and postoperative day 7 (p <0.0001 each), maximum NRS score on postoperative day 7 (p = 0.0082) and amount of 25 mg tramadol (p = 0.0062) were significantly lower in SPVAS group than in VATS group. CONCLUSION: Our results suggest that SPVATS pulmonary wedge resection offers better pain control and cost-effectiveness than three-port VATS pulmonary wedge resection. These findings should contribute to the body of evidence for SPVATS.

Cost-Effectiveness Analysis of Fibrinolysis vs Thoracoscopic Decortication for Early Empyema.

BACKGROUND: Surgical decortication is recommended by national guidelines for management of early empyema, but intrapleural fibrinolysis is frequently used as a first-line therapy in clinical practice. This study compared the cost-effectiveness of video-assisted thoracoscopic surgery (VATS) decortication with intrapleural fibrinolysis for early empyema. METHODS: A decision analysis model was developed. The base clinical case was a 65-year-old man with early empyema treated either by VATS decortication or intrapleural tissue plasminogen activator and deoxyribonuclease. The likelihood of key outcomes occurring was derived from the literature. Medicare diagnosis-related groups and manufacturers' drug prices were used for cost estimates. Successful treatment was defined as complete or nearly complete resolution of empyema on imaging. Effectiveness was defined as health utility 1 year after empyema. RESULTS: Intrapleural tissue plasminogen activator and deoxyribonuclease were more cost-effective than VATS decortication for treating early empyema for the base clinical case. Surgical decortication had a slightly lower cost than fibrinolysis ($13,345 vs $13,965), but fibrinolysis had marginally higher effectiveness at 1 year (health utility of 0.80 vs 0.71). Therefore, fibrinolysis was the more cost-effective option. Sensitivity analyses found that fibrinolysis as the initial therapy was more cost-effective when the probability of success was greater than 60% or the initial cost was less than $13,000. CONCLUSIONS: Surgical decortication and intrapleural fibrinolysis have nearly equivalent cost-effectiveness for early empyema in patients who can tolerate both procedures. Surgeons should consider patient-specific factors, as well as the cost and effectiveness of both modalities, when deciding on an initial treatment for early empyema.

Ninety-day hospital costs associated with prolonged air leak following lung resection.

OBJECTIVES: Our goal was to assess the postoperative 90-day hospital costs of patients with prolonged air leak (PAL) including costs incurred after discharge from the initial index hospitalization. METHODS: We performed a retrospective analysis of 982 patients undergoing lobectomy (898) or segmentectomy (78) (April 2014-August 2018). A total of 167 operations were open, 780 were video-assisted thoracoscopic surgery and 28 were robotic. A PAL was defined as an air leak >5 days. The 90-day postoperative costs included all fixed and variable costs incurred during the 90 days following surgery. The postoperative costs of patients with and without PAL were compared. The independent association of PAL with postoperative 90-day costs was tested after adjustment for patient-related factors and other complications by a multivariable regression analysis. RESULTS: PAL occurred in 261 patients (27%). Their postoperative stay was 4 days longer than that of those without PAL (9.6 vs 5.7; P < 0.0001). Compared to patients without PAL, those with PAL had 27% higher index postoperative costs [7354€, standard deviation (SD) 7646 vs 5759€, SD 7183, P < 0.0001] and 40% higher 90-day postoperative costs (18 340€, SD 23 312 vs 13 102€, SD 10 264; P < 0.0001). The relative postoperative costs (the difference between 90-day and index postoperative costs) were 50% higher in PAL patients compared to non-PAL patients (P < 0.0001) and accounted for 60% of the total 90-day costs. Multivariable regression analysis showed that PAL remained an independent factor associated with 90-day costs (P < 0.0001) along with the occurrence of other cardiopulmonary complications (P < 0.0001), male gender (P = 0.018), low carbon monoxide lung diffusion capacity (P = 0.043) and thoracotomy approach (P = 0.022). CONCLUSIONS: PAL is associated not only with increased index hospitalization costs but also with increased costs after discharge. Evaluation of the cost-effectiveness of measures to prevent air leaks should also include post-discharge costs.

Comparative effectiveness and cost-efficiency of surgical approaches for thymectomy.

BACKGROUND: We compared the clinical outcomes and cost-efficiency of surgical approaches (sternotomy-open, video assisted thoracoscopic surgery, and robotic assisted thoracic surgery) for thymectomy. METHODS: This is a retrospective review of 220 consecutive patients who underwent thymectomy between January 1, 2007, and January 31, 2017. Surgical approach was determined by the surgeon, but we only included cases that could be resected using any of the 3 approaches. RESULTS: Open approach was used in 69 patients, whereas minimally invasive technique was used in 151 (97, video assisted thoracoscopic surgery; 54, robotic assisted thoracic surgery). Open surgery was associated with greater total hospital cost ($22,847 ± $20,061 vs $14,504 ± $10,845, P < .001). Open group also revealed longer duration of intensive care unit (1.2 ± 2.8 vs 0.2 ± 1.3 days, P < .001) and hospital stay (4.3 ± 4.0 vs 2.0 ± 2.6 days, P < .001). There were no differences in major adverse clinical outcomes. Long-term recurrence-free survival after resection of thymoma was similar between the groups. CONCLUSION: Minimally invasive techniques were equally efficacious compared with the open approach in the resection of the thymus. Additionally, their use was associated with decreased hospital duration of stay and reduced cost. Hence the use of minimally invasive approaches should be encouraged in the resection of thymus.

Radioguided Surgery, a Cost-Effective Strategy for Treating Solitary Pulmonary Nodules: 20-Year Experience of a Single Center.

INTRODUCTION: Surgical resection with minimally invasive approach is the gold standard for both definitive diagnosis and treatment of solitary pulmonary nodules (SPNs); however, it can be difficult to pinpoint small, deep, or subsolid nodes without palpating lung parenchyma. The primary endpoint of this study is showing that radioguided surgery is a cost-effective strategy to improve the effectiveness of video-thoracoscopic localization/resection of SPNs/ground-glass opacities (GGOs). Secondary endpoints are analyzing the morbidity of this technique and tips and tricks to better manage this method. METHODS: SPN smaller than 20 mm and/or with a distance from the visceral pleura ≥5 mm underwent minimally invasive resection after computed tomography-guided injection of a solution composed of 0.1/0.2 mL of 99Tc-labeled human serum albumin microspheres and 0.1 mL of nonionic contrast. In the operating theater, a collimated probe connected to a gamma ray detector allowed localization of the target area. RESULTS: Between 1997 and 2018, a total of 451 patients with SPN/GGO underwent minimally invasive surgery with a radioguided technique at our hospital. The mean SPN diameter was 13 mm (range, 5-20 mm), and the mean distance from the visceral pleura was 15 mm (range, 6-29 mm). The mean time to a localizing nodule was 3 minutes (range, 1-5 minutes). No significant injection-related complications were reported; only 3.3% of patients (15 of 451) developed pneumothorax. Both 30- to 60-day and 90-day mortality were 0%. The rate of postoperative complications was 2.53% (prolonged air leak). The conversion rate to thoracotomy was 1.55% (7 of 451). CONCLUSIONS: Our 20-year experience shows that radioguided thoracoscopic surgery is a safe and feasible strategy to treat suspicious SPN/GGO, with a success rate of 98%.

Subxiphoid uniportal thoracoscopic pulmonary segmentectomy for stage I non-small cell lung cancer: Feasibility, quality of life and financial worthiness.

BACKGROUND: Subxiphoid uniportal video-assisted thoracoscopic surgery (SVATS) is more technically challenging than intercostal uniportal video-assisted thoracoscopic surgery (UVATS), especially in more complex procedures such as segmentectomy. We therefore aimed to investigate the worthiness of undertaking the more demanding subxiphoid approach in patients who had undergone anatomical segmentectomy for stage IA non-small cell lung cancer (NSCLC). METHODS: A total of 491 patients were included in our study who had undergone anatomical segmentectomy for stage IA non-small cell lung cancer from September 2014 to April 2018. They were divided into two groups; 278 patients in the UVATS group and 213 patients in the SVATS group. Different perioperative variables, postoperative pain, quality of life and cost were analyzed and compared between both groups. RESULTS: The SVATS group showed a significantly longer operative time (P = 0.007) and more operative blood loss than the intercostal group (P = 0.004). There was no significant difference between both groups regarding postoperative drainage, duration of chest tube, postoperative hospital stay, operative conversion or postoperative complications. The SVATS group showed a significantly lower pain score postoperatively (P < 0.001). In addition, the SVATS group showed a significantly better postoperative quality of life score along the first postoperative year (P < 0.001). UVATS segmentectomy appeared to be significantly cheaper than SVATS segmentectomy (P < 0.001). CONCLUSIONS: SVATS segmentectomy for stage IA lung cancer is a safe procedure that is worth proceeding with as it is associated with better postoperative pain and better quality of life in the first postoperative year. Further studies are recommended to evaluate the actual cost-effectiveness of SVATS segmentectomy. KEY POINTS: • Significant findings of the study Subxiphoid uniportal approach for pulmonary segmentectomy is safe and feasible approach. It has better postoperative pain and better quality of life than the uniportal intercostal approach; however, it is more expensive. • What this study adds Subxiphoid uniportal approach for pulmonary segmentectomy gives a better quality of life in Chinese patients than the intercostal approach; however, it is more expensive.

Cost-effectiveness of stereotactic body radiation therapy versus video assisted thoracic surgery in medically operable stage I non-small cell lung cancer: A modeling study.

OBJECTIVES: Stage I non-small cell lung cancer (NSCLC) can be treated with either Stereotactic Body Radiotherapy (SBRT) or Video Assisted Thoracic Surgery (VATS) resection. To support decision making, not only the impact on survival needs to be taken into account, but also on quality of life, costs and cost-effectiveness. Therefore, we performed a cost-effectiveness analysis comparing SBRT to VATS resection with respect to quality adjusted life years (QALY) lived and costs in operable stage I NSCLC. MATERIALS AND METHODS: Patient level and aggregate data from eight Dutch databases were used to estimate costs, health utilities, recurrence free and overall survival. Propensity score matching was used to minimize selection bias in these studies. A microsimulation model predicting lifetime outcomes after treatment in stage I NSCLC patients was used for the cost-effectiveness analysis. Model outcomes for the two treatments were overall survival, QALYs, and total costs. We used a Dutch health care perspective with 1.5 % discounting for health effects, and 4 % discounting for costs, using 2018 cost data. The impact of model parameter uncertainty was assessed with deterministic and probabilistic sensitivity analyses. RESULTS: Patients receiving either VATS resection or SBRT were estimated to live 5.81 and 5.86 discounted QALYs, respectively. Average discounted lifetime costs in the VATS group were €29,269 versus €21,175 for SBRT. Difference in 90-day excess mortality between SBRT and VATS resection was the main driver for the difference in QALYs. SBRT was dominant in at least 74 % of the probabilistic simulations. CONCLUSION: Using a microsimulation model to combine available evidence on survival, costs, and health utilities in a cost-effectiveness analysis for stage I NSCLC led to the conclusion that SBRT dominates VATS resection in the majority of simulations.

Cost-effective homemade automatically opening endobag for video-assisted thoracic surgery.

Because specimen removal is often required during video-assisted thoracic surgery, an easily produced, simple-to-use and cost-effective endobag is necessary to avoid wound metastasis. However, commercial endobags are expensive. Here I describe a homemade automatically opening, cost-effective, safe and easily produced endobag for video-assisted thoracic surgery that is suitable for use in low-income locations with limited health budgets.

Comparative Effectiveness of Robotic-Assisted Surgery for Resectable Lung Cancer in Older Patients.

BACKGROUND: Robotic-assisted surgery (RAS) is a novel surgical approach increasingly used for patients with non-small cell lung cancer (NSCLC). However, data comparing the effectiveness and costs of RAS vs open thoracotomy and video-assisted thoracoscopic surgery (VATS) for NSCLC are limited. METHODS: Patients > 65 years old with stage I to IIIA NSCLC treated with RAS, VATS, or open thoracotomy were identified from the Surveillance, Epidemiology, and End Results-Medicare database and matched according to age, sex, stage, and extent of resection. Propensity score methods were used to compare adjusted rates of postoperative complications, adequate lymph node staging, survival, and treatment-related costs. RESULTS: In this matched study cohort of 2,766 patients with resected NSCLC, RAS was associated with lower complication rates (OR, 0.57; 95% CI, 0.42-0.79) compared with open thoracotomy, and similar complication rates (OR, 1.02; 95% CI, 0.76-1.37) compared with VATS. Patients undergoing RAS were as likely to have adequate lymph node sampling as those undergoing open thoracotomy (OR, 1.28; 95% CI, 0.94-1.74) or VATS (OR, 0.88; 95% CI, 0.66-1.18). There was no significant difference in overall survival after RAS vs open thoracotomy (hazard ratio, 0.81; 95% CI, 0.63-1.04) or VATS (hazard ratio, 0.91; 95% CI, 0.70-1.18). Costs were similar for RAS ($54,702) vs open thoracotomy ($57,104; P = .08), and higher compared with VATS ($48,729; P = .02). CONCLUSIONS: RAS led to improved operative outcomes compared with open thoracotomy but may not offer an advantage over VATS. The comparative effectiveness of RAS should be further evaluated prior to widespread adoption.

Utilization Trends, Outcomes, and Cost in Minimally Invasive Lobectomy.

BACKGROUND: Minimally invasive lobectomy is associated with decreased morbidity and length of stay. However, there have been few published analyses using recent, population-level data to compare clinical outcomes and cost by surgical approach, inclusive of robotic-assisted thoracoscopic surgery (RATS). The objective of this study was to compare outcomes and hospitalization costs among patients undergoing open, video-assisted thoracoscopic surgery (VATS) and RATS lobectomy. METHODS: We identified patients who underwent elective lobectomy in the Healthcare Cost and Utilization Project Florida State Inpatient Database (2008 to 2014). Hierarchical logistic and linear regression models were used to compare in-hospital mortality, postoperative complications, prolonged length of stay, 30-day readmissions, and index hospitalization costs among cohorts. RESULTS: We identified 15,038 patients, of whom 8501 (56.5%), 4608 (30.7%), and 1929 (12.8%) underwent open, VATS, and RATS lobectomy, respectively. Robotic-assisted lobectomies comprised less than 1% of total lobectomy volume in 2008, and grew to 25% of lobectomy volume by 2014. Both VATS and RATS lobectomies were associated with decreased in-hospital mortality compared to thoracotomy (VATS odds ratio 0.69, 95% confidence interval, 0.50 to 0.94; RATS odds ratio 0.58, 95% confidence interval, 0.35 to 0.96; P = .016). After adjusting for patient age, sex, income, comorbidities, and hospital teaching status, VATS lobectomy was 2% less expensive (P = .007) and robotic-assisted lobectomy was 13% more expensive (P < .001) than the open approach. CONCLUSIONS: Minimally invasive approaches were associated to improved clinical outcomes compared with open lobectomy. However, only robotic-assisted lobectomy has had rapid growth in utilization. Despite additional cost, RATS lobectomy appears to provide a viable minimally invasive alternative for general thoracic procedures.

Rationale and design of PASSAT - patients' satisfaction with local or general anaesthesia in video-assisted thoracoscopic surgery: study protocol for a randomised controlled trial with a non-randomised side arm.

BACKGROUND: Although general anaesthesia (GA) with one-lung ventilation is the current standard of care, minor thoracoscopic surgery, i.e. treatment of pleural effusions, biopsies and small peripheral pulmonary wedge resections, can also be performed using local anaesthesia (LA), analgosedation and spontaneous breathing. Whilst the feasibility and safety of LA have been demonstrated, its impact on patient satisfaction remains unclear. Most studies evaluating patient satisfaction lack control groups or do not meet psychometric criteria. We report the design of the PASSAT trial (PAtientS' SATisfaction in thoracic surgery - general vs. local anaesthesia), a randomised controlled trial with a non-randomised side arm. METHODS: Patients presenting for minor thoracoscopic surgery and physical eligibility for GA and LA are randomised to surgery under GA (control group) or LA (intervention group). Those who refuse to be randomised are asked to attend the study on the basis of their own choice of anaesthesia (preference arm) and will be analysed separately. The primary endpoint is patient satisfaction according to a psychometrically validated questionnaire; secondary endpoints are complication rates, capnometry, actual costs and cost effectiveness. The study ends after inclusion of 54 patients in each of the two randomised study groups. DISCUSSION: The PASSAT study is the first randomised controlled trial to systematically assess patients' satisfaction depending on LA or GA. The study follows an interdisciplinary approach, and its results may also be applicable to other surgical disciplines. It is also the first cost study based on randomised samples. Comparison of the randomised and the non-randomised groups may contribute to satisfaction research. TRIAL REGISTRATION: German Clinical Trials Register, DRKS00013661 . Registered on 23 March 2018.

Cost-utility analysis of minimally invasive surgery for lung cancer: a randomized controlled trial.

OBJECTIVES: Minimally invasive video-assisted thoracic surgery (VATS) was first introduced in the early 1990s. For decades, numerous non-randomized studies demonstrated advantages of VATS over thoracotomy with lower morbidity and shorter hospital stay, but only recently did a randomized trial document that VATS results in lower pain scores and better quality of life. Opposing arguments for VATS have always been increased costs and concerns about oncological adequacy. In this paper, we aim to investigate the cost-effectiveness of VATS. METHODS: The study was designed as a cost-utility analysis of the first 12 months following surgery and was performed together with a clinical randomized controlled trial of VATS versus thoracotomy for lobectomy of stage 1 lung cancer during a 6-year period (2008-2014). All health-related expenses were retrieved from a national database (Statistics Denmark) including hospital readmissions, outpatient clinic visits, prescription medication costs, consultations with general practitioners, specialists, physiotherapists, psychologists and chiropractors. RESULTS: One hundred and three VATS patients and 103 thoracotomy patients were randomized. Mean costs per patient operated by VATS were 103 108 Danish Kroner (Dkr) (€13 818) and 134 945 Dkr (€18 085) by thoracotomy, making the costs for VATS 31 837 Dkr (€4267) lower than thoracotomy (P < 0.001). The difference in quality-adjusted life years gained over 52 weeks of follow-up was 0.021 (P = 0.048, 95% confidence interval -0.04 to -0.00015) in favour of VATS. The median duration of the surgical procedure was shorter after thoracotomy (79 vs 100 min; P < 0.001). The mean length of hospitalization was shorter following VATS (4.8 vs 6.7 days; P = 0.027). The use of other resources was not significantly different between groups. The costs of resources were lower in the VATS group. This difference was primarily due to reduced costs of readmissions (VATS 29 247 Dkr vs thoracotomy 51 734 Dkr; P < 0.001) and costs of outpatient visits (VATS 51 412 Dkr vs thoracotomy 61 575 Dkr; P = 0.012). CONCLUSIONS: VATS is a cost-effective alternative to thoracotomy following lobectomy for stage 1 lung cancer. Economical outcomes as measured by quality-adjusted life years were significantly better and overall costs were lower for VATS. CLINICAL TRIAL REGISTRATION NUMBER: NCT01278888.

Hospital cost and clinical effectiveness of robotic-assisted versus video-assisted thoracoscopic and open lobectomy: A propensity score-weighted comparison.

OBJECTIVE: To compare cost and perioperative outcomes of robotic, video-assisted thoracoscopic surgery (VATS), and open surgical approaches to pulmonary lobectomy. METHODS: Patients who underwent pulmonary lobectomy between 2012 and 2017 at a single tertiary referral center were reviewed. Propensity score adjustment by inverse probability of treatment weighting (IPTW) was used to balance baseline patient characteristics. The primary outcomes of the study were direct hospital cost and perioperative outcomes, including operative time, complications rates, and length of stay. Indirect cost and charges were secondary financial outcomes. RESULTS: A total of 697 patients underwent pulmonary lobectomy by robotic (n = 296), VATS (n = 161), and open thoracotomy (n = 240). In the IPTW-adjusted analysis, open thoracotomy had the shortest mean operating room time (robotic 278 minutes vs VATS 298 minutes vs open 265 minutes, P = .05), and lowest operating room costs (robotic $9,912 vs VATS $9491 vs open $8698, P = .001). Length of stay was significantly shorter after robotic and VATS lobectomy (robotic 3.8 days vs VATS 3.8 days vs open 5.4 days, P < .001), with significantly fewer events of atelectasis and pneumonia as compared with the open group. In sum, no significant differences were seen in IPTW-adjusted direct cost (robotic $17,223 vs VATS $17,260 vs open $18,075, P = .48), indirect cost, or charges for the total hospital stay. CONCLUSIONS: Robotic and VATS lobectomy were associated with similar cost and improved clinical effectiveness as compared with the open thoracotomy approach. Increased procedural cost of minimally invasive lobectomy can be recovered by postoperative costs reductions, associated with improved postoperative outcomes and shorter hospital stay.

The cost and quality of life outcomes in developing a robotic lobectomy program.

The use of the robotic platform is increasingly being utilized for lung resections. Our aim was to compare outcomes of thoracoscopic (VATS) versus robotic-assisted thoracoscopic (RATS) lobectomy early in a program's adoption of robotic surgery, including perioperative outcomes, cost, and long-term quality of life. A prospective database was retrospectively reviewed for all patients undergoing minimally invasive lobectomy by either VATS or RATS techniques from 2010 to 2012. Patients' operative, post-operative complications, cost (operating room and hospital) and quality of life were compared between the two resection techniques. Long-term follow-up including assessment using the European Organization for Research and Treatment of Cancer quality of life questionnaire was documented. During the first 25 RATS lobectomies, there were 73 VATS lobectomies performed, for a total of 98 cases. There was no significant difference in cancer stage, operative time, estimated blood loss, lymph node count, or hospital length of stay. The RATS resections had significantly higher operative and total hospital cost (p < 0.0001 and p < 0.05). At a median of 65-month follow-up, 29 patients (9 robotic; 20 VATS) completed the EORTC questionnaire. The global health status and symptom scale median scores were similar to the general population and did not significantly differ between groups. While transitioning from thoracoscopic to robotic lobectomy incurs increased operative and total hospital cost, equivalent operative outcomes, length of hospitalization, and long-term quality of life can be maintained during this transition. With increasing patient and surgeon interest in robotic resection, it appears both safe and feasible to adopt this approach while maintaining outcomes.

Dissection of Incomplete Fissure Using Electrocautery Is a Safe and Acceptable Method for Thoracoscopic Right Upper Lobectomy.

OBJECTIVE: The incidence of prolonged air leak may be highest after right upper lobectomy due to incomplete minor fissure. The objective of this study was to compare the efficacy of direct electrocautery division and suture with that of a fissureless technique during thoracoscopic right upper lobectomy with incomplete fissure. METHODS: One hundred and two patients underwent right upper lobectomy between January 2016 and December 2016. Of these, 60 patients underwent a right upper lobectomy conducted using the fissureless technique (group A), and 42 consecutive patients underwent a right upper lobectomy via electrocautery division of the fissure and suture (group B). The preoperative, operative, and postoperative parameters were compared between the two groups. RESULTS: The electrocautery and suture group had a higher incidence of prolonged air leak (> 5 days) (30% [12/40] vs 11% [7/62], p = 0.00), a higher incidence of air leakage (20 [32%] vs 38 [95%], p = 0.00), a longer air leak duration (days) (4.93 ± 0.86 vs 3.00 ± 1.60 days, p = 0.00), a longer duration of chest tube (mean 5.30 ± 1.20 vs 3.13 ± 1.88 days, p = 0.00), and a lower hospitalization cost (6463.28 ± 958.30 vs 7459.07 ± 1185.00 €, p = 0.00) than did the fissureless technique group. No differences were observed with respect to patient characteristics, operative characteristics, perioperative mortality, or duration of hospital stay after surgery. CONCLUSIONS: The number of patients with prolonged air leak was higher in the electrocautery group. However, electrocautery does not prolong overall length of stay and decreases hospitalization costs. Dissection of incomplete fissure using electrocautery is a safe and acceptable method for thoracoscopic right upper lobectomy.

Role of medical Thoracoscopy in the Management of Multiloculated Empyema.

BACKGROUND: The treatment of early pleural empyema depends on the treatment of ongoing infection by antimicrobial therapy along with thoracocentesis. In complicated empyema this treatment does not work and lung will not expand until removal of adhesions. The objective of the current study is to analyze the experience of management of multiloculated, exudative and fibrinopurulent empyema through rigid medical thoracoscopy under local anaesthesia and to explore new ways to manage the entity. METHODS: This is a descriptive case series in which 160 patients were recruited through non-probability convenient sampling, from department of pulmonology, Jinnah postgraduate medical centre, Karachi, from September 2014 to August 2016. All patients underwent medical thoracoscopy under local anesthesia. Written Informed consent was taken from the study participants. Ethical approval was obtained from Ethical Review Committee of the hospital. Patients age > 70 years, those with multiple organ failure and bleeding disorders were excluded. RESULTS: Out of 160 patients, 108 (67.50%) were male and 52 (32.5%) were female with mean age 25.37 years (range 16 to 70 years). Out of total, 102 (63.7%) had tuberculous empyema, while pleural biopsy of 58 (36.3%) patients was suggestive of non-tuberculous empyema. Final evolution through chest x-ray revealed complete resolution in 92 (57.5%), partial resolution in 58 (36.25%) patients. 9 (5.6%) developed persistent air leak while 1 (0.6%) patient expired due to urosepsis. CONCLUSION: Medical Thoracoscopy under local anesthesia is a safe, efficient and cost effective intervention for management of complicated empyema, particularly in resource constraint settings.

Robotic Versus Video-Assisted Thoracoscopic Surgery Pulmonary Segmentectomy: A Cost Analysis.

OBJECTIVE: Pulmonary segmentectomy using robotic assistance is often perceived as being more expensive than segmentectomy using video-assisted thoracic surgery. The robotic technique allows for meticulous dissection during segmentectomy, potentially leading to fewer parenchymal injuries, fewer air leaks, and shorter length of stay. This study compared pulmonary segmentectomy costs using video-assisted thoracic surgery versus robotic with manual staplers versus robotic with robotic staplers. METHODS: Retrospective analyses were performed evaluating our early experience with robotic pulmonary segmentectomy for 30 months compared with the video-assisted thoracic surgery approach. All 50 anatomical segmentectomies performed since introduction of robotic technique in the practice were included. Twenty-eight procedures were robotic-assisted and 22 were video-assisted thoracic surgery. Procedure-specific evaluation of direct costs was performed, including cost of robotic instruments, staplers, and average length of stay in the hospital. RESULTS: The mean ± SD age was 70 ± 10 years (range = 43-91 years). There were 12 males in the robotic group and eight in the video-assisted thoracic surgery group (P = 0.642). The mean age was 69 years in the robotic group and 71 years in the video-assisted thoracic surgery group (P = 0.367). The median length of stay was 2 (2-4) days in the robotic group (range = 1-9) and 4 (2-5) days in the video-assisted thoracic surgery group (range = 1-20, P = 0.089). The cost of robotic segmentectomy with manual staplers was less than that with robotic staplers. Both robotic techniques cost less than video-assisted thoracic surgery. CONCLUSIONS: In this small series, cost and outcomes in our early experience with robotic-assisted segmentectomy were comparable with our video-assisted thoracic surgery approach with trends toward shorter length of stay and fewer complications. Larger series are needed to validate these results.

Financial validation of the European Society of Thoracic Surgeons risk score predicting prolonged air leak after video-assisted thoracic surgery lobectomy.

OBJECTIVES: The objective of this study was to verify whether the European Society of Thoracic Surgeons prolonged air leak risk score for video-assisted thoracoscopic lobectomy was associated with incremental postoperative costs. METHODS: We retrospectively analyzed 353 patients subjected to video-assisted thoracoscopic lobectomy or segmentectomy (April 2014 to March 2016). Postoperative costs were obtained from the hospital Finance Department. Patients were grouped in different classes of risk according to their prolonged air leak risk score. To verify the independent association of the prolonged air leak risk score with postoperative costs, we performed a stepwise multivariable regression analysis in which the dependent variable was postoperative cost. RESULTS: Prolonged air leak developed in 56 patients (15.9%). Their length of stay was 3 days longer compared with those without prolonged air leak (8.3 vs 5.4, P < .0001). Their postoperative cost was higher than that of patients without prolonged air leak: $5939.8 versus $4381.7 (P = .001). After grouping the patients according to their prolonged air leak risk score, prolonged air leak incidence was 12.3% in class A, 13.7% in class B, 28.8% in class C, and 22.2% in class D (P = .020). The average postoperative cost was $4031.0 in class A, $4498.2 in class B, $6146.6 in class C, and $6809.3 in class D (analysis of variance test, P < .001). Multivariable regression analysis showed that being in classes C and D of PAL score (P = .001) and the presence of cardiopulmonary complications (P < .0001) were the only independent factors significantly associated with postoperative costs. CONCLUSIONS: We financially validated the European Society of Thoracic Surgeons prolonged air leak risk score for video-assisted thoracoscopic lobectomies, which appears useful in selecting those patients in whom the application of additional intraoperative interventions to avoid prolonged air leak may be more cost-effective.