Video-Assisted vs Robotic-Assisted Lung Lobectomies for Operating Room Resource Utilization and Patient Outcomes.

Importance: With increased use of robots, there is an inadequate understanding of minimally invasive modalities' time costs. This study evaluates the operative durations of robotic-assisted vs video-assisted lung lobectomies. Objective: To compare resource utilization, specifically operative time, between video-assisted and robotic-assisted thoracoscopic lung lobectomies. Design, Setting, and Participants: This retrospective cohort study evaluated patients aged 18 to 90 years who underwent minimally invasive (robotic-assisted or video-assisted) lung lobectomy from January 1, 2020, to December 31, 2022, with 90 days' follow-up after surgery. The study included multicenter electronic health record data from 21 hospitals within an integrated health care system in Northern California. Thoracic surgery was regionalized to 4 centers with 14 board-certified general thoracic surgeons. Exposures: Robotic-assisted or video-assisted lung lobectomy. Main Outcomes and Measures: The primary outcome was operative duration (cut to close) in minutes. Secondary outcomes were length of stay, 30-day readmission, and 90-day mortality. Comparisons between video-assisted and robotic-assisted lobectomies were generated using the Wilcoxon rank sum test for continuous variables and the χ2 test for categorical variables. The average treatment effects were estimated with augmented inverse probability treatment weighting (AIPTW). Patient and surgeon covariates were adjusted for and included patient demographics, comorbidities, and case complexity (age, sex, race and ethnicity, neighborhood deprivation index, body mass index, Charlson Comorbidity Index score, nonelective hospitalizations, emergency department visits, a validated laboratory derangement score, a validated institutional comorbidity score, a surgeon-designated complexity indicator, and a procedural code count), and a primary surgeon-specific indicator. Results: The study included 1088 patients (median age, 70.1 years [IQR, 63.3-75.8 years]; 704 [64.7%] female), of whom 446 (41.0%) underwent robotic-assisted and 642 (59.0%) underwent video-assisted lobectomy. The median unadjusted operative duration was 172.0 minutes (IQR, 128.0-226.0 minutes). After AIPTW, there was less than a 10% difference in all covariates between groups, and operative duration was a median 20.6 minutes (95% CI, 12.9-28.2 minutes; P < .001) longer for robotic-assisted compared with video-assisted lobectomies. There was no difference in adjusted secondary patient outcomes, specifically for length of stay (0.3 days; 95% CI, -0.3 to 0.8 days; P = .11) or risk of 30-day readmission (adjusted odds ratio, 1.29; 95% CI, 0.84-1.98; P = .13). The unadjusted 90-day mortality rate (1.3% [n = 14]) was too low for the AIPTW modeling process. Conclusions and Relevance: In this cohort study, there was no difference in patient outcomes between modalities, but operative duration was longer in robotic-assisted compared with video-assisted lung lobectomy. Given that this elevated operative duration is additive when applied systematically, increased consideration of appropriate patient selection for robotic-assisted lung lobectomy is needed to improve resource utilization.

The role of the surgical volume for clinical outcomes in VATS lobectomy for lung cancer: a national large database multicenter analysis.

Improving the quality of lung cancer care at a cost that can be sustained is a hotly debated issue. High-risk, low-volume procedures (such as lung resections) are believed to improve significantly when centralised in high-volume centres. However, limited evidence exists to support volume requirements in lung cancer surgery. On the other hand, there was no evidence that the number of lung resections affected either the short-term perioperative results or the long-term cost. Using data from an extensive nationwide registry, this study investigated the correlations between surgical volumes and selected perioperative outcomes. A retrospective analysis of a prospectively filled national registry that follows stringent quality assurance and security procedures was conducted to ensure data accuracy and security. Patients who underwent VATS lobectomy from 2014 to 2019 at the participating centres were included. Selected perioperative outcomes were reported. Total direct hospital cost is measured at discharge for hospitalisations with a primary diagnosis of lung cancer, hospital stay costs, and postoperative length of hospital stay after lobectomy. After the propensity score matched, centres were divided into three groups according to the surgical volume of the unit where VATS lobectomies were performed (high-volume centre: > 500 lobectomies; medium-volume centre: 200-500 lobectomies; low-volume centre: < 200 lobectomies). 11,347 patients were included and matched (low-volume center = 2890; medium-volume center = 3147; high-volume center = 2907). The mean operative time density plot (Fig. 1A) showed no statistically significant difference (p = 0.67). In contrast, the density plot of the harvested lymph nodes (Fig. 1B) showed significantly higher values in the high-volume centres (p = 0.045), albeit without being clinically significant. The adjusted rates of any and significant complications were higher in the low-volume centre (p = 0.034) without significantly affecting the length of hospital stay (p = 0.57). VATS lobectomies for lung cancer in higher-volume centres seem associated with a statistically significantly higher number of harvested lymph nodes and lower perioperative complications, yet without any significant impact in terms of costs and resource consumption. These findings may advise the investigation of the learning curve effect in a complete economic evaluation of VATS lobectomy in lung cancer. Fig. 1 The mean operative time density plot showed no statistically significant difference (p = 0.67).

Microalbuminuria assessment after thoracic surgery: Early identification of complication risks.

INTRODUCTION: Microalbuminuria (MA) is considered a reflection of systemic capillary leak and an early marker of acute stress reaction to the surgical insult, proportional to the severity of the initiating condition and predictive of the individual response to surgical stress. OBJECTIVES: We conducted a prospective study to assess for the variation of MA within 4 days after thoracic surgery. We correlated observed MA levels with both their respective PaO2 /FiO2 respiratory ratio and the onset of postoperative complications. METHODS: This single-centre study enrolled 255 consecutive patients having an American Society of Anaesthesiologists (ASA) score ≤ 3. The mean age was 62 years with 67% male. All patients were scheduled for elective pulmonary resection. MA was measured in urine samples as the albumin-to-creatinine ratio (A/C), prior to, at and after extubation up to 96 hours. PaO2 /FiO2 was measured at extubation and on the first postoperative day. RESULTS: Overall, preoperative A/C levels resulted normal, with a significant average increase at extubation which peaked 6 hours later (P < 0.001). Larger postoperative A/C increases were observed in patients who developed postoperative complications, compared to those without these complications (P < 0.019). Moreover, patients undergoing major open pulmonary resections had larger postoperative A/C increases, compared to those undergoing minor video-assisted thoracic surgery resections (P < 0.006). At the time of extubation, A/C was inversely related to the PaO2 /FiO2 ratio (r = -0.25; P = 0.038). Peak A/C > 61 mg/g (P = 0.0003) was associated with postoperative cardio-pulmonary complications (OR 3.85; P = 0.003). CONCLUSION: Within 6 hours after extubation, MA assessment may be a rapid and relatively inexpensive method for better predicting perioperative risk in an ASA score ≤ 3 population.

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.

Rural-Urban Differences in Access to Thoracic Surgery in the United States, 2010 to 2014.

BACKGROUND: Because of recent lung cancer screening recommendations and corresponding insurance coverage, it is expected that more early stage cases will be identified that require thoracic surgery. However, these services may not be equally available in all regions. Our objective is to describe the availability of thoracic surgeons by examining geographic variation, rural-urban differences, and temporal changes before and after screening recommendation and insurance coverage policy changes. METHODS: We examined the U.S. thoracic surgery workforce using the 2010 and 2014 Area Health Resource Files. We calculated the density of thoracic surgeons per 100,000 persons for each year at the state and county level. We performed descriptive statistics and developed maps highlighting changes over time and geographic regions. RESULTS: Despite an overall increase in thoracic surgeons from 2010 to 2014, we observed declining density nationwide (1.5% change) and in sparsely populated states. The difference in thoracic surgeon density widened slightly between 2010 from 0.80 per 100,000 compared with 0.84 per 100,000 in 2014 in all rural counties compared with urban counties (P < .001 for both years). The difference in thoracic surgeon density was most pronounced between small adjacent rural and urban counties (0.95 and 0.96 per 100,000 for 2010 and 2014, respectively; P < .001 for both years). The Northeast held a disproportionate share of the thoracic surgery workforce. CONCLUSIONS: Limited access to thoracic surgeons in rural areas is a concern, given an older and retiring surgical workforce, the higher burden of lung cancer in rural areas, and recent policy changes for screening reimbursement.

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.

Decreasing Exposure to Radiation, Surgical Risk, and Costs for Pediatric Complicated Pneumonia: A Guideline Evaluation.

OBJECTIVES: This report describes the creation and successful implementation of a complicated pneumonia care algorithm at our institution. Outcomes are measured for specific goals of the algorithm: to decrease radiation exposure, surgical risk, and patient charges without adversely affecting clinical outcomes. METHODS: We describe steps involved in algorithm creation and implementation at our institution. To depict outcomes of the algorithm, we completed a retrospective cohort study of hospitalized pediatric patients with a diagnosis of complicated pneumonia at a single institution between January 2010 and April 2016 who met criteria for the algorithm. Charts were manually reviewed and data were analyzed via Wilcoxon rank sum, χ2, and Fisher's exact tests. RESULTS: Throughout the algorithm creation process, our institution began to see a change in practice. We saw a statistically significant decrease in the number of patients who underwent a chest computed tomography scan and an increase in patients who underwent a chest ultrasound (P < .001). We also saw an increase in the use of chest tube placement with fibrinolytics and a decrease in the use of video-assisted thoracoscopic surgery as the initial chest procedure (P ≤ .001) after algorithm implementation. These interventions reduced related charges without significantly affecting length of stay, readmission rate, or other variables studied. CONCLUSIONS: The collaborative creation and introduction of an algorithm for the management of complicated pneumonia at our institution, combined with an effort among physicians to incorporate evidence-based clinical care into practice, led to reduced radiation exposure, surgical risk, and cost to patient.

A risk-adjusted financial model to estimate the cost of a video-assisted thoracoscopic surgery lobectomy programme.

OBJECTIVE: To develop a clinically risk-adjusted financial model to estimate the cost associated with a video-assisted thoracoscopic surgery (VATS) lobectomy programme. METHODS: Prospectively collected data of 236 VATS lobectomy patients (August 2012-December 2013) were analysed retrospectively. Fixed and variable intraoperative and postoperative costs were retrieved from the Hospital Accounting Department. Baseline and surgical variables were tested for a possible association with total cost using a multivariable linear regression and bootstrap analyses. Costs were calculated in GBP and expressed in Euros (EUR:GBP exchange rate 1.4). RESULTS: The average total cost of a VATS lobectomy was €11 368 (range €6992-€62 535). Average intraoperative (including surgical and anaesthetic time, overhead, disposable materials) and postoperative costs [including ward stay, high dependency unit (HDU) or intensive care unit (ICU) and variable costs associated with management of complications] were €8226 (range €5656-€13 296) and €3029 (range €529-€51 970), respectively. The following variables remained reliably associated with total costs after linear regression analysis and bootstrap: carbon monoxide lung diffusion capacity (DLCO) <60% predicted value (P = 0.02, bootstrap 63%) and chronic obstructive pulmonary disease (COPD; P = 0.035, bootstrap 57%). The following model was developed to estimate the total costs: 10 523 + 1894 × COPD + 2376 × DLCO < 60%. The comparison between predicted and observed costs was repeated in 1000 bootstrapped samples to verify the stability of the model. The two values were not different (P > 0.05) in 86% of the samples. A hypothetical patient with COPD and DLCO less than 60% would cost €4270 more than a patient without COPD and with higher DLCO values (€14 793 vs €10 523). CONCLUSIONS: Risk-adjusting financial data can help estimate the total cost associated with VATS lobectomy based on clinical factors. This model can be used to audit the internal financial performance of a VATS lobectomy programme for budgeting, planning and for appropriate bundled payment reimbursements.

Long-term mortality after VATS lobectomy for early stage non-small cell lung cancer: a brief review of VATS and estimation of excess risks.

A brief description of current developments involving video assisted thoracic surgery (VATS) and calculations of the excess risk of survivors who underwent VATS lobectomy for early stage, non small cell lung cancer (NSCLC). The source article was produced by a Korean university hospital.

Use of new treatment modalities for non-small cell lung cancer care in the Medicare population.

BACKGROUND: Many older patients with early stage non-small cell lung cancer (NSCLC) do not receive curative therapy. New surgical techniques and radiation therapy modalities, such as video-assisted thoracoscopic surgery (VATS), potentially allow more patients to receive treatment. The adoption of these techniques and their impact on access to cancer care among Medicare beneficiaries with stage I NSCLC are unknown. METHODS: We used the Surveillance, Epidemiology and End Results-Medicare database to identify patients with stage I NSCLC diagnosed between 1998 and 2007. We assessed temporal trends and created hierarchical generalized linear models of the relationship between patient, clinical, and regional factors and type of treatment. RESULTS: The sample comprised 13,458 patients with a mean age of 75.7 years. The proportion of patients not receiving any local treatment increased from 14.6% in 1998 to 18.3% in 2007. The overall use of surgical resection declined from 75.2% to 67.3% ( P , .001), although the proportion of patients undergoing VATS increased from 11.3% to 32.0%. Similarly, although the use of new radiation modalities increased from 0% to 5.2%, the overall use of radiation remained stable. The oldest patients were less likely to receive surgical vs no treatment (OR, 0.12; 95% CI, 0.09-0.16) and more likely to receive radiation vs surgery (OR, 13.61; 95% CI, 9.75-19.0). CONCLUSION: From 1998 to 2007, the overall proportion of older patients with stage I NSCLC receiving curative local therapy decreased, despite the dissemination of newer, less-invasive forms of surgery and radiation.

Impact of hospital volume of thoracoscopic lobectomy on primary lung cancer outcomes.

BACKGROUND: This study evaluated hospital operative volume of video-assisted thoracoscopic surgery (VATS) lobectomy in primary lung cancer as a predictor of short-term outcomes after pulmonary lobectomy on a national scale. Some previous analyses comparing VATS vs open lobectomy outcomes have been limited by inaccuracies in patient cohort identification. METHODS: The 2008 Healthcare Utilization Project-Nationwide Inpatient Sample database was culled using the International Classification of Diseases (9th Clinical Modification) procedure codes specifically distinguishing VATS vs open lobectomies (32.41 and 32.49, respectively) available only after October 2007. High hospital VATS volume was defined as 95th percentile or higher (>20 VATS/year). Univariable and multivariable analyses were used to identify independent predictors of the following outcome measures: 30-day in-hospital morbidity and mortality, hospital length of stay (LOS), and hospital costs. RESULTS: We identified 6,292 primary lung cancer patients undergoing pulmonary lobectomy, including 1,523 undergoing VATS (24%). Compared with open, VATS patients had fewer complications (38% vs 44%, p<0.001) and median LOS (5 vs 7 days; p<0.001). In multivariable analysis, VATS was an independent predictor of fewer total complications (odds ratio, 0.83; p=0.004) and shorter LOS (2.3±0.3-day difference, p<0.001). Patients undergoing VATS at high-volume VATS hospitals had shorter median LOS (4 vs 6 days, p=0.001) compared with low-volume VATS hospitals. Multivariable analysis showed high hospital VATS volume independently predicted shorter LOS (0.9±0.4-day difference, p=0.001). CONCLUSIONS: In a national database, VATS lobectomy was associated with fewer complications and shorter LOS than open lobectomy in primary lung cancer patients. Among patients undergoing VATS, high hospital volume was also associated with shorter LOS.

Video-assisted thoracoscopic lobectomy is less costly and morbid than open lobectomy: a retrospective multiinstitutional database analysis.

BACKGROUND: The Premier Perspective Database (Premier Inc, Charlotte, NC) was used to compare hospital costs and perioperative outcomes for video-assisted thoracoscopic surgery (VATS) and open lobectomy procedures in the United States. METHODS: Eligible patients underwent a lobectomy for cancer by a thoracic surgeon, by VATS or open thoracotomy and were captured in the database between third quarter of 2007 and through 2008. Multivariable logistic regression analyses were performed for binary outcomes. Ordinary least-squares regressions were used to estimate continuous outcomes. All models were adjusted for patient and hospital characteristics. RESULTS: A total of 3,961 patients underwent a lobectomy by a thoracic surgeon by open (n = 2,907) or VATS (n = 1,054) approach. Hospital costs were higher for open versus VATS; $21,016 versus $20,316 (p = 0.027). Adjustment for surgeon experience with VATS over the 6 months prior to each operation showed a significant association between surgeon experience and cost. Average costs ranged from $22,050 for low volume surgeons to $18,133 for high volume surgeons. For open lobectomies, cost differences by surgeon experience were not significant and both levels were estimated at $21,000. Length of stay was 7.83 versus 6.15 days, for open versus VATS (p = 0.000). Surgery duration was shorter for open procedures at 3.75 versus 4.09 for VATS (p = 0.000). The risk of adverse events was significantly lower in the VATS group, odds ratio of 1.22 (p = 0.019). CONCLUSIONS: Lobectomy performed by the VATS approach as compared with an open technique results in shorter length of stay, fewer adverse events, and less cost to the hospital. Economic impact is magnified as the surgeon's experience increases.

Primary operative management for pediatric empyema: decreases in hospital length of stay and charges in a national sample.

OBJECTIVE: To determine whether primary operative management (decortication within the first 2 days of hospitalization) decreases hospital length of stay (LOS) and total charges in children with empyema. DESIGN: Retrospective cohort study. SETTING: Nationally representative Kids' Inpatient Database for 2003. PARTICIPANTS: Children and adolescents aged 0 to 18 years (hereinafter referred to as children) with empyema. MAIN OUTCOME MEASURES: Hospital LOS and total charges. RESULTS: A total of 1173 children with empyema were identified. Compared with children treated with primary nonoperative management, children treated with primary operative management had a shorter hospital LOS by 4.3 (95% confidence interval [CI], 2.3-6.4) days and lower total hospital charges by $21,179.80 (95% CI, -$34,111.12 to -$8248.48) and were less likely to be transferred to another short-term hospital (0% vs 13.3%). In addition, children with primary operative management were less likely to have therapeutic failure (odds ratio, 0.08 [95% CI, 0.04-0.15]). There was no difference in complications between the 2 groups (odds ratio, 1.01 [95% CI, 0.59-1.74]). CONCLUSION: Primary operative management is associated with decreased LOS, hospital charges, and likelihood of transfer to another short-term hospital, compared with nonoperative management.

[Assessment of thoracic sympathectomy by transpleural posterolateral and thoracoscopic approach in surgical treatment of Raynaud's syndrome]. / Ocena wartosci sympatektomii piersiowej w chirurgicznym leczeniu zespolu Raynauda metodami przezoplucnowego dostepu tylno-bocznego i wideotorakoskopii.

Operative treatment of patients with Raynaud's Syndrome is rarely used, and is recommended by most authors only in the case of disthrophic changes or so advanced symptoms, which disturb normal social and daily life. Recently, thoracoscopic sympathectomy is applied more frequently. The aim of this study was to assess the usefulness of thoracoscopic sympathectomy by the presentation of early and long-term outcome of 43 thoracic and eight lumbar sympathectomies performed in 41 patients with Raynaud's Syndrome. Transpleural posterio-lateral thoracotomy was performed 29 times in 27 patients, whereas thoracoscopic sympatectomy 14 times in 8 patients. Surgical techniques, early and long-term results were discussed. Based on early and long-term outcome, there were no significant differences between applied surgical techniques. Moreover, thoracoscopic sympathectomy was safe in the aspect of a short duration as well as good therapeutic and cosmetic effect of the procedure. It should be applied instead of others, so far used methods, with the exception of patients with massive pleural adhesions, which need thoracotomy.

Is video-assisted thoracic surgery justified at first spontaneous pneumothorax?

OBJECTIVE: The fundamental role of video-assisted thoracic surgery (VATS) in the treatment of spontaneous pneumothorax is generally acknowledged today. This study intends to evaluate whether VATS is justified at the onset of a first spontaneous pneumothorax through analysis of parameters tested on two group of patients treated respectively with pleural drainage and VATS. PATIENTS/METHODS: The study includes 70 patients affected by first spontaneous pneumothorax divided into two groups of 35 patients for the purpose of therapeutic treatment. The first group underwent pleural drainage while the second underwent VATS. Parameters analyzed were as follows: (1) prolonged air leaks (more than 6 days); (2) time required for pleural drainage; (3) time of hospital stay; (4) management costs; (5) recurrences (follow-up at 12 months). RESULTS: Prolonged air leaks occurred in four patients (11.4%) in the first group and two patients (5.7%) in the second; recurrences occurred in eight patients in the first group (22.8%), and only one in the second group (2.8%). Mean time for drainage and hospitalization was, respectively, 9 and 12 days in patients with pleural drainage against 3.9 and 6 days of those using VATS. Average management costs per patients including hospitalization was calculated at $2,750.00 per patient for the first group compared with $1,925.00 for the second group. CONCLUSIONS: The use of VATS at first spontaneous pneumothorax is justified in the interest of both patients and health administrations as demonstrated by the number of recurrences in patients in the first group and economy savings resulting from use of VATS.