Transoral robotic surgery for oropharyngeal and tongue cancer in the United States.

OBJECTIVES/HYPOTHESIS: To compare the clinical and cost outcomes of transoral robotic surgery (TORS) versus open procedures following the U.S. Food and Drug Administration approval in December 2009. STUDY DESIGN: Retrospective analysis of the Nationwide Inpatient Sample from 2008 to 2011. METHODS: Elective partial pharyngectomies and partial glossectomies for neoplasm were identified by International Classification of Diseases, 9th Revision, Clinical Modification code. RESULTS: TORS represented 2.1% in 2010 and 2.2% in 2011 of all transoral ablative procedures. Patients undergoing open partial pharyngectomy for oropharyngeal neoplasms (n = 1426) had more severe illness compared to TORS (n = 641). However, after controlling for minor-to-moderate severity of illness, open partial pharyngectomy was associated with longer hospital stay (5.2 vs. 3.7 days, P < 0.001), higher charge ($98,228 vs. $67,317, P < 0.001), higher cost ($29,365 vs. $20,706, P < 0.001), higher rates of tracheostomy and gastrostomy tube placement, and more wound and bleeding complications. TORS was associated with a higher rate of dysphagia (19.5% vs. 8.0%, P < 0.001). The lower cost of TORS remained significant in the major-to-extreme severity of illness group but was associated with higher complication rates when compared to open cases of the same severity of illness. A similar analysis of TORS partial glossectomy for base of tongue tumors had similar cost and length of stay benefits, whereas TORS partial glossectomy for anterior tongue tumors revealed longer hospital stays and no benefit in charge or cost compared to open. CONCLUSIONS: Early data demonstrate a clinical and cost benefit in TORS partial pharyngectomy and partial glossectomy for the base of tongue but no benefit in partial glossectomy of the anterior tongue. It is likely that anatomic accessibility and extent of surgery factor into the effectiveness of TORS.

Determining the efficacy and cost-effectiveness of the ActiValve: results of a long-term prospective trial.

OBJECTIVES/HYPOTHESIS: To investigate 1) whether the Provox ActiValve results in increased device-life in individuals with below average device-life, 2) whether it is cost-effective, and 3) whether it has any impact on voice-related quality of life. STUDY DESIGN: Prospective study. METHODS: Individuals who experienced below-average tracheoesophageal prosthesis (TEP) life were studied. RESULTS: Individuals with persistent below-average TEP life were enrolled in the study and underwent periodic re-evaluation. The majority (73%) experienced significant improvement as a result of use of the device. Those who continued to wear the device were followed for an average of 30.45 months (range, 14.70-43.49 months) and wore a total of 31 devices over this time. They demonstrated an average increase in device-life of more than 500%, going from an average of 1.93 months with a traditional indwelling device to 10.30 months with the ActiValve. The majority of individuals found that voicing with the ActiValve was either the same or better than with their previous indwelling TEP. Voice-related quality of life was not significantly different from that of a group of controls. Overall satisfaction with the device was high, and the majority would have chosen the ActiValve in the future. Overall, there were estimated to be cost savings to third-party payers through use of the ActiValve in this population. CONCLUSIONS: The ActiValve is effective in increasing device-life in selected patients who have failed conservative measures. Our protocol for use of the device requires individuals to meet several usage criteria before initial placement and to return for periodic monitoring.

Impact of surgeon and hospital volume on short-term outcomes and cost of oropharyngeal cancer surgical care.

OBJECTIVE: To evaluate the impact of surgeon and hospital case volume and other related variables on short-term outcomes after surgery for oropharyngeal cancer. METHODS: The Maryland Health Service Cost Review Commission database was queried for oropharyngeal cancer surgical case volumes from 1990 to 2009. Multivariable regression models were used to identify significant associations between surgeon and hospital case volume, as well as independent variables predictive of in-hospital death, postoperative wound complications, length of hospitalization, and hospital-related cost of care. RESULTS: Overall, 1,534 oropharyngeal cancer surgeries were performed during the study period. Complete financial data was available for 1,482 oropharyngeal cancer surgeries, performed by 233 surgeons at 36 hospitals. The only independently significant factors associated with the risk of in-hospital death were an APR-DRG mortality risk score of 4 (odds ratio [OR] = 14.0, P < .001) and total glossectomy (OR = 5.6, P = .020). Wound fistula or dehiscence was associated with an increased mortality risk score (OR = 5.9, P < .001), total glossectomy (OR = 6.9, P < .001), mandibulectomy (OR = 3.4, P < .001), and flap reconstruction (OR = 2.1, P = .038). Increased mortality risk score, total glossectomy, pharyngectomy, mandibulectomy, flap reconstruction, neck dissection, and Black race were associated with an increased length of stay and hospital-related costs. After controlling for all other variables, a statistically significant negative correlation was observed between surgery at a high-volume hospital and length of hospitalization and hospital-related costs. CONCLUSIONS: After controlling for other factors, high-volume hospital care is associated with a shorter length of hospitalization and lower hospital-related cost of care for oropharyngeal cancer surgery.

Endoscopic stapling technique for the treatment of Zenker diverticulum vs standard open-neck technique: a direct comparison and charge analysis.

BACKGROUND: Presently, the 2 most widely used methods for the treatment of Zenker diverticulum are endoscopic stapling of the common party wall between the diverticulum sac and the esophagus and the standard open-neck technique involving diverticulectomy and cricopharyngeal myotomy. OBJECTIVE: To perform an analysis of the hospital charges to determine the economic efficiency of each technique based on our experience at the Mt Sinai Medical Center, New York, NY. METHODS: A retrospective analysis of 16 patients diagnosed as having Zenker diverticulum was conducted. Eight randomly chosen patients underwent endoscopic stapling with an EndoGIA 35-mm endoscopic stapler (Ethicon Inc, Somerville, NJ), and 8 randomly chosen patients underwent a standard open approach with diverticulectomy. Medical records were reviewed to determine operative time, length of hospital stay, time to oral intake, and postoperative complications. A charge analysis of the operative and postoperative fees was also performed. Statistical analysis between the 2 groups was conducted using analysis of variance and the paired t test. RESULTS: The mean +/- SD operative time for the endoscopic stapling technique was 25.5 +/- 15.78 minutes, which was significantly less (P<.001) than that for the open procedure, 87.6 +/- 35.10 minutes. The mean operative charges were roughly equivalent at US$ 5178 for the endoscopic procedure and US$ 5113 for the open procedure. The endoscopic procedure, while shorter in operative time, had the added expense of specialized equipment, specifically the EndoGIA endoscopic stapler. The mean +/- SD length of hospital stay for the endoscopic procedure was significantly shorter (P<.001) at 1.3 +/- 0.59 days vs 5.2 +/- 1.03 days for the open procedure. The inpatient hospital charges for the endoscopic group was also significantly less (P<.001) at a mean of US$ 3589 per stay vs US$ 11,439 for the open group. The mean +/- SD time to oral intake was significantly shorter (<.001) at a mean of US$ 3589 per stay vs US$ 11,439 for the open group. The mean +/- SD time to oral intake was significantly shorter (P<.001) in the endoscopic group at 0.8 +/- 0.26 days vs 5.1 +/- 1.25 days for the open group. There were no major complications in either group, and all patients experienced resolution of preoperative symptoms. CONCLUSIONS: Compared with the standard open technique, the endoscopic stapling technique for the treatment of Zenker diverticulum results in a statistically significant shorter operative time, hospital stay, and time to resume oral feedings. While the charges of the operative procedures were roughly equivalent, the total hospital charges were significantly less for the patients treated endoscopically.