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.

Activity-Based Cost Analysis of Robotic Anatomic Lung Resection During Program Implementation.

BACKGROUND: While robotic-assisted lung resection has seen a significant rise in adoption, concerns remain regarding initial programmatic outcomes and potential increased costs. We present our initial outcomes and cost analysis since initiation of a robotic lung resection program. METHODS: Patients undergoing either video-assisted thoracoscopic lobectomy or segmentectomy (VATS) or robotic-assisted lobectomy or segmentectomy (RALS) between August of 2014 and January of 2017 underwent retrospective review. Patients underwent 1:1 propensity matching based on preoperative characteristics. Perioperative and 30-day outcomes were compared between groups. Detailed activity-based costing analysis was performed on individual patient encounters taking into effect direct and indirect controllable costs, including robotic operative supplies. RESULTS: There were no differences in 30-day mortality between RALS (n = 74) and VATS (n = 74) groups (0% vs 1.4%; P = 1). RALS patients had a decreased median length of stay (4 days vs 7 days; P < .001) and decreased median chest tube duration (3 days vs 5 days, P < .001). Total direct costs, including direct supply costs, were not significantly different between RALS and VATS ($6621 vs $6483; P = .784). Median total operating costs and total unit support costs, which are closely correlated to length of stay, were lower in the RALS group. Overall median controllable costs were significantly different between RALS and VATS ($16,352 vs $21,154; P = .025). CONCLUSIONS: A potentially cost-advantageous robotic-assisted pulmonary resection program can be initiated within the context of an existing minimally invasive thoracic surgery program while maintaining good clinical outcomes when compared with traditional VATS. Process-of-care changes associated with RALS may account for decreased costs in this setting.

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.

Economic Considerations of Lung Volume Reduction Surgery and Bronchoscopic Valves.

Chronic obstructive pulmonary disease is a challenging disease to treat, and at advanced stages of the disease, procedural interventions become some of the only effective methods for improving quality of life. However, these procedures are often very costly. This article reviews the medical literature on cost-effectiveness of lung volume reduction surgery and bronchoscopic valve placement for lung volume reduction. It discusses the anticipated costs and economic impact in the future as technique is perfected and outcomes are improved.

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.

Initial and Longitudinal Cost of Surgical Resection for Lung Cancer.

BACKGROUND: The longitudinal cost of treating patients with non-small cell lung cancer (NSCLC) undergoing surgical resection has not been evaluated. We describe initial and 4-year resource use and cost for NSCLC patients aged 65 years of age or greater who were treated surgically between 2008 and 2013. METHODS: Using clinical data for NSCLC resections from The Society of Thoracic Surgeons General Thoracic Surgery Database linked to Medicare claims, resource use and cost of preoperative staging, surgery, and subsequent care through 4 years were examined ($2017). Cost of hospital-based care was estimated using cost-to-charge ratios; professional services and care in other settings were valued using reimbursements. Inverse probability weighting was used to account for administrative censoring. Outcomes were stratified by pathologic stage and by surgical approach for stage I lobectomy patients. RESULTS: Resection hospitalizations averaged 6 days and cost $31,900. In the first 90 days, costs increased with stage ($12,430 for stage I to $26,350 for stage IV). Costs then declined toward quarterly means more similar among stages. Cumulative costs ranged from $131,032 (stage I) to $205,368 (stage IV). In the stage I lobectomy cohort, patients selected for minimally invasive procedures had lower 4-year costs than did thoracotomy patients ($120,346 versus $136,250). CONCLUSIONS: The 4-year cost of surgical resection for NSCLC was substantial and increased with pathologic stage. Among stage I lobectomy patients, those selected for minimally invasive surgery had lower costs, particularly through 90 days. Potential avenues for improving the value of surgical resection include judicious use of postoperative intensive care and earlier detection and treatment of disease.

Costs Associated With Lobectomy for Lung Cancer: An Analysis Merging STS and Medicare Data.

BACKGROUND: Costs related to care of patients who undergo lobectomy for lung cancer may vary depending on patient, disease, and treating facility characteristics. We aimed to identify underlying case mix factors that contribute to variability of 90-day costs of lobectomy for early-stage lung cancer. METHODS: The Society of Thoracic Surgeons General Thoracic Surgery Database was queried for lobectomy for clinical stage I lung cancer (2008-2013). Demographics, clinical outcomes, and 90-day episode-of-care costs across all care settings were analyzed for patients successfully linked to Medicare data. Hospital costs were estimated from charges using cost-to-charge ratios. Comprehensive regression models were created to identify impact of preoperative patient factors and hospital characteristics on costs, and to delineate additive costs due to perioperative outcomes and complications. RESULTS: The mean 90-day cost for lobectomy was $45,080 ± $38,239. Variables associated with significant additive costs were age greater than or equal to 75 years, American Society of Anesthesiologists classification III or IV, forced expiratory volume in 1 second less than 80% predicted, body mass index less than 18.5 or greater than 35, current or past smoker, cerebrovascular disease, chronic kidney disease, impaired functional status, open thoracotomy, prolonged operative time, government hospitals, metropolitan setting, and geographic location. Patients with 1 or more postoperative complication resulted in an overall mean added cost of $27,259. Added costs increased with the number of complications; isolated recurrent laryngeal nerve paresis ($3,911) and respiratory failure ($35,011) were associated with the least and most additive cost, respectively. CONCLUSIONS: Lobectomy is associated with substantial variability of episode-of-care costs. Variability is driven by patient demographic and clinical factors, hospital characteristics, and the occurrence and severity of complications.

Variations in surgical spending within hospital systems for complex cancer surgery.

BACKGROUND: Approximately 70% of hospitals today are part of larger health systems. Proponents of hospital consolidation tout its potential to reduce health spending and improve outcomes, but to the authors' knowledge the available evidence has suggested that this promise is unrealized. Variations in costs and outcomes within systems may highlight opportunities for collaborative quality improvement and practice standardization. To assess this potential, the authors sought to measure variations in episode spending within and across hospital systems among Medicare beneficiaries undergoing complex cancer surgery. METHODS: Using 100% Medicare claims data, the authors identified fee-for-service Medicare patients who were undergoing elective pancreatectomy, lung resection, or colectomy for cancer from 2014 through 2016. Risk-adjusted, price-standardized payments for the surgical episode from admission through 30 days after discharge were calculated. The authors then assessed the reliability-adjusted variations at the hospital and system levels. RESULTS: Average episode payments varied nearly as much within hospital systems for pancreatectomy ($1946 between the lowest and highest spending systems; 95% CI, $1910-$1972), lung resection ($625 between the lowest and highest spending systems; 95% CI, $621-$630), and colectomy ($813 between the lowest and highest spending systems; 95% CI, $809-$817) as they did between the lowest and highest spending hospitals (pancreatectomy: $2034; lung resection: $1789; and colectomy: $770). For pancreatectomy, this variation was driven by index hospitalization spending whereas both index hospitalization and postacute care use drove variations for lung resection and colectomy. CONCLUSIONS: In this analysis of Medicare patients undergoing complex cancer surgery, wide variations in surgical episode spending were noted both within and across hospital systems. System leaders may seek to better understand variations in practices among their hospitals to standardize care and reduce variations in outcomes, use, and costs.

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.

Impact of Hospital Volume on Outcomes of Elective Pneumonectomy in the United States.

BACKGROUND: Despite advances in surgical technique and perioperative management, pneumonectomy remains associated with significant morbidity and mortality. The purpose of this study was to examine the impact of annual institutional volume of anatomic lung resections on outcomes after elective pneumonectomy. METHODS: We evaluated all patients who underwent elective pneumonectomy from 2005 to 2014 in the National Inpatient Sample. Patients less than 18 years of age, or with trauma-related diagnoses, mesothelioma, or a nonelective admission were excluded. Hospitals were divided into volume quartiles based on annual institutional anatomic lung resection caseload. We studied the effect of institutional volume on inhospital mortality, complications, and failure to rescue, as well as costs and length of stay. RESULTS: During the study period, an estimated 22,739 patients underwent pneumonectomy, with a reduction in national mortality from 7.9% to 5.5% (P trend = .045). Compared with the highest volume centers, operations performed at the lowest volume hospitals were associated with 1.74 increased odds of mortality (95% confidence interval, 1.14 to 2.66). Despite similar odds of postoperative complications, low volume hospital status was associated with increased failure to rescue rates (18.3% vs 12.7%, P = .024) and adjusted odds of mortality (1.70; 95% confidence interval, 1.09 to 2.64) after any complication. CONCLUSIONS: High volume hospital status is strongly associated with reduced mortality and failure to rescue rates after pneumonectomy. Efforts to centralize care or disseminate best practices may lead to improved national outcomes for this high-risk procedure.

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.

Outcomes and cost of lung cancer patients treated surgically or medically in Catalunya: cost-benefit implications for lung cancer screening programs.

Lung cancer screening programs with computed tomography of the chest reduce mortality by more than 20%. Yet, they have not been implemented widely because of logistic and cost implications. Here, we sought to: (1) use real-life data to compare the outcomes and cost of lung cancer patients with treated medically or surgically in our region and (2) from this data, estimate the cost-benefit ratio of a lung cancer screening program (CRIBAR) soon to be deployed in our region (Catalunya, Spain). We accessed the Catalan Health Surveillance System (CHSS) and analysed data of all patients with a first diagnosis of lung cancer between 1 January 2014 and 31 December 2016. Analysis was carried forward until 30 months (t = 30) after lung cancer diagnosis. Main results showed that: (1) surgically treated lung cancer patients have better survival and return earlier to regular home activities, use less healthcare related resources and cost less tax-payer money and (2) depending on incidence of lung cancer identified and treated in the program (1-2%), the return on investment for CRIBAR is expected to break even at 3-6 years, respectively, after its launch. Surgical treatment of lung cancer is cheaper and offers better outcomes. CRIBAR is estimated to be cost-effective soon after launch.

Factors associated with switching between low and super utilization in the surgical population: A study in medicare expenditure.

BACKGROUND: Considered the top 5% of healthcare utilizers, "super-utilizers" are estimated to consume as much as 40-55% of all healthcare costs. The aim of this study was to identify factors associated with switching between low- and super-utilization. METHODS: Low and super-utilizers who underwent abdominal aortic aneurysm (AAA) repair, coronary artery bypass graft (CABG), colectomy, total hip arthroplasty (THA), total knee arthroplasty (TKA), or lung resection between 2013 and 2015 were identified from 100% Medicare Inpatient Standard Analytic Files. RESULTS: Among 1,049,160 patients, 788,488 (75.1%) and 21,700 (2.1%) patients were low- or super-utilizers prior to surgery, respectively. Among patients who were super-utilizers before surgery, 23% remained super-utilizers post-operatively, yet 26.8% patients became low-utilizers after surgery. Factors associated with moving from low-to super-utilization in the pre-versus post-operative setting included AAA repair, higher Charlson, and pulmonary failure. In contrast, pre-operative super-utilizers who became low-utilizers in the post-operative setting were less likely to be African American or have undergone CABG. CONCLUSION: While 3% of pre-operative low-utilizers became super-utilizers likely due to complications, nearly one quarter of all pre-operative super-utilizers became low-utilizers following surgery suggesting success of the surgery to resolve underlying conditions associated with preoperative super-utilization.

Medico-economic impact of robot-assisted lung segmentectomy: what is the cost of the learning curve?

OBJECTIVES: The objective of this study was to assess the learning curve (LC) of robot-assisted lung segmentectomy and to evaluate hospital-related costs. METHODS: We conducted a retrospective study of Robot-assisted thoracic surgery (RATS) segmentectomies performed by 1 surgeon during 5 years. Perioperative and medical device data were collected. The LC, based on operating time, was assessed by Cumulative SUM analysis and an exponential model. Cost of care was estimated using the French National Cost Study method. RESULTS: One hundred and two RATS segmentectomies were included. The LC was completed at ∼30 procedures according to both models without significant difference in patients' characteristics before or after the LC. Mean operative time decreased from 136 min [95% confidence intervals (CI) 124-149] for the first 30 procedures to 97 min (95% CI 88-107) for the last 30 procedures. Mean length of stay decreased non-significantly (P = 0.10 for linear trend) from 8.1 days (95% CI 6.1-11.0) to 6.2 days (95% CI 4.9-7.9). The overall costs for the last 30 procedures as compared with the first 30 did not significantly decrease in the primary economic analysis but significantly decreased (P = 0.02) by €1271 (95% CI -2688 to +108, P = 0.02 for linear trend) after exclusion of 1 outlier (hospitalization-related costs > €10 000). After exclusion of this outlier, costs related to EndoWrist® instruments significantly decreased by €-135 (95% CI -220 to -35, P = 0.004), whereas costs related to clips decreased non-significantly (P = 0.28). CONCLUSIONS: The LC was completed at ∼30 procedures. Inexperienced surgeons may have higher procedure costs, related to consumable medical devices and operating time.

Hospital Variation in Spending for Lung Cancer Resection in Medicare Beneficiaries.

BACKGROUND: As cancer payment models transition from fee for service toward payment "bundles" based on episodes of care, a deeper understanding of the costs associated with stage I lung cancer treatment becomes increasingly relevant. To better understand costs in early lung cancer care, we sought to characterize hospital-level variation in Medicare expenditure after lobectomy for stage I non-small cell lung carcinoma. METHODS: Patients who were diagnosed with stage I non-small cell lung carcinoma from 2006 through 2011 and undergoing lobectomy were selected from the Surveillance, Epidemiology and End Results-Medicare linked database. We used Medicare claims to estimate costs of care in the 90 days after initial surgical hospitalization. Hospitals were grouped into quintiles of mean excess cost, calculated as the mean difference between observed costs and risk-adjusted predicted costs. The association between hospital factors and mean excess cost were compared across hospitals, including complication rates and hospital volume. RESULTS: A total of 3530 patients underwent lobectomy at 156 hospitals. Hospitals in the lowest cost quintile had index hospitalizations $6226 less costly than predicted. Conversely, the most expensive hospital quintile had index hospital costs that were $6151 costlier than predicted. Increased costs were positively associated with the number of complications per patient (P < .001), but not hospital volume (P = .85). CONCLUSIONS: Among Medicare beneficiaries undergoing lobectomy for stage I non-small cell lung carcinoma, the cost of perioperative care varied substantially across hospitals and was strongly associated with complication rate, but not hospital volume.

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.

Clinical and economic benefits associated with the use of powered and tissue-specific endoscopic staplers among the patients undergoing thoracoscopic lobectomy for lung cancer.

Background: Thoracoscopic lobectomy for lung cancer is a complex procedure where endoscopic staplers play a critical role in transecting the lung parenchyme, vasculature, and bronchus. This retrospective study was performed to investigate the economic benefits of powered and tissue-specific endoscopic staplers such as gripping surface technology (GST) and powered vascular stapler (PVS) compared to standard staplers.Methods: Two hundred and seventy-five patients who received a thoracoscopic lobectomy between 2008 and 2016 were included. Group 1 (n = 117) consisted of patients who received the operation with manual endoscopic staplers, whereas Group 2 (n = 158) consisted of patients who received the operation with GST and PVS.Results: Patient demographics and clinical characteristics were comparable, except smoking history, pulmonary function, and pleural adhesion. All patients received the operation successfully without mortalities and broncho-pleural fistula. Operation time and blood loss were higher in Group 1. Pleurodesis was performed less in Group 2 than in Group 1 (18.0% vs 3.8%, p < 0.0001). Group 2 had statistically significant lower adjusted hospital costs (Korean Won, 14,610,162 ± 4,386,628 vs 12,876,111 ± 5,010,878, p < 0.0001), lower adjusted hemostasis related costs (198,996 ± 110,253 vs 175,291 ± 191,003, p = 0.0101); lower cartridge related adjusted costs (1,105,091 ± 489,838 vs 839,011 ± 307,894, p < 0.0001) compared to Group 1. As well, Group 2 showed ∼12% lower adjusted total hospital costs compared to Group 1. Multivariable analysis revealed that Group 1 was related to increased hospital costs.Conclusions: This study showed that thoracoscopic lobectomy with powered and tissue-specific endoscopic staplers were associated with better clinical outcomes and reduced adjusted hospital costs when compared in Korean real-world settings.

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.

Current status of robot-assisted thoracoscopic surgery for lung cancer.

The robotic surgical system was designed to overcome the drawbacks of conventional endoscopic surgery. Since national health insurance in Japan began covering robotic-assisted thoracoscopic surgery (RATS) for malignant lung and mediastinal tumors in 2018, the number of RATS procedures being performed domestically has increased rapidly. This review evaluates the advantages and disadvantages of RATS for patients with lung cancers, based on an electronic literature search of PubMed. The main advantages of RATS are its ability to achieve excellent lymph-node removal with low morbidity and mortality, and minimal postoperative pain. Conversely, its disadvantages include a long operation time and the need for specialized instruments. However, the learning curve for RATS is reported to be shorter than that for VATS: some studies recommend that a surgeon needs to perform 18-22 robotic operations to attain sufficient skill. RATS for lung cancer is more expensive than VATS and the cost of training is high. Although the main disadvantage of RATS is that it reduces operator's tactile senses, the endoscope, which is directly manipulated by the surgeon at the console, using various magnifications, and 3D HD images on the monitor, may compensate for this. Ultimately, RATS offers better maneuverability, accuracy, and stability over VATS.

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.