Impact of Powered and Tissue-Specific Endoscopic Stapling Technology on Clinical and Economic Outcomes of Video-Assisted Thoracic Surgery Lobectomy Procedures: A Retrospective, Observational Study

Abstract

IntroductionVideo-assisted thoracic surgery (VATS) lung resections are complex procedures with a critical role played by endoscopic staplers in the transection of vessels, bronchi, and lung tissue. This retrospective, observational study compared hospital resource use, costs, and complications of VATS lobectomy procedures for whom powered versus manual endoscopic surgical staplers were used.MethodsPatients ≥ 18 years of age undergoing elective VATS lobectomy during an inpatient admission from January 1, 2012 to September 30, 2016 were identified from the Premier Healthcare Database (first admission = index admission). Use of either powered or manual endoscopic staplers during the index admission was identified from hospital administrative records. Multivariable regression analyses adjusting for patient, hospital, and provider characteristics and hospital-level clustering were carried out to compare the following outcomes between the powered and manual stapler groups: hospital length of stay (LOS), operating room time (ORT), hospital costs, complications (bleeding and/or transfusions, air leak complications, pneumonia, and infection), discharge status, and 30-, 60-, and 90-day all-cause readmissions.ResultsThe powered and manual stapler groups comprised 659 patients (mean age 66.1 years; 53.6% female) and 3100 patients (mean age 66.7 years; 54.8% female), respectively. In the multivariable analyses, the powered stapler group had shorter LOS (4.9 vs. 5.9 days, P < 0.001), lower total hospital costs ($23,841 vs. $26,052, P = 0.009), and lower rates of combined hemostasis complications (bleeding and/or transfusions; 8.5% vs. 16.0%, P < 0.001) and transfusions (5.4% vs. 10.9%, P = 0.002), compared with the manual stapler group. Other outcomes did not differ significantly between the study groups. Similar trends were observed in subanalyses comparing devices across predominant manufacturers in each group, and in subanalyses of patients with comorbid chronic obstructive pulmonary disease.ConclusionIn this analysis of VATS lobectomy procedures, powered staplers were associated with significant benefits with respect to selected types of hospital resource use, costs, and clinical outcomes when compared with manual staplers.FundingJohnson & Johnson.Electronic supplementary materialThe online version of this article (10.1007/s12325-018-0679-z) contains supplementary material, which is available to authorized users.

<p>The Impact of Endoscopic Stapler Selection on Bleeding at the Vascular Stump in Pulmonary Artery Transection</p>

“…Powered endoscopic staplers reportedly lead to fewer bleeding events during pulmonary vessel transection than manual endoscopic staplers due to increased stability during firing. 3,4 Miller et al also found that powered staplers demonstrate superior results in reduced total hospital length of stay and total hospital cost in addition to bleeding management; however, this study was limited by differences in patient characteristics and different approaches in multiple centers and/or surgeons' experience, making it difficult to draw clear conclusions about the full benefits of powered versus manual staplers. 4 Our results, from a single center, demonstrate that tremors during firing may not be the leading cause of bleeding during vessel transection.…”

“…3,4 Miller et al also found that powered staplers demonstrate superior results in reduced total hospital length of stay and total hospital cost in addition to bleeding management; however, this study was limited by differences in patient characteristics and different approaches in multiple centers and/or surgeons' experience, making it difficult to draw clear conclusions about the full benefits of powered versus manual staplers. 4 Our results, from a single center, demonstrate that tremors during firing may not be the leading cause of bleeding during vessel transection. Differences in bleeding after stapling did not appear to be due to variation in staple characteristics or stapler anvil jaw angle, but rather loaded and closed anvil jaw gap; the closed anvil jaw gap for the loaded Endo-GIA TM iDrive TM stapler plus gray cartridge was up to six times smaller than that of the loaded ECHELON FLEX TM PVS.…”

“…2 Powered staplers incorporate a motor to power both staple firing and the cutting action of the blade. By reducing movement at the distal tip up to 88% versus manual staplers, powered staplers minimize the impact of surgeons' hand tremors during firing; 3,4 this reduces trauma to adjacent tissue and potential instances of bleeding. Expert consensus regarding endoscopic stapling in thoracic surgery is that improved device stability could reduce surgeons' stress and prevent unintentional tissue damage during surgery.…”

“…5 Recent research has demonstrated evidence of potential clinical (bleeding and transfusion) and economic benefits associated with the use of powered staplers compared to manual staplers in videoassisted thoracoscopic surgery (VATS) lobectomies. 4 However, no comparison between outcomes associated with the use of differently powered staplers has been reported to date.…”

<p>Comparative Effectiveness Assessment of Two Powered Surgical Stapling Platforms in Laparoscopic Sleeve Gastrectomy: A Retrospective Matched Study</p>

“…The lower in-hospital hemostasis-related complications associated with Ethicon’s powered staplers is consistent with previously published findings in both bariatric and thoracic procedures. 2 , 3 , 5 , 8 However, while these earlier publications could not characterize such differences beyond the potential impact of powered firing (as they compared powered to manual stapling technologies), this analysis suggests that, potentially, there are additional differences between the stapling platforms that drive hemostasis-related complications. From an innovation perspective, although certain components of SIG are newer, the TriStaple TM cartridge reload remains the same as in Medtronic’s older manual stapling technology – potentially offering similar tissue effects as observed in the earlier studies.…”