The association between the use of powered staplers and the decreased postoperative complications following VATS lobectomy

In the May 2018 issue of Adv Ther, Miller et al. (1), reported on the influence of powered and tissue specific endoscopic stapling technology on clinical and economic results of VATS lobectomy procedures. This was a real world, non-randomized study, based on data extracted from the Premier Healthcare Database. The study compared, hospital length of stay (LOS), operating room time, hospital charges, complications, discharge status and readmissions, between 659 patients who had undergone VATS lobectomy with powered staplers and 3100 who had undergone lobectomy with manual stapling procedure. The authors reported that powered stapler group had overall 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%, P<0.001) and transfusions (4.3% vs. 6.8%, P=0.002) compared with the manual stapler group. Operating room time, discharge status, other complications (air leak complications, pneumonia and infections) and all-cause readmissions did not differ significantly between the study groups. Furthermore, in the subgroup analyses, the authors aimed to compare the two predominant manufacturers within the powered (99.4% Ethicon) and manual (75.8% Medtronic) staplers; the former group resulted to have statistically significant shorter LOS (4.89 vs. 5.66 days, P<0.037), lower total hospital costs ($23.785 vs. $26.180, P=0.008), lower equipment costs ($5,021 vs. $5,989, P=0.016), lower room and board costs ($6,795 vs. $7,984, P=0.039) and lower rates of both the composite hemostasis complication outcome (8.2% vs. 13.9%, P=0.022) and transfusion (4.7% vs. 9.3%, P=0.018). Statistical analysis, restricted to the Ethicon PVS (powered vascular stapler), revealed shorter LOS (4.99 vs. 5.82 days, P=0.047) and lower rates of the composite hemostasis complication outcome (4.8% vs. 14.2%, P=0.01) compared to the Medtronic manual staplers. Additionally, in the subgroup of the COPD patients, lower rates of the composite hemostasis complication outcome (8.6% vs. 18.9%, P=0.002) and transfusion (6.2% vs. 13.2%, P=0.011) were observed in favour of the powered staplers group.

Postoperative outcome and hospitalization costs have been frequently adopted as indicators for quality of care (2,3). Various adverse events have been reported to complicate major thoracic surgery procedures (4); among these, the rate of cardiovascular complications can be high (5). In order to improve the postoperative outcome of major thoracic surgery candidates any clinical and instrumental risk feature need to be thoroughly identified (6,7). Moreover, over the past decade, the widespread of minimally-invasive thoracic surgery has helped to reduce hospital costs, LOS and incidence of complications (8). Furthermore, the standardization of surgical techniques, the definition of the learning curve and the development of highly sophisticated devices have led to an improvement in intraoperative performance and postoperative results (8,9). Given that endoscopic staplers are necessary in VATS surgery, a comparison among current devices would benefit clinical activity (10).

Here, Miller et al. sought to address this issue. However, this analysis was narrow in its scope in that it compared only the two “predominant players” in each field. Comparing the powered versus the manual devices in the bariatric surgery setting, Roy et al., reported better economic outcomes and lower bleeding/transfusion rates for the former (11). Likewise, in the thoracic surgery field, surgeons participating in a Chinese multicentre study including 94 VATS procedures reported excellent results regarding the articulation and usability of powered staplers (12). In line with the above, Miller et al., stated that powered staplers were associated not only to superior clinical outcomes, but also to lower costs and better hospital resource use (1). What seems to be troubling with the Miller et al. study is that the sub analyses comparing the “two predominant manufactures” was not thoroughly explained regarding its motivation. In conclusion, it is desirable that in the near future prospective randomized studies seek to concentrate on demonstrating associations between the use of powered staplers and postoperative complications following VATS lobectomy.

Acknowledgments

Funding: None.

Footnote

Provenance and Peer Review: This article was commissioned and reviewed by the Section Editor Federico Raveglia (Department of Thoracic Surgery, ASST - Santi Paolo e Carlo, University of Milan Medical School, Milan, Italy).

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at http://dx.doi.org/10.21037/vats.2018.09.01). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Miller DL, Roy S, Kassis ES, et al. 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. Adv Ther 2018;35:707-23. [Crossref] [PubMed]
2. Ferguson MK, Celauro AD, Vigneswaran WT. Validation of a modified scoring system for cardiovascular risk associated with major lung resection. Eur J Cardiothorac Surg 2012;41:598-602. [Crossref] [PubMed]
3. Sandri A, Papagiannopoulos K, Milton R, et al. Major morbidity after video-assisted thoracic surgery lung resections: a comparison between the European Society of Thoracic Surgeons definition and the Thoracic Morbidity and Mortality system. J Thorac Dis 2015;7:1174-80. [PubMed]
4. Vannucci J, Scarnecchia E, Cagini L, et al. Pneumoperitoneum as a valuable option in the treatment of post lower lobectomy bronchopleural fistula. Interact Cardiovasc Thorac Surg 2015;21:121-3. [Crossref] [PubMed]
5. Cagini L, Capozzi R, Tassi V, et al. Fluid and electrolyte balance after major thoracic surgery by bioimpedance and endocrine evaluation. Eur J Cardiothorac Surg 2011;40:e71-6. [PubMed]
6. Cagini L, Andolfi M, Leli C, et al. B-type natriuretic peptide following thoracic surgery: a predictor of postoperative cardiopulmonary complications. Eur J Cardiothorac Surg 2014;46:e74-80. [Crossref] [PubMed]
7. Rodseth RN, Biccard BM, Le Manach Y, et al. The prognostic value of pre-operative and post-operative B-type natriuretic peptides in patients undergoing noncardiac surgery: B-type natriuretic peptide and N-terminal fragment of pro-B-type natriuretic peptide: a systematic review and individual patient data meta-analysis. J Am Coll Cardiol 2014;63:170-80. [Crossref] [PubMed]
8. Long H, Tan Q, Luo Q, et al. Thoracoscopic Surgery Versus Thoracotomy for Lung Cancer: Short-Term Outcomes of a Randomized Trial. Ann Thorac Surg 2018;105:386-92. [Crossref] [PubMed]
9. Bendixen M, Jørgensen OD, Kronborg C, et al. Postoperative pain and quality of life after lobectomy via video-assisted thoracoscopic surgery or anterolateral thoracotomy for early stage lung cancer: a randomised controlled trial. Lancet Oncol 2016;17:836-44. [Crossref] [PubMed]
10. Licht PB, Ribaric G, Crabtree T, et al. Prospective Clinical Study to Evaluate Clinical Performance of a Powered Surgical Stapler in Video-assisted Thoracoscopic Lung Resections. Surg Technol Int 2015;27:67-75. [PubMed]
11. Roy S, Yoo A, Yadalam S, et al. Comparison of economic and clinical outcomes between patients undergoing laparoscopic bariatric surgery with powered versus manual laparoscopic surgical staplers. J Med Econ 2017;20:423-33. [Crossref] [PubMed]
12. Qiu B, Yan W, Chen K. A multi-center evaluation of a powered surgical stapler in video-assisted thoracic lung resection procedures in China. J Thorac Dis 2016;8:1007-13. [Crossref] [PubMed]