Comparison of economic and clinical outcomes between patients undergoing laparoscopic bariatric surgery with powered versus manual endoscopic surgical staplers

Effect of Compressive Strain Rates on Viscoelasticity and Water Content in Intact Porcine Stomach Wall Tissues

Laparoscopic staplers are used extensively to seal and transect tissue. These devices compress tissue between the stapler jaws to achieve a desired compressed tissue thickness in preparation for stapling. The extent and rate of compression are dependent on surgeon technique, tissue characteristics, and stapler type, all of which can impact stapling outcomes such as bleeding, staple line leaks, and tissue healing. Historically, surgeons have relied on their experience, training, and tactile feedback from the device to optimize stapling. In recent years, the transition to electromechanical and robotic staplers has greatly impacted the tactile feedback available to the surgeon. This raises new questions about the optimal rates of tissue compression and the resultant tissue forces. This study quantifies the transmural biomechanics of the porcine stomach wall. Multirate indentation tests were used to observe the effects of indentation rate on the viscoelastic behavior of the stomach tissue during indentation, stress relaxation, and unconstrained recovery. Results show that the stomach wall demonstrates higher stress relaxation (88% versus 80%) and greater strain recovery (52% versus 47%) when indented at high rates (37.5%/s) versus slow rates (7.5%/s). Additionally, water content analysis was used to study fluid flow away from indented regions. Unindented regions were found to have greater water content compared to indented regions (78% compared to 75%). This data generated in this study may be used to enable the development of constitutive models of stomach tissue, which in turn may inform the control algorithms that drive compressive surgical devices.

Powered stapler and polyglycolic acid sheet for pancreatic fistula after distal pancreatectomy

BACKGROUND

Although distal pancreatectomy (DP) is crucial for the treatment of pancreatic diseases, it often leads to postoperative pancreatic fistula (POPF), a complication with significant management challenges and health effects. Despite the use of various techniques, including suturing methods, staplers, and biodegradable materials, the optimal strategy to reduce POPF remains unclear. This study investigated the combined use of powered staplers and polyglycolic acid (PGA) sheets to mitigate POPF.

METHODS

This study retrospectively analyzed the data of 165 patients who underwent DP at Sapporo Medical University Hospital between January 2013 and August 2023. This study compared the incidence of clinically relevant POPF (CR-POPF) between patients treated without (group O, n = 50) and with powered staplers and PGA sheets (group P, n = 115). In addition, the surgical techniques, patient demographics, and postoperative outcomes were examined.

RESULTS

This study found no significant difference in the overall incidence of POPF between the groups. However, group P had a significantly lower incidence of CR-POPF than group O (20.9% vs 40.0%, respectively; P = .011). Multivariate analysis demonstrated that male sex (odds ratio [OR], 2.81; 95% CI, 1.26-6.26; P = .012) and pancreatic thickness of more than 14 mm (OR, 2.85; 95% CI, 1.17-6.95; P = .021) were independent risk factors for CR-POPF. The use of powered staplers and PGA sheets (OR, 0.38; 95% CI, 0.17-0.85; P = .017) was associated with reduced CR-POPF risk.

CONCLUSION

The combined use of powered staplers and PGA sheets can significantly decrease the incidence of CR-POPF in patients with DP.

Comparing surgical outcomes of powered versus manual surgical staplers: a systematic review and meta-analysis

BACKGROUND

The growing use of staplers, manual and powered, especially in minimally invasive surgeries, necessitates evaluating their efficacy in gastrointestinal and thoracic surgeries. Parameters analysed include anastomotic and air leakage rates, bleeding, infection, cost, and operative duration.

METHODS

We searched Cochrane Library, CINAHL, EMBASE, PubMed, and Web of Science using terms like "surgical staplers," "manual staplers," "automatic staplers," and "powered staplers." We assessed study quality using the Joanna Briggs Institute (JBI) Critical Appraisal tools and conducted meta-analysis using Review Manager software.

RESULTS

A total of 43,104 patients with a mean age of 60.8 were involved in the studies. The meta-analysis revealed a significant reduction in anastomotic leaks in GI surgery patients (OR 0.31, p = 0.0001) and a significant decrease in postoperative air leakage in thoracic surgery patients (OR 0.65, p = 0.05) when powered staplers were employed. Additionally, we observed a significant decline in hemostasis-related complications for both thoracic and GI surgeries (OR 0.48, p = 0.002) with the use of powered staplers. Although individually costlier than manual staplers, powered staplers significantly decreased total hospitalisation costs (MD -1725.82, p < 0.00001) amoungst the thoracic surgeries, due to the cost saved on remedying the lower rate of complications compared to manual staplers. It also decreased the average operative times in thoracic and GI surgeries, although not significant (p = 0.06, p = 0.07 respectively).

CONCLUSION

Powered staplers surpass manual staplers by reducing operative duration, total hospital costs, and complications like anastomotic leaks and bleeding. Hence, they are poised to become the preferred alternative in future surgeries.

RESULTS OF MECHANIC VERSUS MOTORIZED STAPLER USED IN GASTRIC SURGERY: PROSPECTIVE STUDY

BACKGROUND

Mechanic sutures represent an enormous benefit for digestive surgery in decreasing postoperative complications. Currently, the advantages of motorized stapler are under evaluation.

AIMS

To compare the efficacy of mechanic versus motorized stapler in gastric surgery, analyzing rate of leaks, bleeding, time of stapling, and postoperative complications.

METHODS

Ninety-eight patients were submitted to gastric surgery, divided into three groups: laparoscopic sleeve gastrectomy (LSG) (n=47), Roux-en-Y gastric bypass (LRYGB) (n=30), and laparoscopic distal gastrectomy (LDG) (n=21). Motorized staplers were employed in 61 patients. The number of firings, number of clips, time of total firings, total time to complete the surgery, and postoperative outcome were recorded in a specific protocol.

RESULTS

Patients submitted to LSG, LRYGB, and LDG recorded a shorter time to complete the procedure and a smaller number of firings were observed using motorized stapler (p<0.0001). No differences were identified regarding the number of clips used in patients submitted to LSG. In the group that used mechanic stapler to complete gastrojejunostomy, jejuno-jejuno-anastomosis, and jejunal transection, it was observed more prolonged time of firing and total time for finishing the procedure (p=0.0001). No intraoperative complications were found comparing the two devices used. Very similar findings were noted in the group of patients undergoing LDG.

CONCLUSIONS

The motorized stapler offers safety and efficacy as demonstrated in prior reports and is relevant since less total time of surgical procedure without intraoperative or postoperative complications were confirmed.

Defining digital surgery: a SAGES white paper

BACKGROUND

Digital surgery is a new paradigm within the surgical innovation space that is rapidly advancing and encompasses multiple areas.

METHODS

This white paper from the SAGES Digital Surgery Working Group outlines the scope of digital surgery, defines key terms, and analyzes the challenges and opportunities surrounding this disruptive technology.

RESULTS

In its simplest form, digital surgery inserts a computer interface between surgeon and patient. We divide the digital surgery space into the following elements: advanced visualization, enhanced instrumentation, data capture, data analytics with artificial intelligence/machine learning, connectivity via telepresence, and robotic surgical platforms. We will define each area, describe specific terminology, review current advances as well as discuss limitations and opportunities for future growth.

CONCLUSION

Digital Surgery will continue to evolve and has great potential to bring value to all levels of the healthcare system. The surgical community has an essential role in understanding, developing, and guiding this emerging field.

Global Surgeon Opinion on the Impact of Surgical Access When Using Endocutters Across Specialties

Background: Despite design enhancements in endocutters, key challenges related to limited surgical access and space can impact stapling and, potentially, surgical outcomes. Objectives: This study aimed to develop consensus statements outlining the clinical value of precise articulation and greater anatomical access in minimally invasive surgery performed by bariatric, colorectal, and thoracic surgeons. Methods: Colorectal, bariatric, and thoracic surgeons from Japan, the United States, United Kingdom, and France participated in a 2-round modified Delphi panel. Round 1 included binary, Likert scale-type, multiple-response, and open-ended questions. These were converted to affirmative statements for round 2 if sufficient agreement was reached. Consensus was set at a predefined threshold of at least 90% of panelists across all surgical specialties and regions selecting the same option ("agree" or "disagree") for the affirmative statements. Results: Of the 49 statements in the round 2 questionnaire, panelists (n=135) reached consensus that (1) tissue slippage outside stapler jaws can occur due to limited access and space; (2) greater jaw aperture could help to manipulate thick or fragile tissue more easily; (3) articulation of an endocutter is clinically important in laparoscopic surgeries; (4) improved access to hard-to-reach targets and in limited space would improve safety; and (5) an endocutter with improved access through greater articulation would become common use. Discussion: By understanding user-specific challenges and needs from both specialty- and region-wide perspectives, endoscopic stapling devices can continue to be refined. In this study, improved articulation and greater jaw aperture were the key design features examined. Improved articulation and greater jaw aperture were key stapler design features identified in this study that may mitigate the risk of instrument clashes and intraoperative complications such as anastomotic leaks. Conclusions: This study gained insights into surgeons' perspective across a variety of specialties and from 3 distinct geographies. Participating surgeons reached consensus that an endocutter with greater jaw aperture and articulation may improve surgical access and has potential to improve surgical outcomes.

Powered stapling system with gripping surface technology for pulmonary resection of lung cancer: real-world clinical effectiveness

OBJECTIVES

Surgical lung resection involves a critical task of stapled ligation and transection of major vascular structures and tissue, which may lead to bleeding and complications. A newer powered stapling system with Gripping Surface Technology (GST) was introduced to account for tissue movements. This study aimed to examine the real-world effectiveness of GST system on intraoperative and postoperative outcomes of pulmonary resection.

METHODS

A retrospective analysis was conducted using the electronic medical records of Sichuan Provincial People's Hospital between July 2020 and March 2021 in China. Patients who underwent their first procedures of single-port lobectomy or multi-port segmentectomy by video-assisted thoracoscopic surgery were identified and grouped as GST group or manual stapler group (manual group) by the stapler types. The intraoperative outcomes such as bleeding rate, blood loss volume, and intervention rate at the staple line (including intraoperative pressure, suture, and electrocoagulation) were documented by trained nurses during the surgery. Propensity score matching was performed between the two groups, controlling forage, BMI, smoking history, history of surgery, complications, and level of complexity of pneumonectomy.

RESULTS

A total of 108 matched patients were included in the analysis (54 in the GST group and 54 in the manual group). GST group had lower risks for intraoperative bleeding (22.8% vs 51.9%; p = 0.003) and intraoperative interventions (31.5% vs 55.6%; p = 0.02), compared to the manual group. A decrease in the intraoperative blood loss was observed in the GST group, but not statistically significant (134.39 ± 52.82 ml vs 158.11 ± 73.14 ml, p = 0.102). The use of NEOVEIL (reinforcement material to prevent air leakage from the staple line) intraoperatively during surgery was significantly lower in the GST group (24.1%) than in the manual group (50%, p = 0.01).

CONCLUSION

The GST system was associated with better intraoperative outcomes in clinical practice in China.

Safety considerations in laparoscopic surgery: A narrative review

Laparoscopic surgery has many advantages over open surgery. At the same time, it is not without its risks. In this review, we discuss steps that could enhance the safety of laparoscopic surgery. Some of the important safety considerations are ruling out pregnancy in women of the childbearing age group; advanced discussion with the patient regarding unexpected intraoperative situations, and ensuring appropriate equipment is available. Important perioperative safety considerations include thromboprophylaxis; antibiotic prophylaxis; patient allergies; proper positioning of the patient, stack, and monitor(s); patient appropriate pneumoperitoneum; ergonomic port placement; use of lowest possible intra-abdominal pressure; use of additional five-millimetre (mm) ports as needed; safe use of energy devices and laparoscopic staplers; low threshold for a second opinion; backing out if unsafe to proceed; avoiding hand-over in the middle of the procedure; ensuring all planned procedures have been performed; inclusion of laparoscopic retrieval bags and specimens in the operating count; avoiding 10-15 mm ports for placement of drains; appropriate port closures; and use of long-acting local anaesthetic agents for analgesia. Important postoperative considerations include adequate analgesia; early ambulation; careful attention to early warning scores; and appropriate discharge advice.

Stapler Malfunctions in Bariatric Surgery: An Analysis of the MAUDE Database

Background

Staple line leaks are a serious problem in bariatric surgery and a major cause of serious morbidity and mortality. Adverse events caused by medical devices are reported to the Food and Drug Administration which maintains the Manufacturer and User Facility Device Experience (MAUDE) database. We examined adverse stapler events reported to the MAUDE database, specifically with regards to bariatric surgery.

Methods

The MAUDE database was queried for adverse events caused by staplers between January 1, 2018 - December 31, 2020; events reported by Intuitive, Ethicon, and Medtronic/Covidien; and limited our search to "gastric bypass", "sleeve gastrectomy", "stapler malfunction" combined with each company.

Results

There were 883 adverse events reported for Medtronic, 353 for Ethicon, and 35 for Intuitive. Approximately 3.5 million staple reloads sold in the study period. The reported misfire rate for Medtronic was 0.04% and for Ethicon was 0.02%. Data for Intuitive was unavailable. The most common reported event for Medtronic was failure to fire (n = 349), followed by misfire (n = 186). For Ethicon, the most common event was failure to fire (n = 146), followed by mechanical problems (n = 27). The most common event with the Intuitive stapler was leak (n = 10) and bleeding from staple line (n = 8).

Conclusions

Stapler malfunction is a very rare event in metabolic and bariatric surgery. All of the major stapler producers have transitioned to powered staplers with excellent safety profiles. Open and honest reporting about stapler malfunction is essential to determine the true safety of these ubiquitous devices.

Long-term Emergency Department Visits and Readmissions After Laparoscopic Roux-en-Y Gastric Bypass: a Systematic Review

PURPOSE

There is considerable evidence on short-term outcomes after laparoscopic Roux-en-Y gastric bypass (LRYGB), but data on long-term outcome is scarce, especially on postoperative emergency department (ED) visits and readmissions. We aim to systematically review evidence on the incidence, indications, and risk factors of ED visits and readmissions beyond 30 days after LRYGB.

MATERIALS AND METHODS

A systematic search in PubMed, Scopus, Embase.com , Cochrane Library, and PsycINFO was performed. All studies reporting ED visits and readmissions > 30 days after LRYGB, with ≥ 50 patients, were included. PRISMA statement was used and the Newcastle-Ottawa Scale for quality assessment.

RESULTS

Twenty articles were included. Six studies reported on ED visits (n = 2818) and 19 on readmissions (n = 276,543). The rate of patients with an ED visit within 90 days after surgery ranged from 3.9 to 32.6%. ED visits at 1, 2, and 3 years occurred in 25.6%, 30.0%, and 31.1% of patients. Readmissions within 90 days and at 1-year follow-up ranged from 4.1 to 20.5% and 4.75 to 16.6%, respectively. Readmission was 29% at 2 years and 23.9% at 4.2 years of follow-up. The most common reason for ED visits and readmissions was abdominal pain.

CONCLUSION

Emergency department visits and readmissions have been reported in up to almost one in three patients on the long-term after LRYGB. Both are mainly indicated for abdominal pain. The report on indications and risk factors is very concise. A better understanding of ED visits and readmissions after LRYGB is warranted to improve long-term care, in particular for patients with abdominal pains.

Outcomes associated with the use of a new powered circular stapler for left-sided colorectal reconstructions: a propensity score matching-adjusted indirect comparison with manual circular staplers

Background

This was a retrospective, matching-adjusted indirect comparison of clinical outcomes between patients from a single-arm trial of the ECHELON CIRCULAR™ Powered Stapler (ECP) and those from a historical cohort of patients who underwent left-sided colorectal resection using conventional manual circular staplers, extracted from the Premier Healthcare Database.

Methods

Patients in the ECP trial cohort were propensity score matched to those in the historical cohort through nearest neighbor matching. Outcomes included 30-day readmission rates; length of stay (LOS) for the index admission; rates of anastomotic leak, pelvic abscess, ileus/small bowel obstruction, infection, bleeding, and stoma creation.

Results

The study included 168 patients in the ECP trial cohort and 4544 patients in the historical cohort; 165 ECP trial patients were matched to 1348 historical cohort patients. After matching, conversions were more prevalent in the historical cohort than the ECP trial cohort (4.2% ECP vs. 10.2% historical, p = 0.001). Relative to the historical cohort, the ECP trial cohort had statistically significant lower rates of 30-day inpatient readmission (6.1% vs. 10.8%, p = 0.019), anastomotic leak (1.8% vs. 6.9%, p < 0.001), ileus/small bowel obstruction (4.8% vs. 14.7%, p < 0.001), infection (1.8% vs. 5.7%, p = 0.001), and bleeding (1.8% vs. 9.2%, p < 0.001) during the index admission or within 30 days thereafter. No statistically significant differences in rates of pelvic abscess, stoma creation, or LOS were found between the two cohorts. Three sensitivity analyses to address the difference in conversion rates yielded largely consistent results, with loss of statistical significance for inpatient admission in some cases. This study is limited by its potential for differences in unmeasurable factors between the ECP trial and historical cohorts.

Conclusions

In this study, the ECP trial cohort had lower incidence proportions of several surgical complications as compared with the historical cohort. Further controlled prospective clinical studies are needed to confirm the validity of this finding.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00464-021-08542-7.

Design and performance evaluation of a powered stapler for gastrointestinal anastomosis

OBJECTIVE

This paper reports the design of a powered stapler for gastrointestinal anastomosis and evaluates its performance. The proposed stapling instrument is intended to simplify and optimize the current procedure of mechanical stapling, while providing controllable operation for the powered stapling procedure, such as conditioning the tissue to the right stage before firing of the stapler.

MATERIAL AND METHODS

The feasibility and efficacy of the prototype were assessed by ex vivo experiments with porcine small intestine segments, where the tissue conditioning operation, burst pressure of the stapled intestine samples, and staple malformation rate were examined.

RESULTS

The functionality of the developed powered stapler was validated, where the theoretical, numerical, and experimental results agree well with each other. The preliminary results indicated that the proposed tissue conditioning operation could lower the clamping pressure with a maximum level of 1.35 g/mm². The average burst pressure of the stapled segments (16 samples) is 6.37 kPa, and the maximum malformation rate of the tested groups (five groups, each group with 90 staplers) was 5.56%.

CONCLUSION

The developed novel tissue conditioning procedure could reduce the pressure response of the intestine tissue samples. The proposed powered stapler proves effective for performing gastrointestinal anastomosis procedures.

Incidence, predictors, and economic burden of circular anastomotic complications in left-sided colorectal reconstructions involving manual circular staplers

STUDY AIM

Manual circular staplers are widely used in colorectal surgery; however, limited literature exists examining complications related to circular anastomoses when such devices are used. The present study evaluated the incidence, predictors, and economic burden of circular anastomotic complications in left-sided colorectal reconstructions involving manual circular staplers.

MATERIALS AND METHODS

Patients aged ≥18 years who underwent hemicolectomy, low anterior resection, or sigmoidectomy between 1 October 2016 and 31 December 2018 were identified from the Premier Healthcare Database. Manual circular stapler use was identified from hospital administrative billing records. Circular anastomotic complications were defined as a composite endpoint of multiple circular stapler use (proxy for stapler failure) or other circular anastomotic complications (anastomotic leak, bleeding, device/surgical complications, infection, and transfusion). Multivariable analyses were used to model the associations between circular anastomotic complications and total hospital costs, length of stay, operating room time, and 30-, 60-, and 90-day readmission rates.

RESULTS

A total of 13,167 patients met the study criteria, of whom 2,984 (22.7%) had circular anastomotic complications. Predictors of circular anastomotic complications included age, procedure type, provider region, and select patient comorbidities. As compared with those who did not, patients who suffered circular anastomotic complications had significantly higher adjusted total hospital costs ($26,924 vs. $18,748; p < .0001), length of stay (7.79 vs. 4.99 days; p < .0001), operating room time (280 vs. 239 min; p < .0001), non-home discharge status (9.63% vs. 4.61%; p < .0001), and all-cause readmission at 30 days (12.2% vs. 8.7%; p < .0001), 60 days (16.0% vs. 11.6%; p < .0001), and 90 days (18.5% vs. 13.4%; p < .0001).

LIMITATIONS

The present study is limited by the observational nature and potential for measurement error that is inherent to administrative healthcare databases.

CONCLUSIONS

In this analysis of patients undergoing left-sided colorectal reconstructions involving a manual circular stapler, circular anastomotic complications were associated with adverse economic consequences.

Utility of the powered stapler for radical pulmonary resection: a propensity score-matched analysis

PURPOSE

Anatomical pulmonary resection, such as lobectomy, is a common procedure. Staplers play an important role in dividing an incomplete interlobular fissure, especially in thoracoscopic surgery. This study evaluates the effectiveness of a powered stapler for reducing the need for intraoperative fibrin glue and the incidence of air leakage after radical pulmonary resection.

METHODS

The subjects of this retrospective study were 478 patients who underwent radical pulmonary resection. Propensity score analysis generated two matched pairs of 177 patients treated using powered and manual staplers, respectively.

RESULTS

The need for fibrin glue intraoperatively during radical pulmonary resection was significantly less in the powered-stapler group (47.5%) than in the manual-stapler group (58.8%, p = 0.033). The incidence of postoperative air leakage following radical pulmonary resection was also significantly lower in the powered-stapler group (2.8%) than in the manual-stapler group (10.7%, p = 0.003). Logistic regression analysis identified use of the powered stapler as a factor independently associated with both non-use of fibrin glue intraoperatively (odds ratio, 0.63; p = 0.040) and no postoperative air leakage (odds ratio, 0.26; p = 0.010).

CONCLUSION

Using a powered stapler to divide the incomplete interlobular fissure decreased the need for additional intraoperative management using fibrin glue and reduced postoperative air leakage in radical pulmonary resection.

Surgical Outcomes, Health Care Utilization, and Costs Associated with Staple Line Buttressing Among Primary Sleeve Gastrectomy Patients

Purpose

Staple line buttressing is a method of reinforcing surgical staple lines using buttress materials. This study evaluated surgical outcomes, hospital utilization, and hospital costs associated with staple line buttressing among patients who underwent primary laparoscopic sleeve gastrectomy (PLSG) in the United States.

Methods

This was a retrospective cohort study using Premier Healthcare Database data from January 1, 2012 to December 31, 2017. Patients aged ≥ 18 years who underwent PLSG were selected and assigned to buttress or non-buttress cohorts based on the use of buttress material during their hospitalization for PLSG (index). Propensity score matching (PSM) was conducted to balance patient demographic and clinical characteristics between the cohorts. Generalized estimating equation models were used to compare the clinical and economic outcomes of the matched buttress and non-buttress users during the index hospitalization.

Results

A total of 38,231 buttress and 27,349 non-buttress patients were included in the study. After PSM, 24,049 patients were retained in each cohort. Compared with non-buttress cohort, the buttress cohort patients had a similar rate of in-hospital leaks (0.28% vs 0.39%; p = 0.160) and a lower rate of bleeding (1.37% vs 1.80%, p = 0.015), transfusion (0.56% vs 0.77%, p = 0.050), and composite bleeding/transfusion (1.57% vs 2.04%, p = 0.019). Total costs ($12,201 vs $10,986, p < 0.001) and supply costs ($5366 vs $4320, p < 0.001) were higher in the buttress cohort compared with the non-buttress cohort.

Conclusions

Staple line buttressing was associated with an improvement in complication rates for bleeding and transfusion. Total and supply costs were higher in the buttress cohort, necessitating further research into cost-effective buttressing materials.

Electronic supplementary material

The online version of this article (10.1007/s11695-020-04917-2) contains supplementary material, which is available to authorized users.

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

Objective

To compare outcomes between the two latest innovations in powered stapling technology, the ECHELON FLEX™ GST system (GST) and the Signia™ Stapling System (SIG), among patients undergoing sleeve gastrectomy for obesity.

Patients and Methods

Using the Premier Healthcare Database of US hospital discharge records, we selected patients undergoing inpatient sleeve gastrectomy with dates of surgical admission between March 1, 2017 (SIG launch), and December 31, 2018. Outcomes measured during the surgical admission included in-hospital hemostasis-related complications (bleeding/transfusion; primary outcome), leak, total hospital costs, length of stay (LOS), and operating room time; 30-, 60-, and 90-day all-cause inpatient readmissions were also examined. We used 1:1 cardinality matching to balance the GST and SIG groups on numerous patient and hospital/provider characteristics, allowing a maximum standardized mean difference (SMD) ≤0.05 for all matching covariates. Generalized estimating equations (GEE) accounting for hospital-level clustering were used to compare the study outcomes between the GST and SIG groups.

Results

Of the 5573 identified cases, there were 491 patients in each group (982 total) after matching. The observed incidence proportion of hemostasis-related complications during the surgical admission was lower in the GST group as compared with the SIG group (3 events/491 [0.61%] vs 11 events/491 [2.24%]; odds ratio [SIG=reference] = 0.28, 95% CI=0.13–0.60, P=0.0012). Differences between the GST and SIG groups were not statistically significant for leak, total hospital costs, LOS, OR time, and all-cause inpatient readmission at 30, 60, and 90 days.

Conclusion

In this retrospective study of 982 matched patients undergoing sleeve gastrectomy, the ECHELON FLEX™ GST system was associated with a lower rate of hemostasis-related complications as compared with the Signia™ Stapling System. Further controlled prospective studies are needed to confirm the validity of this finding.

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

OBJECTIVE

To assess bleeding following transection of the pulmonary artery with powered and manual endoscopic staplers.

METHODS

Cases of video-assisted and open-chest thoracic surgical procedures for non-small cell lung cancer at Ishikawa Prefectural Central Hospital were reviewed between 2012 and 2018. Three stapler groups were assessed: Group 1 - Ethicon ECHELON FLEXTM Powered Vascular Stapler (PVS), Group 2 - Medtronic Endo-GIATM iDriveTM powered stapler, Group 3 - Ethicon and Medtronic manual staplers.

RESULTS

Of 239 patients, 82 cases (34.3%) were Group 1, 94 cases (39.3%) were Group 2 and 63 cases (26.4%) were Group 3. Mean age was 68.3 years (range 36-88 years), and most patients received video-assisted right upper lobectomy (82.8%). Bleeding occurred in 24 cases: 17 (70.8%) in Group 2 and 7 (29.2%) cases in Group 3. No bleeding occurred in Group 1. The loaded ECHELON FLEXTM PVS and Endo-GIATM iDriveTM with gray cartridge combinations had the greatest and smallest closed anvil jaw gaps (>0.63 µm and <0.15 µm, respectively); Endo-GIATM iDriveTM gray cartridge combinations resulted in ruptures of inner and middle membranes of the pulmonary artery. No ruptures were observed using the ECHELON FLEXTM PVS.

CONCLUSION

An excessively narrow gap between cartridge and anvil may damage the blood vessel wall and lead to bleeding following transection. This study provides preliminary evidence that the use of the ECHELON FLEXTM PVS and tan cartridges for pulmonary artery stapling may help to prevent tissue damage and intraoperative bleeding.

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.

Global hospital and operative costs associated with various ventral cavity procedures: a comprehensive literature review and analysis across regions

Objectives: The aim of this literature review was to provide a comprehensive report on hospital costs, and cost components, for a range of ventral cavity surgical procedures across three regions of focus: (1) Americas, (2) Europe, Middle East and Africa (EMEA), and (3) Asia-Pacific. Methods: A structured search was performed and utilized a combination of controlled vocabulary (e.g., "Hepatectomy", "Colectomy", "Costs and Cost Analysis") and keywords (e.g. "liver resection", "bowel removal", "economics"). Studies were considered eligible for inclusion if they reported hospital-related costs associated with the procedures of interest. Cost outcomes included operating room (OR) time costs, total OR costs, ward stay costs, total admission costs, OR cost per minute and ward cost per day. All costs were converted to 2018 USD. Results: Total admission costs were observed to be highest in the Americas, with an average cost of $15,791. The average OR time cost per minute was found to vary by region: $24.83 (Americas), $14.29 (Asia-Pacific), and $13.90 (EMEA). A cost-breakdown demonstrated that OR costs typically comprised close to 50%, or more, of hospital admission costs. This review also demonstrates that decreasing OR time by 30 min provides cost savings approximately equivalent to a 1-day reduction in ward time. Conclusion: This literature review provided a comprehensive assessment of hospital costs across various surgical procedures, approaches, and geographical regions. Our findings indicate that novel processes and healthcare technologies that aim to reduce resources such as operating time and hospital stay, can potentially provide resource savings for hospital payers.

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

Introduction

Video-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.

Methods

Patients ≥ 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.

Results

The 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.

Conclusion

In 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.

Funding

Johnson & Johnson.

Electronic supplementary material

The online version of this article (10.1007/s12325-018-0679-z) contains supplementary material, which is available to authorized users.

Evaluation of hospitalization costs and associated factors among maternity stays involving low-risk and moderate- to high-risk childbirths in the United States

OBJECTIVES

This study aimed to assess the costs of childbirth and to identify factors associated with such hospital costs for low- and moderate/high-risk childbirth groups.

METHODS

All hospitalizations for childbirth between 2010-2014 in the Premier Perspective Hospital Database were identified. Risk category for each birth was defined by the age of the subject and/or presence of specific maternal comorbidities and obstetric risk factors. Hospital childbirth costs were determined and stratified by risk groups. Factors associated with costs for each risk group were evaluated by multiple regression.

RESULTS

Among 2,367,195 hospitalizations for childbirth, vaginal birth was the most common delivery method (n = 1,596,757; 68%). Among women characterized as moderate/high-risk, 42% (n = 642,495) had C-sections, while 11% (n = 90,211) of women categorized as low-risk had C-sections. The proportion of women with serious maternal morbidity among moderate/high-risk vs. low-risk women was 2% (n = 29,496) vs. 0.3% (n = 2749), respectively. The mean costs for moderate/high-risk vs. low-risk hospitalizations were $6145 (median = $5760) and $5397 (median = $5001), respectively (p < 0.0001). Factors significantly associated with costs for moderate/high-risk hospitalizations included delivery type (C-section vs. vaginal birth), LOS, urban/rural hospital status, geographic regions, calendar year of hospitalization, teaching status, payer types and serious maternal morbidity. Similar factors were found to impact costs among low-risk hospitalizations.

CONCLUSIONS

Characteristics such as delivery type, LOS, geographical region, teaching status, serious maternal morbidity and hospital urban/rural status were shown to impact hospital costs of childbirth. Screening and prevention strategies of factors that negatively impact costs may aid in reducing the hospitalization costs associated with childbirths.