Procedure costs associated with the use of Harmonic devices compared to conventional techniques in various surgeries: a systematic review and meta-analysis

A Retrospective Study of Transaxillary Endoscopic Breast Augmentation Using Ultrasonic Scalpel or Conventional Electrocautery for Implant Pocket Dissection

BACKGROUND

Ultrasonic scalpel has been reported to be superior to conventional electrocautery in many studies. However, with respect to transaxillary endoscopic breast augmentation, few studies on the effect of ultrasonic scalpel are available in the literature.

METHODS

The medical records of 173 female patients who underwent breast augmentation via endoscopic transaxillary approach from January 2018 to December 2020 were reviewed retrospectively. The patients were divided into two groups according to the implant pocket dissection instruments. In group A, the implant pockets were dissected with conventional electrocautery (EC group) on 81 patients, and in group B, ultrasonic scalpel (US group) was used for implant pockets on 92 patients. All operations were performed by the same senior plastic surgeon and the same surgical team. The operation time, intraoperative blood loss, postoperative total drainage volume, days of drainage, postoperative surgical site pain and hospital stay time of the two groups were compared and analyzed statistically.

RESULTS

The average operation time of the US group (83.82 ± 11.57 min) was significantly shorter than that of the EC group (101.40 ± 14.36 min), intraoperative blood loss in the US group was significantly less than that of the EC group (18.67 ± 6.20 ml vs. 21.59 ± 6.44 ml), the mean hospital stay days (2.96 ± 0.69 vs. 4.30 ± 1.11), total drainage volume (122.24 ± 43.81 vs. 232.37 ± 99.15), and duration of drain (2.52 ± 0.54 vs. 3.77 ± 1.10), mean VAS score for surgical site pain on 3 postoperative days (5.08 ± 1.35 vs. 6.51 ± 1.36, 4.08 ± 1.16 vs. 5.40 ± 1.32, 3.04 ± 0.91 vs. 4.06 ± 1.11) were significantly lower in the US group compared to the EC group.

CONCLUSIONS

The ultrasonic scalpel reduces operative time, intraoperative blood loss, postoperative drainage, postoperative pain, hospital stay time, and incidence of complications. The ultrasonic scalpel is safe and reliable for transaxillary endoscopic breast augmentation.

LEVEL OF EVIDENCE IV

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An umbrella review of the surgical performance of Harmonic ultrasonic devices and impact on patient outcomes

BACKGROUND

For thirty years, the Harmonic scalpel has been used for precise dissection, sealing and transection. There are numerous meta-analyses on individual surgical procedures with Harmonic, but no overarching review covering all the areas. This umbrella review seeks to summarize the clinical results from the use of Harmonic across surgical fields and broadly quantify its effects on patient outcomes.

METHODS

MEDLINE, EMBASE, and Cochrane Databases were searched for meta-analyses (MAs) of randomized controlled trials (RCTs) comparing Harmonic devices to conventional techniques or advanced bipolar (ABP) devices. For each procedure type, the most comprehensive MAs were evaluated. RCTs not already analysed in a MA were also included. Operating time, length of stay, intraoperative blood loss, drainage volume, pain, and overall complications were evaluated, and the methodological quality and certainty of evidence were assessed.

RESULTS

Twenty-four systematic literature reviews were identified on colectomy, hemorrhoidectomy, gastrectomy, mastectomy, flap harvesting, cholecystectomy, thyroidectomy, tonsillectomy, and neck dissection. There were also 83 RCTs included. In every MA evaluated, Harmonic devices were associated with either statistically significant or numerical improvements in every outcome compared with conventional techniques; most MAs reported a reduction in operating time of ≥ 25 min. Harmonic versus ABP device MAs in colectomy and thyroidectomy showed no significant differences in outcomes.

CONCLUSION

Across surgical procedures, Harmonic devices demonstrated improved patient outcomes for operating time, length of stay, intraoperative bleeding, drainage volume, pain, and overall complications compared to conventional techniques. Additional studies are required to assess differences between Harmonic and ABP devices.

Budget impact analysis of HARMONIC FOCUS™+ Shears for mastectomy and breast-conserving surgery with axillary lymph node dissection compared with monopolar electrocautery from an Italian hospital perspective

Background

Mastectomy or breast conserving surgery, both with axillary lymph node dissection, are common treatments for early-stage breast cancer. Monopolar electrocautery is typically used for both procedures, despite evidence of improved clinical outcomes with HARMONIC FOCUS™+. This analysis evaluated the budget impact of adopting HARMONIC FOCUS™+ versus monopolar electrocautery for patients undergoing these procedures from an Italian hospital perspective.

Methods

Total costs for an annual caseload of 100 patients undergoing mastectomy or breast conserving surgery, with axillary lymph node dissection, with either the intervention or comparator were calculated. Italian clinical and cost input data were utilised. The analysis included costs for the device, operating room time, postoperative length of stay, treating seroma and managing postoperative chest wall drainage. Deterministic and probabilistic sensitivity analyses assessed uncertainty of model input values. Two scenario analyses investigated the impact of conservative estimates of postoperative length of stay reduction and daily hospital cost on the simulated cost difference.

Results

HARMONIC FOCUS™+ achieves annual savings of EUR 100,043 compared with monopolar electrocautery, derived from lower costs for operating room time, postoperative length of stay and seroma and postoperative chest wall drainage management, offsetting the incremental device cost increase (EUR 43,268). Cost savings are maintained in scenario analyses and across all variations in parameters in deterministic sensitivity analysis, with postoperative hospital stay costs being key drivers of budget impact. The mean (interquartile range) cost savings with HARMONIC FOCUS™+ versus monopolar electrocautery in probabilistic sensitivity analysis are EUR 101,637 (EUR 64,390–137,093) with a 98% probability of being cost saving.

Conclusions

The intervention demonstrates robust cost savings compared with monopolar electrocautery for mastectomy or breast conserving surgery, with axillary lymph node dissection, in an Italian hospital setting, and improved clinical and resource outcomes. These findings, with other clinical and cost analyses, support HARMONIC FOCUS™+ use in this setting.

Common haemostatic techniques used in surgical practice

Intraoperative bleeding can be difficult to manage and is associated with worse patient outcomes. Good intraoperative haemostasis by the surgeon is a key factor in ensuring a bloodless field and reducing intraoperative blood loss. There is a myriad of mechanical, thermal and energy-based techniques available to use, each of which has their own benefits and drawbacks. The decision of which to use will depend on patient and procedural factors as well as the surgeon's preference. This article reviews techniques commonly used in surgical practice to maintain intraoperative haemostasis.

A device category economic model of electrosurgery technologies across procedure types: a U.S. hospital budget impact analysis

AIMS

The electrosurgical technology category is used widely, with a diverse spectrum of devices designed for different surgical needs. Historically, hospitals are supplied with electrosurgical devices from several manufacturers, and those devices are often evaluated separately; it may be more efficient to evaluate the category holistically. This study assessed the health economic impact of adopting an electrosurgical device-category from a single manufacturer.

METHODS

A budget impact model was developed from a U.S. hospital perspective. The uptake of electrosurgical devices from EES (Ethicon Electrosurgery), including ultrasonic, advanced bipolar, smoke evacuators, and reusable dispersive electrodes were compared with similar MED (Medical Energy Devices) from multiple manufacturers. It was assumed that an average hospital performed 10,000 annual procedures 80% of which involved electrosurgery. Current utilization assumed 100% MED use, including advanced energy, conventional smoke mitigation options (e.g. ventilation, masks), and single-use disposable dispersive electrode devices. Future utilization assumed 100% EES use, including advanced energy devices, smoke evacuators (i.e. 80% uptake), and reusable dispersive electrodes. Surgical specialties included colorectal, bariatric, gynecology, thoracic and general surgery. Systematic reviews, network meta-analyses, and meta-regressions informed operating room (OR) time, hospital stay, and transfusion model inputs. Costs were assigned to model parameters, and price parity was assumed for advanced energy devices. The costs of disposables for dispersive electrodes and smoke-evacuators were included.

RESULTS

The base-case analysis, which assessed the adoption of EES instead of MED for an average U.S. hospital predicted an annual savings of $824,760 ($101 per procedure). Savings were attributable to associated reductions with EES in OR time, days of hospital stay, and volume of disposable electrodes. Sensitivity analyses were consistent with these base-case findings.

CONCLUSIONS

Category-wide adoption of electrosurgical devices from a single manufacturer demonstrated economic advantages compared with disaggregated product uptake. Future research should focus on informing comparisons of innovative electrosurgical devices.

Energy vessel sealant devices are associated with decreased risk of neck hematoma after thyroid surgery

Postoperative neck hematomas following thyroidectomy occur in up to 6.5% of cases. It is unclear whether the use of energy vessel sealant devices effects the rate of PNH. We hypothesized use of an EVSD to be associated with decreased risk of PNH in patients undergoing thyroidectomy. The 2016-2017 American College of Surgeons Thyroidectomy database was queried for patients undergoing thyroidectomy with and without EVSDs. A multivariable logistic regression analysis was performed to evaluate for risk of PNH. From 11,355 patients undergoing thyroidectomy, an EVSD was used for 7460 (65.7%) patients. Age distribution was similar between the two groups (52 vs. 53-years old, p = 0.467). Compared to patients without EVSD used, patients with EVSD used had higher rates of comorbid hypertension (40.6% vs. 34.8%, p < 0.001) and diabetes (14.2% vs. 11.5%, p < 0.001); however, a lower rate of PNH (1.4% vs. 2.4%, p < 0.001). After adjusting for known risk factors for PNH including age, prior neck surgery, and comorbidities, EVSD use was associated with a decreased risk of PNH (OR 0.453, 95% CI 0.330-0.620, p < 0.001). The strongest associated risk factors for PNH were hypertension (OR 1.823, 95% CI 1.283-2.591, p = 0.001) and toxic goiter (OR 1.837, 95% CI 1.144-2.949, p = 0.012). When compared to standard vessel ligation, EVSD use was associated with a lower risk of PNH in patients undergoing thyroidectomy. The strongest associated risk factor for PNH was toxic goiter. Future prospective research is needed to confirm these findings and if corroborated, then increased use of an EVSD should be employed.

Retrospective Study on the Clinical Superiority of the Vacuum-Assisted Closure System with a Silicon-based Dressing over the Conventional Tie-over Bolster Technique in Skin Graft Fixation

Background and Objectives: The tie-over bolster technique has been conventionally used for skin graft fixation; however, long operative times and postoperative pain are the main disadvantages of this method. In this study, we introduce a new method using vacuum-assisted closure (VAC) with a silicon-based dressing as an alternative for skin graft fixation. This retrospective study aimed to evaluate the clinical effect of the VAC plus silicon-based dressing method and the conventional tie-over bolster technique for skin graft fixation in terms of pain, operative time, and skin graft take rate. Materials and Methods: Sixty patients who underwent skin graft surgery performed by a single surgeon from January 2017 to October 2018 were included in this clinical study. They were divided into two groups based on the type of treatment: tie-over bolster technique and vacuum-assisted closure (VAC), or silicon-based dressing groups. The operative times were recorded twice (during suturing or stapling of the graft and during removal of the dressing) in the two groups; similarly, pain was assessed using a numeric rating scale (NRS) after surgery and during dressing removal. Skin graft take rate was evaluated two weeks after dressing removal. Results: Twenty-six patients who met the eligibility criteria were enrolled into the study and assigned to one of the two groups (n = 13 each). No significant differences in age, gender, and graft area were noted between the two groups of patients. The VAC plus silicon-based dressing group demonstrated higher skin graft take rates (p < 0.05), shorter operation times (p < 0.05), and lower levels of pain (postoperative pain and pain during dressing removal) compared with the tie-over bolster technique group (p < 0.05). Conclusions: These findings indicate that VAC with silicon-based dressing can be used for skin graft fixation due to its superior properties when compared with the conventional method, and can improve the quality of life of patients undergoing skin graft fixation.

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.

A budget impact analysis of a magnetic sphincter augmentation device for the treatment of medication-refractory mechanical gastroesophageal reflux disease: a United States payer perspective

BACKGROUND

Medication-refractory gastroesophageal reflux disease (GERD) is sometimes treated with laparoscopic Nissen fundoplication (LNF); however, this is a non-reversible procedure associated with important side effects and the need for repeat surgery. Removable magnetic sphincter augmentation (MSA) devices are an alternative, effective, and safe treatment option for such patients who have some lower esophageal sphincter function. The objective of this study was to assess the economic impact of introducing MSA technology (i.e., LINX Reflux Management System) into current practice from a US-payer perspective.

METHODS

An economic budget impact model was developed over a 1-year time horizon that compared current treatment of GERD patients who are medically managed (but refractory) or receiving LNF to future treatment of GERD patients that included a mix of patients treated with medical management only, LNF, or MSA. Resources included within the analyses were index procedures (inpatient and outpatient use), reoperations (revisions and removals), readmissions, healthcare visits, diagnostic tests, procedures, and medications. Medicare payment rates were typically used to inform unit costs.

RESULTS

Assuming a hypothetical commercial insurance population of 1 million members, the base-case analysis estimated a net cost savings of $111,367 with introduction of the MSA. This translates to a savings of $0.01 per member per month. Results were largely driven by avoided inpatient procedures with use of the MSA device. Alternative analyses exploring the potential impact of increasing surgical volumes predicted that results would remain cost saving if the proportion of MSA market share taken from LNF was ≥ 90%.

CONCLUSIONS

This study predicts that the introduction of the MSA device would lead to favorable budget impact results for the treatment of medication-refractory mechanical GERD for commercial payers. Future analyses will benefit from inclusion of middle-ground treatments as well as longer time horizons.