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Background: Malignant pleural effusion (MPE) is a common cancer complication. Clinical and economic implications of different recurrent MPE treatment pathways have not been evaluated fully., Research Question: What clinical outcomes, complications, health care resource use, and costs are associated with various rapidly recurrent MPE treatment pathways?, Study Design and Methods: This retrospective cohort study using Surveillance, Epidemiology and End Results Medicare data (2011-2015) included patients 66 to 90 years of age with rapidly recurrent MPE. Rapid recurrence was defined as receipt of a second pleural procedure within 14 days of the first thoracentesis, including nondefinitive repeated thoracentesis or a definitive treatment option including chest tube, indwelling pleural catheter (IPC), or thoracoscopy., Results: Among 8,378 patients with MPE, 3,090 patients (36.9%) had rapidly recurrent MPE (mean ± SD age, 75.9 ± 6.6 years; 45.6% male; primary cancer, 62.9% lung and 37.1% other). Second pleural procedures were nondefinitive thoracentesis (62.3%), chest tube (17.1%), IPC (13.2%), or thoracoscopy (7.4%). A third pleural procedure was required more frequently if the second pleural procedure was nondefinitive thoracentesis vs chest tube placement, IPC placement, or thoracoscopy (70.3% vs 44.1% vs 17.9% vs 14.4%, respectively). The mean number of subsequent pleural procedures over the patient's lifetime varied significantly among the procedures (1.74, 0.82, 0.31, and 0.22 procedures for patients receiving thoracentesis, chest tube, IPC, and thoracoscopy, respectively; P < .05). Average total costs after the second pleural procedure to death adjusted for age at primary cancer diagnosis, race, year of second pleural procedure, Charlson comorbidity index, cancer stage at primary diagnosis, and time from primary cancer diagnosis to diagnostic thoracentesis were lower with IPC ($37,443; P < .0001) or chest tube placement ($40,627; P = .004) vs thoracentesis ($47,711). Patients receiving thoracoscopy ($45,386; P = .5) incurred similar costs as patients receiving thoracentesis., Interpretation: Early definitive treatment was associated with fewer subsequent procedures and lower costs in patients with rapidly recurrent MPE., Competing Interests: Financial/Nonfinancial Disclosures The authors have reported to CHEST the following: C. G., M. J., M. W., S. X., A. T., and E. E. are employees of Becton, Dickinson, and Company. D. E. O. is a consultant for Becton, Dickinson, and Company, and author for UpToDate, on the test writing committee for the American Board of Internal Medicine, and an intuitive surgical consultant for Johnson and Johnson., (Copyright © 2024 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.)

Background: Long-term clinical outcomes of catheter ablation (CA) compared to thoracoscopic surgical ablation (SA) to treat patients with long-standing persistent atrial fibrillation (LSPAF) are not known., Objective: The purpose of this study was to compare the long-term (36-month) clinical efficacy, quality of life, and cost-effectiveness of SA and CA in LSPAF., Methods: Participants were followed up for 3 years using implantable loop recorders and questionnaires to assess the change in quality of life. Intention-to-treat analyses were used to report the findings., Results: Of the 115 patients with LSPAF treated, 104 (90.4%) completed 36-month follow-up [CA: n = 57 (95%); SA: n = 47 (85%)]. After a single procedure without antiarrhythmic drugs, 7 patients (12%) in the CA arm and 5 (11%) in the SA arm [hazard ratio 1.22; 95% confidence interval (CI) 0.81-1.83; P = .41] were free from atrial fibrillation/tachycardia (AF/AT) ≥30 seconds at 36 months. Thirty-three patients (58%) in the CA arm and 26 (55%) in the SA arm (hazard ratio 1.04; 95% CI 0.57-1.88; P = .91) had their AF/AT burden reduced by ≥75%. The overall impact on health-related quality of life was similar, with mean quality-adjusted life year estimates of 2.45 (95% CI 2.31-2.59) for CA and 2.32 (95% CI 2.13-2.52) for SA. Estimated costs were higher for SA (mean £24,682; 95% CI £21,746-£27,618) than for CA (mean £18,002; 95% CI £15,422-£20,581)., Conclusion: In symptomatic LSPAF, CA and SA were equally effective at achieving arrhythmia outcomes (freedom from AF/AT ≥30 seconds and ≥75% burden reduction) after a single procedure without antiarrhythmic drugs. However, SA is significantly more costly than CA., Competing Interests: Disclosures The authors have no conflicts of interest to disclose., (Crown Copyright © 2024. Published by Elsevier Inc. All rights reserved.)

Minimally invasive procedures have seen increasing utilization in the pediatric patient population since the 1990s. Most thoracic and abdominal operations in pediatric surgery can be performed in a minimally invasive manner including those performed in neonates and infants. Thoracoscopic or laparoscopic operations can reduce hospital length of stay, minimize postoperative pain, and lead to more aesthetic results. However, it is important to be aware of the inherent risks, limitations, and adverse effects associated with these thoracoscopic and laparoscopic techniques, particularly in special populations. In this article, we will review the risks and limitations of laparoscopy in pediatric patients such as cost, operative time, reduced effectiveness, air embolism, hypercarbia, hypothermia, and access-related injuries., Competing Interests: None declared., (Georg Thieme Verlag KG Stuttgart · New York.)

Background: Malignant pleural effusion (MPE) poses a considerable healthcare burden, but little is known about trends in directly attributable hospital utilization., Objective: We aimed to study national trends in healthcare utilization and outcomes among hospitalized MPE patients., Methods: We analyzed adult hospitalizations attributable to MPE using the Healthcare Cost and Utilization Project - National Inpatient Sample (HCUP-NIS) databases from 2004, 2009, and 2014. Cases were included if MPE was coded as the principal admission diagnosis or if unspecified pleural effusion was coded as the principal admission diagnosis in the setting of metastatic cancer. Annual hospitalizations were estimated for the entire US hospital population using discharge weights. Length of stay (LOS), hospital charges, and hospital mortality were also estimated., Results: We analyzed 92,034 hospital discharges spanning a decade (2004-2014). Yearly hospitalizations steadily decreased from 38,865 to 23,965 during this time frame, the mean LOS decreased from 7.7 to 6.3 days, and the adjusted hospital mortality decreased from 7.9 to 4.5% (p = 0.00 for all trend analyses). The number of pleurodesis procedures also decreased over time (p = 0.00). The mean inflation-adjusted charge per hospitalization rose from USD 41,252 to USD 56,951, but fewer hospitalizations drove the total annual charges down from USD 1.51 billion to USD 1.37 billion (p = 0.00 for both analyses)., Conclusions: The burden of hospital-based resource utilization associated with MPE has decreased over time, with a reduction in attributable hospitalizations by one third in the span of 1 decade. Correspondingly, the number of inpatient pleurodesis procedures has decreased during this time frame., (© 2020 S. Karger AG, Basel.)

Purpose: This study aims to compare the effects and prognosis of medical thoracoscopy-assisted argon plasma coagulation (APC) combined with electrosurgical unit (ESU) surgery, video-assisted thoracic surgery (VATS), and pleurodesis surgery, in providing appropriate treatment for elderly refractory pneumothorax patients., Methods: Patients with refractory pneumothorax aged over 65 years were divided into three groups: APC combined with ESU (N = 20), VATS (N = 26), and pleurodesis (N = 24). Data on demographic characteristics, lung function evaluation, and short- and long-term prognoses were collected., Results: Following surgery, compared with the APC-ESU and pleurodesis groups, patients in the VATS group demonstrated poor short-term prognoses, with high pleural effusion drainage levels and high visual analog scores (VAS; P <0.05). After the surgery, St. George's Respiratory Questionnaire (SGRQ) scores in the pleurodesis group were slightly elevated, whereas SGRQ scores in both the APC-ESU and VATS groups demonstrated a continual decrease. Finally, medical resource consumption analysis demonstrated a significant difference in hospitalization costs among the three groups; the VATS group being the most expensive., Conclusion: Medical thoracoscopy-assisted APC combined with ESU is a safe, effective, and affordable treatment for elderly patients with refractory pneumothorax.

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.

The use of the robotic platform is increasingly being utilized for lung resections. Our aim was to compare outcomes of thoracoscopic (VATS) versus robotic-assisted thoracoscopic (RATS) lobectomy early in a program's adoption of robotic surgery, including perioperative outcomes, cost, and long-term quality of life. A prospective database was retrospectively reviewed for all patients undergoing minimally invasive lobectomy by either VATS or RATS techniques from 2010 to 2012. Patients' operative, post-operative complications, cost (operating room and hospital) and quality of life were compared between the two resection techniques. Long-term follow-up including assessment using the European Organization for Research and Treatment of Cancer quality of life questionnaire was documented. During the first 25 RATS lobectomies, there were 73 VATS lobectomies performed, for a total of 98 cases. There was no significant difference in cancer stage, operative time, estimated blood loss, lymph node count, or hospital length of stay. The RATS resections had significantly higher operative and total hospital cost (p < 0.0001 and p < 0.05). At a median of 65-month follow-up, 29 patients (9 robotic; 20 VATS) completed the EORTC questionnaire. The global health status and symptom scale median scores were similar to the general population and did not significantly differ between groups. While transitioning from thoracoscopic to robotic lobectomy incurs increased operative and total hospital cost, equivalent operative outcomes, length of hospitalization, and long-term quality of life can be maintained during this transition. With increasing patient and surgeon interest in robotic resection, it appears both safe and feasible to adopt this approach while maintaining outcomes.

Thoracoscopy in the endoscopy suite, has a high diagnostic yield of undiagnosed pleural effusions with minimal and mild complications. Whereas relatively minimal invasive techniques, such as thoracentesis, image-guided pleural biopsy or blind pleural biopsy, can yield sufficient cell or tissue material to establish the diagnosis of the underlying condition, more definite invasive diagnostic and therapeutic procedure, such as thoracoscopy, may be required for accurate sampling and diagnosis, and further provide real-time treatment options in same procedure. If thoracoscopy is considered the gold standard for the diagnosis is a fact in case. The current review aims to provide informations on thoracoscopy indications in benign pleural diseases according to up to date publications., (© 2018 John Wiley & Sons Ltd.)

Background: The study aim is to compare the diagnostic yield, safety, and cost of outpatient awake thoracoscopy (AT) with video-assisted thoracoscopic surgery (VATS) pleural biopsy in undiagnosed pleural effusions., Methods: The diagnostic yield of pleural biopsy performed by AT or VATS in patients with undiagnosed exudative pleural effusions at a tertiary thoracic surgery center in Canada between 2011 and 2015 was retrospectively evaluated. Test sensitivity, specificity, positive predictive value, and negative predictive value were compared. Procedure safety, hospital length of stay, additional pleural-based interventions, and procedure-related costs were compared., Results: Patients underwent either AT (n = 78) or VATS (n = 99) during the study period. Sensitivity, specificity, positive predictive value, and negative predictive value were 85%, 100%, 100%, and 79% for AT and 93%, 94%, 99%, and 76% for VATS, with no significant difference in diagnostic test performance. There was no difference in the rate of major complications (2 AT [2.6%] versus 4 VATS [4.0%], p = 0.696), minor complications (14 AT [17.9%] versus 16 VATS [16.2%], p = 0.841) or need for additional pleural-based procedures (20 AT [25.6%] versus 18 VATS [18.2%], p = 0.270). The VATS was associated with longer median hospital stay (VATS 3 days [interquartile range: 1 to 4] versus AT 0 days [interquartile range: 0 to 1], z = 6.98, p < 0.001) and a higher procedure-related average cost (VATS Canadian dollars $7,962 [95% confidence interval: $7,134 to $8,790] versus AT Canadian dollars $2,815 [95% confidence interval: $2,010 to $3,620], p < 0.001)., Conclusions: Awake thoracoscopy and VATS have similar diagnostic yield and safety profiles in the assessment of undiagnosed pleural effusions; however, AT is associated with shorter length of stay and lower average per-procedure cost. In the appropriate clinical setting, AT may be the diagnostic test of choice., (Copyright © 2018 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objective: Thoracoscopic esophagectomy (TSE), as a minimally invasive technique, has obtained wide acceptance for treating esophageal cancer. In this study, we report our experience of the transfer from open sweet esophagectomy (OSE) to TSE and compare cost associated with the two approaches for esophageal cancer., Patients and Methods: Data were taken through a retrospective review of operative outcomes, complications and cost of 91 patients who underwent OSE or TSE for esophageal cancer from January 2012 to June 2014., Results: Among 91 patients, 48 patients underwent TSE, and 43 patients underwent OSE. Patients dealt with TSE had significantly less blood loss (152 ml vs. 204 ml, P = 0.004), shorter chest drainage time (3.3 days vs. 4.5 days, P < 0.001), less patients admitted to the Intensive Care Unit after surgery (6.3% vs. 30.2%, P = 0.003), and lower incidence of respiratory complications (16.7% vs. 37.2%, P = 0.026). However, the operative time was statistically longer in TSE group (276.0 min vs. 207.4 min, P < 0.001). The total cost (¥61,817 vs. ¥48,712, P < 0.001) and the day of surgery cost (¥29,701 vs. ¥19,446, P < 0.001) were significantly higher in the TSE group., Conclusion: This study shows that TSE is a safe and acceptable alternative to OSE. TSE will be more competitive if its cost can be reduced., Competing Interests: There are no conflicts of interest

Background A minimally invasive approach to esophagectomy is being used increasingly, but concerns remain regarding the feasibility, safety, cost, and outcomes. We performed an analysis of the costs and benefits of minimally invasive, hybrid, and open esophagectomy approaches for esophageal cancer surgery. Methods The data of 83 consecutive patients who underwent a McKeown's esophagectomy at Prince of Songkla University Hospital between January 2008 and December 2014 were analyzed. Open esophagectomy was performed in 54 patients, minimally invasive esophagectomy in 13, and hybrid esophagectomy in 16. There were no differences in patient characteristics among the 3 groups Minimally invasive esophagectomy was undertaken via a thoracoscopic-laparoscopic approach, hybrid esophagectomy via a thoracoscopic-laparotomy approach, and open esophagectomy by a thoracotomy-laparotomy approach. Results Minimally invasive esophagectomy required a longer operative time than hybrid or open esophagectomy ( p = 0.02), but these patients reported less postoperative pain ( p = 0.01). There were no significant differences in blood loss, intensive care unit stay, hospital stay, or postoperative complications among the 3 groups. Minimally invasive esophagectomy incurred higher operative and surgical material costs than hybrid or open esophagectomy ( p = 0.01), but there were no significant differences in inpatient care and total hospital costs. Conclusion Minimally invasive esophagectomy resulted in the least postoperative pain but the greatest operative cost and longest operative time. Open esophagectomy was associated with the lowest operative cost and shortest operative time but the most postoperative pain. Hybrid esophagectomy had a shorter learning curve while sharing the advantages of minimally invasive esophagectomy.

Aim: To estimate cost-effectiveness of botulinum toxin therapy for axillary hyperhidrosis compared to the standard surgical intervention of endoscopic thoracic sympathectomy (ETS)., Methods: The validated dermatology life quality index questionnaire was given to patients attending for treatment over a 4 month period, to assess their quality of life (QoL) over the preceding week (n = 44). Follow-up was performed 4-6 weeks later by telephone using the same questionnaire to validate the effectiveness of the treatment. The duration of effect of the botulinum toxin treatment was also recorded and this data was used as the basis for cost effectiveness analysis. Using HIPE data, the baseline cost for single intervention using botulinum toxin and ETS was retrieved. Using figures provided by HIPE and expert opinion of the costs of complications, a stochastic model for 10,000 patients was used to evaluate the total costs for ETS including the complications., Results: The results from the QoL analysis show that botulinum toxin therapy is a successful therapy for improvement of symptoms. It was revealed that the mean interval before recurrence of original symptoms after botulinum toxin therapy was 5.6 months. The baseline cost for both treatments are €389 for botulinum toxin and €9389 for uncomplicated ETS. The stochastic model yields a mean cost of €11,390 for ETS including complications., Conclusions: Treatments reached cost equivalence after 13.3 years. However, given the efficacy of the botulinum toxin therapy and the low risk we propose that botulinum toxin therapy for hyperhidrosis should be considered the gold standard., (Copyright © 2015 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved.)

Purpose: We sought to determine factors influencing survival and resource utilization in patients undergoing surgical resection of congenital lung malformations (CLM). Additionally, we used propensity score-matched analysis (PSMA) to compare these outcomes for thoracoscopic versus open surgical approaches., Methods: Kids' Inpatient Database (1997-2009) was used to identify congenital pulmonary airway malformation (CPAM) and pulmonary sequestration (PS) patients undergoing resection. Open and thoracoscopic CPAM resections were compared using PSMA., Results: 1547 cases comprised the cohort. In-hospital survival was 97%. Mortality was higher in small vs. large hospitals, p<0.005. Survival, pneumothorax (PTX), and thoracoscopic procedure rates were higher, while transfusion rates and length of stay (LOS) were lower, in children ≥3 vs. <3months (p<0.001). Multivariate analysis demonstrated longer LOS for older patients and Medicaid patients (all p<0.005). Total charges (TC) were higher for Western U.S., older children, and Medicaid patients (p<0.02). PSMA for thoracoscopy vs. thoracotomy in CPAM patients showed no difference in outcomes., Conclusion: CLM resections have high associated survival. Children <3months of age had higher rates of thoracotomy, transfusion, and mortality. Socioeconomic status, age, and region were independent indicators for resource utilization. Extent of resection was an independent prognostic indicator for in-hospital survival. On PSMA, thoracoscopic resection does not affect outcomes., (Copyright © 2016. Published by Elsevier Inc.)

Background: Deep muscle relaxation has been shown to facilitate operating conditions during laparoscopic surgery. Minimally invasive esophageal surgery is a high-risk procedure in which the use of deep neuromuscular block (NMB) may improve conditions in the thoracic phase as well. Neuromuscular antagonists can be given on demand or by continuous infusion (deep NMB). However, the positioning of the patient often hampers train-of-four (TOF) monitoring. A continuous infusion thus may result in a deep NMB at the end of surgery. The use of neostigmine not only is insufficient for reversing deep NMB but also may be contraindicated for this procedure because of its cholinergic effects. Sugammadex is an effective alternative but is rather expensive. This study aims to evaluate the use of deep versus on-demand NMB on operating, anaesthesiologic conditions, and costs in patients undergoing a two- or three-phase thoracolaparoscopic esophageal resection., Methods/design: We will conduct a single-center randomized controlled double-blinded intervention study. Sixty-six patients undergoing a thoracolaparoscopic esophageal resection will be included. Patients will receive either continuous infusion of rocuronium 0.6 mg/kg per hour (group 1) or continuous infusion of NaCl 0.9 % 0.06 ml/kg per hour (group 2). In both groups, on-demand boluses of rocuronium can be given (open-label design). The primary aim of this study is to compare the surgical rating scale (SRS) during the abdominal phase. Main secondary aims are to evaluate SRS during the thoracic phase, to evaluate anesthesiologic conditions, and to compare costs (in euros) associated with use of rocuronium, sugammadex, and duration of surgery., Discussion: This study is the first to evaluate the benefits of deep neuromuscular relaxation on surgical and anaesthesiologic conditions during thoracolaparoscopic esophageal surgery. This surgical procedure is unique because it consists of both an abdominal phase and a thoracic phase taking place in different order depending on the subtype of surgery (a two- or three-stage transthoracic esophagectomy). In addition, possible benefits associated with deep NMB, such as decrease in operating time, will be weighed against costs., Trial Registration: European Clinical Trials Database (EudraCT) number: 2014-002147-18 (obtained 19 May 2014) ClinicalTrials.gov: NCT02320734 (obtained 18 Dec. 2014).

Background: In recent years, Da Vinci robot system applied in the treatment of intrathoracic surgery mediastinal diseases become more mature. The aim of this study is to summarize the clinical data about mediastinal lesions of General Hospital of Shenyang Military Region in the past 4 years, then to analyze the treatment effect and promising applications of da Vinci robot system in the surgical treatment of mediastinal lesions., Methods: 203 cases of mediastinal lesions were collected from General Hospital of Shenyang Military Region between 2010 and 2013. These patients were divided into two groups da Vinci and video-assisted thoracoscopic surgery (VATS) according to the selection of the treatments. The time in surgery, intraoperative blood loss, postoperative drainage amount within three days after surgery, the period of bearing drainage tubes, hospital stays and hospitalization expense were then compared., Results: All patients were successfully operated, the postoperative recovery is good and there is no perioperative death. The different of the time in surgery between two groups is Robots group 82 (20-320) min and thoracoscopic group 89 (35-360) min (P>0.05). The intraoperative blood loss between two groups is robot group 10 (1-100) mL and thoracoscopic group 50 (3-1,500) mL. The postoperative drainage amount within three days after surgery between two groups is robot group 215 (0-2,220) mL and thoracoscopic group 350 (50-1,810) mL. The period of bearing drainage tubes after surgery between two groups is robot group 3 (0-10) d and thoracoscopic group: 5 (1-18) d. The difference of hospital stays between two groups is robot group 7 (2-15) d and thoracoscopic group 9 (2-50) d. The hospitalization expense between two groups is robot group (18,983.6±4,461.2) RMB and thoracoscopic group (9,351.9±2,076.3) RMB (All P<0.001)., Conclusions: The da Vinci robot system is safe and efficient in the treatment of mediastinal lesions compared with video-assisted thoracoscopic approach, even though its expense is higher.

Aim: To compare outcomes of thoracoscopic clipping (TC) versus transcatheter occlusion (TO) for patent ductus arteriosus (PDA)., Patients and Methods: One hundred patients were enrolled in the study from May 2010 to December 2011. Those patients were randomized into 2 groups: group one received TC, group two received TO., Result: There were no significant differences concerning width or length of the ductus (P>0.05). However the median age and median weight of patients in the TO group were greater than in the TC group (P<0.05). Mean operative time was 32 ± 12 min in the TC group versus 20 ± 3 min in the TO group (P<0.05). There were no deaths in either group. There were no complications in the TC group whereas three patients in the TO group had complications and required subsequent operation. Median postoperative stay was 3.5 days (IQR: 3.0-4.3) in the TC group versus 3 days (IQR: 2.0-4.0) in the TO group (P<0.05). There was no residual shunting in either group. Average cost for one patient was $645 ± 232 in the TC group versus $1,260 ± 204 in the TO group (P<0.001)., Conclusion: Thoracoscopic clipping is safer than transcatheter occlusion for PDA repair, with the same effectiveness and lower cost., (© 2014.)

Background: For esophageal cancer patients, radical esophagolymphadenectomy is the cornerstone of multimodality treatment with curative intent. Transthoracic esophagectomy is the preferred surgical approach worldwide allowing for en-bloc resection of the tumor with the surrounding lymph nodes. However, the percentage of cardiopulmonary complications associated with the transthoracic approach is high (50 to 70%).Recent studies have shown that robot-assisted minimally invasive thoraco-laparoscopic esophagectomy (RATE) is at least equivalent to the open transthoracic approach for esophageal cancer in terms of short-term oncological outcomes. RATE was accompanied with reduced blood loss, shorter ICU stay and improved lymph node retrieval compared with open esophagectomy, and the pulmonary complication rate, hospital stay and perioperative mortality were comparable. The objective is to evaluate the efficacy, risks, quality of life and cost-effectiveness of RATE as an alternative to open transthoracic esophagectomy for treatment of esophageal cancer., Methods/design: This is an investigator-initiated and investigator-driven monocenter randomized controlled parallel-group, superiority trial. All adult patients (age ≥ 18 and ≤ 80 years) with histologically proven, surgically resectable (cT1-4a, N0-3, M0) esophageal carcinoma of the intrathoracic esophagus and with European Clinical Oncology Group performance status 0, 1 or 2 will be assessed for eligibility and included after obtaining informed consent. Patients (n = 112) with resectable esophageal cancer are randomized in the outpatient department to either RATE (n = 56) or open three-stage transthoracic esophageal resection (n = 56). The primary outcome of this study is the percentage of overall complications (grade 2 and higher) as stated by the modified Clavien-Dindo classification of surgical complications., Discussion: This is the first randomized controlled trial designed to compare RATE with open transthoracic esophagectomy as surgical treatment for resectable esophageal cancer. If our hypothesis is proven correct, RATE will result in a lower percentage of postoperative complications, lower blood loss, and shorter hospital stay, but with at least similar oncologic outcomes and better postoperative quality of life compared with open transthoracic esophagectomy. The study started in January 2012. Follow-up will be 5 years. Short-term results will be analyzed and published after discharge of the last randomized patient., Trial Registration: Dutch trial register: NTR3291 ClinicalTrial.gov: NCT01544790.

Objective: Assessing the cost-effectiveness of open or thoracoscopic thymectomy compared to medical therapy in managing myasthenia gravis not associated with thymoma., Methods: A Markov model was designed for evaluating three strategies' cost-effectiveness. Transition probabilities were taken from the pertinent literature; the costs were estimated from official tariff manuals. Incremental cost-effectiveness ratios were estimated and probabilistic and deterministic sensitivity analysis was used for clinical variables, costs and the model's assumptions., Results: Thoracoscopic thymectomy was the most effective and least costly strategy and dominated the other two alternatives. The cost per life year gained was Col $ 1 129 531 without discount and Col $ 805 179 with discount. Univariate sensitivity analysis showed that the main variables affecting the results were the effects' discount rate, the cost of a myasthenic crisis and the probability of complete remission. Thoracoscopy thymectomy was the most cost-effective strategy for different thresholds of willingness to pay in probabilistic analysis., Conclusions: Thoracoscopic thymectomy is a cost-effective strategy in the treatment of MG without thymoma.

Background: Major pulmonary resections for early-stage non-small-cell lung cancer (NSCLC) are increasingly being performed by thoracoscopy, but there are economic concerns related to the use of many disposable items and increased operative time. We evaluated and compared the costs of thoracoscopic lobectomy versus open lobectomy., Methods: Data from all patients who underwent lobectomy for clinical stage I NSCLC from January 1, 2007, to December 31, 2009 were reviewed. Two hundred eighty-seven major pulmonary resections (269 lobectomies and 18 anatomic segmentectomies) for NSCLC were performed: 98 cases via a totally endoscopic approach (TS) and 189 via a classical posterolateral thoracotomy (PLT). Direct medical costs [hospital stay, intensive care unit (ICU) stay, disposables, theatre time, laboratory, and radiology costs] were evaluated., Results: Patient demographics were similar in both groups. The two groups did not differ in histology, pathologic stage, or type of lobectomy. There were no differences in postoperative complications or readmissions during the 30-day postoperative period; however, patients in the TS group had significantly fewer chest tube days and shorter hospital length of stay (p < 0.001). Theatre costs were significantly higher in the TS group [2,861 ± 458 vs. 2,260 ± 399 (p < 0.001)]. Mean cost for disposables for TS was 1,800 ± 560.46 vs. 901 ± 328 for PLT (p < 0.001). Thoracoscopic upper-right lobectomy and anatomic segmentectomy were more expensive than other thoracoscopic lobectomies. Mean costs for hospital stay, laboratory, and radiological services for TS were less than for PLT (p < 0.001), although mean ICU stay was similar in both groups. Finally, overall costs were significantly greater for the PLT group (14,145.57 ± 7,117.84) than for the TS group (11,934.13 ± 6,690.25) (p < 0.001)., Conclusion: Thoracoscopic lobectomy was less expensive than open lobectomy for patients with early-stage NSCLC. Although thoracoscopic lobectomy has a higher initial cost, overall cost is less expensive due to a shorter hospital stay.

Medical pleuroscopy (MP) offers a safe and minimally invasive tool for interventional pulmonologists. It allows diagnosis of unexplained effusion, while at the same time allowing drainage and pleurodesis. It can also help in the diagnosis of diffuse interstitial disease or associated peripheral lung abnormality in the presence of effusion. It can have a therapeutic role in pneumothorax and hyperhidrosis or chronic pancreatic pain. This article reviews the technical aspects and range of applications of MP., (Copyright 2010 Elsevier Inc. All rights reserved.)

Background: Excisional biopsy of small subcentimeter pulmonary nodules can be difficult using standard thoracoscopic techniques and may require thoracotomy. Radiotracer-guided thoracoscopic resection (RGTR) was developed to facilitate resection of intraparenchymal subcentimeter pulmonary nodules. Decision analysis, used to model cost and effectiveness, is useful to compare treatment options. We hypothesize that RGTR strategy is more cost-effective compared with thoracotomy for subcentimeter pulmonary nodules., Methods: The cost-effectiveness of RGTR versus thoracotomy for evaluating highly suspicious subcentimeter pulmonary nodules was examined with a decision analysis model (Fig 1). A 40-patient institutional cohort who underwent RGTR was used to estimate probabilities and costs of the two treatment options within the model. Effectiveness was estimated using 5-year, stage-specific cancer survival and population survival curves. The Society of Thoracic Surgeons General Thoracic Database was queried obtaining mortality estimates for thoracotomy and thoracoscopic wedge resections. These were used to adjust the 5-year survival estimates of patients with benign disease. Sensitivity analyses determined model robustness and the thresholds at which the most cost-effective strategy changed., Results: Radiotracer-guided thoracoscopic resection was 95% successful with no mortality. The average cost-to-effectiveness ratio of RGTR strategy was $27,887 versus $32,271 for thoracotomy. Sensitivity analyses demonstrated that the thoracotomy strategy was more cost-effective if the estimated cost of RGTR increased by 33% or the estimated cost-effectiveness of thoracotomy decreased by 14% or more. Radiotracer-guided thoracoscopic resection was more cost-effective as long as the probability of success was greater than 44%., Conclusions: Decision analysis is a useful tool to evaluate treatment options for thoracic surgeons, and RGTR is a more cost-effective strategy than thoracotomy for subcentimeter pulmonary nodules.

Background: Thoracoscopy is highly sensitive and accurate for detecting pleural effusions. However, most respiratory physicians are not familiar with the use of the more common rigid thoracoscope or the flexible bronchoscope, which is difficult to manipulate within the pleural cavity. The semi-rigid thoracoscope combines the best features of the flexible and rigid instruments. Since the practice with this instrument is limited in China, the diagnostic utility of semi-rigid thoracoscopy (namely medical thoracoscopy) under local anesthesia for undiagnosed exudative pleural effusions was evaluated., Methods: In 50 patients with undiagnosed pleural effusions who were studied retrospectively, 23 received routine examinations between July 2004 and June 2005 and the rest 27 patients underwent medical thoracoscopy during July 2005 and June 2006. Routine examinations of the pleural effusions involved biochemistry and cytology, sputum cytology, and thoracentesis. The difference in diagnostic sensitivity, costs related to pleural fluid examination and complications were compared directly between the two groups., Results: Medical thoracoscopy revealed tuberculous pleurisy in 6 patients, adenocarcinoma in 7, squamous-cell carcinoma in 2, metastatic carcinoma in 3, mesothelioma in 2, non-Hodgkin's lymphoma in 1, and others in 4. Only 2 patients could not get definite diagnoses. Diagnostic efficiency of medical thoracoscopy was 93% (25/27). Only 21% patients were diagnosed after routine examinations, including parapneumonic effusion in 2 patients, lung cancer in 2 and undetermined metastatic malignancy in 1. Twelve patients with tuberculous pleurisy were suspected by routine examination. Costs related to pleural effusion testing showed no difference between the two groups (P=0.114). Twenty-three patients in the routine examination group underwent 97 times of thoracentesis. Two pleural infection patients and 2 pneumothorax patients were identified and received antibiotic treatment and drainage. Medical thoracoscopy could be well tolerated by all the patients. The semi-rigid thoracoscope could be easily controlled by chest physicians. The most common complication was transient chest pain (20 of 27 patients) from the indwelling chest tube, which would be managed with conventional analgesics. One case of subcutaneous emphysema and 2 cases of postoperative fever were self-limiting. No severe complications occurred., Conclusions: Medical thoracoscopy is a simple, safe, and cost-effective tool, with a high positive rate. Physicians should extend its access to proper patients if the facilities for medical thoracoscopy are available.

Background: Currently, few data exist regarding the relative costs associated with open and minimally invasive pectus excavatum repair. The aim of this study was to compare the surgical and hospitalization costs for these two surgical techniques and to identify factors responsible for cost differences., Methods: A retrospective review of hospital charts, patient and parent questionnaires, and hospital accounting records was performed for 68 patients who underwent surgical correction of pectus excavatum between June 1996 and December 1999., Results: In this series, 25 patients underwent open repair, whereas 43 patients underwent minimally invasive repair of pectus excavatum (MIRPE). The patient ages ranged from 4 to 19 years. The average ages for open repair (12 years) and MIRPE (11 years) did not differ significantly. As compared with open repair, MIRPE was associated with a 27% lower overall cost of hospitalization ( p < 0.05). The operating room costs were 12% higher for the patients who underwent MIRPE ( p < 0.05). The mean operative time for open repair was 3 h 15 min, whereas MIRPE required 1 h 10 min ( p < 0.001). The hospital stay for open repair averaged 4.4 days, as compared with 2.4 days for MIRPE ( p < 0.001). In contrast to other published series, the postoperative analgesia after MIRPE in this series consisted of narcotics, ketorolac, and methocarbamol. No patient received epidural analgesia, regardless of the repair technique selected. The postoperative complication rate was 4% in the open group and 14% in the MIRPE group. Most of the patients treated with either open or MIRPE reported postoperative oral narcotic usage for 2 weeks or less and returned to routine activities within 3 weeks. The patients and parents alike reported good to excellent overall outcomes in 85% or more of the open repair cases and 90% or more of the MIRPE cases., Conclusions: These data demonstrate for the first time that the use of an alternate pain management strategy including, narcotics, NSAIDs, and methocarbamol, but without epidural catheters, results in reduced hospital length of stay and decreased overall hospitalization costs for MIRPE, as compared with open pectus repair. This cost benefit was achieved without compromising pain management or patient satisfaction with surgical care.

Objective: Port-access coronary bypass grafting (CABG)was performed in an attempt to impact the clinical course of patients with coronary artery disease., Methods: One hundred patients (56 men and 44 women) with a median age of 61 years underwent port-access coronary revascularization. The clinical and financial profiles of these patients were compared with fiscal year 1997 patients (n = 531) who underwent standard median sternotomy coronary bypass., Results: Preoperative clinical demographics were similar in both groups of patients. Among the port-access population there were no incidences of aortic dissection, deep vein thrombosis, conversion to median sternotomy, or death. Total time in the Intensive Care Unit (ICU), incidence of atrial fibrillation, transfusion requirements, and (subjective) pain rating at 28 days postoperatively were less in the port-access group. The average hospital cost per case was $2703.00 (US dollars) more in the port-access patients, despite a similar length of stay versus conventional sternotomy patients., Conclusions: Coronary bypass surgery can be performed safely with port-access technology with significant clinical benefits in selected patients. Currently these benefits are attained at a significant cost to the institution.

It remains unknown whether it is better to perform lung volume reduction surgery (LVRS) through video-assisted thoracoscopy (VATS) or sternotomy. This study compares both approaches in terms of surgical and patient outcomes as well as the associated costs. All patients undergoing LVRS from 1995 to 1997 at one institution by a single surgeon (PFW) were investigated. Preoperative, postoperative, and cost data were obtained from medical and financial records. A total of 42 patients with severe emphysema underwent LVRS (19 via sternotomy and 23 via thoracoscopy). Both groups were comparable preoperatively. Comparison of intraoperative times revealed VATS takes longer to perform (sternotomy, 118 +/- 29 minutes; thoracoscopy, 168 +/- 20 minutes). Postoperatively, the sternotomy patients had more days on the ventilator, more days in the intensive care unit, more days with an air leak, and longer hospital stays. In both groups, the majority of patients reported improvement in oxygen dependence as well as quality of life. Neither surgical approach conferred any long-term medical advantage; however, the average total hospital costs and charges were reduced in the VATS group (average cost: VATS, $27,178; sternotomy, $37,299). This study concludes that 1) LVRS seems to be beneficial for selected patients with end-stage emphysema; 2) postoperative morbidity and length of hospital stay are decreased in the VATS group; 3) long-term improvement in postoperative pulmonary function is not influenced by surgical approach; and 4) the overall charges and costs of the VATS approach is less than that of sternotomy.

Background: The endoscopic treatment of spinal lesions in the thoracolumbar junction (T11-L2) poses a great challenge to the surgeon. From November 1, 1995 to December 31, 1996, we successfully used a combination of video-assisted thoracoscopy and conventional spinal instruments to treat 38 patients with anterior spinal lesions. Twelve of them had lesions in the thoracolumbar junction., Methods: The so-called extended manipulating channel method was used to perform vertebral biopsy, discectomy, decompressive corpectomy, interbody fusions, and/or internal fixations in these patients. The size of the thoracoscopic portals was greater than usual in order to allow conventional spinal instruments and a thoracoscope to enter the chest cavity freely and be manipulated by techniques similar to those used in standard open surgical procedures. In this series, the procedures were performed by using either a three-portal approach (2. 5-3.5 cm) or a modified two-portal technique involving a 5-6 cm larger incision and a small one for introducing the scope., Results: None of the operations resulted in injury to the great vessels, internal organs, or spinal cord. The total time for the operation ranged from 1.5 to 4.5 h (average, 3); and the total blood loss ranged from 50 to 3000 cc (average, 1050). One patient was converted to an open procedure due to severe pleural adhesion. Complications included two instances of transient intercostal neuralgia, one superfical wound infection, and one residual pneumothorax., Conclusions: The video-assisted technique with the extended manipulating channel method presented in this report simplifies thoracoscopic spinal surgery in the thoracolumbar junction and makes it easier. It avoids division of the diaphragm, removal of the rib, and wide spread of the intercostal space, and it allows greater control of intraoperative vessel bleeding. Using this technique, the number of portals required during the procedure can be reduced. In addition, the technique reduces the endoscopic materials required, thus lowering overall cost. It is an effective and promising approach.

Background: Surgical procedures for emphysema have been proposed and in many settings resulted in significant improvement in dyspnea and function. The most prevalent surgical problem in all series is prolonged postoperative air leak., Methods: One hundred twenty-three patients undergoing stapled thoracoscopic unilateral lung volume reduction operation were prospectively randomized to receive either no buttressing of their staple lines or buttressing of all staple lines with bovine pericardial strips., Results: The two groups were comparable in preoperative risks and in the severity of their emphysema. Postoperative complications were identical in the two groups with respect to pneumonia, empyema, and wound infection; however, there was a significant difference in the duration of postoperative air leaks. Those having the pericardial strips used to buttress their staple lines had chest tubes removed 2.5 days sooner and were discharged from the hospital 2.8 days sooner as a result. The cost data revealed that because of the cost of the pericardial sleeves, the overall hospital charges were almost identical for the two groups ($22,108 bovine, $22,060 no bovine) in spite of the shortened hospital stay., Conclusions: The use of bovine pericardial sleeves to buttress the staple lines in thoracoscopic unilateral lung volume reduction operation results in a shorter duration of postoperative air leaks. Total hospital charges were comparable in the two groups as the 2.8 days saved in the hospital were offset by the cost of the pericardial sleeves.

Background: Video-assisted thoracoscopic surgery (VATS) is now an established approach in the management of many thoracic conditions. However, the high cost of this new technology has deterred many Asian hospitals from widely applying this technique., Methods: This article describes our strategies to reduce cost in our practice of VATS over the last few years., Results: VATS involves (1) careful patient selection, (2) use of conventional thoracic instruments as much as possible, (3) modification of conventional instruments, (4) limited use of expensive consumables, and (5) development and application of endoscopic suturing technique., Conclusions: VATS is still in evolution. Cost containment, while desirable in the West, is a high priority in Asia if this new surgical approach is to be applicable even in developing countries. More research is greatly needed in this area.

The aim of this study was to analyse differences in efficacy and costs in treating first time or recurrent spontaneous pneumothorax by conservative therapy (pleural drainage or observation) and video-assisted thoracoscopic surgery (VATS). Retrospectively, 112 patients treated by conservative therapy during 1985-1989 (Period 1) were compared with 97 patients treated by VATS during 1991-1994 (Period 2). Mean follow-up time in each period was more than 2 yrs. Patients in both periods had comparable clinical characteristics. Irrespective of first time or recurrent spontaneous pneumothorax at presentation, drainage and hospitalization times were longer, and complication and recurrence rates were higher in Period 1. When costs due to the waiting time before VATS were excluded, the total costs in Period 1 were higher than in Period 2. Video-assisted thoracoscopic surgery is more effective in treating patients with first time or recurrent spontaneous pneumothorax, with less morbidity and total costs compared to conservative therapy. In view of cost-effectiveness, we feel that a different management of first time or recurrent spontaneous pneumothorax is not justified.

We investigated the role of routine video-assisted thoracoscopy (VAT) prior to thoracotomy. From June 1993 to May 1995, we routinely performed VAT prior to all our elective thoracotomies in adults. Patients who planned to have video-assisted thoracic surgery (VATS), those who underwent emergency thoracotomy, and patients younger than 10 years old were excluded from this study. There were 63 patients (47 men and 16 women; age range, 16 to 84 years), of whom 39 (62%) had malignant disease and 24 (38%) had benign disease. In four cases, VAT could not be performed because of either pleural symphysis or inability to adequately collapse the upper lung. In six cases, thoracoscopic findings influenced subsequent management. Pleural metastases were found in two cases that led to abandonment of thoracotomy; in four cases, identification of chest wall involvement by a malignant or benign process led to proper planning of subsequent thoracotomy. There was no added morbidity from this procedure which took, on average, 6.2 min to complete (range, 3 to 17 min). There was no added cost for consumables. We concluded that: (1) routine VAT is a safe procedure; (2) it adds little to the overall cost or operating time; (3) it can provide useful information that could alter subsequent operative strategy. We recommend routine VAT prior to thoracotomy in patients with known or suspected intrathoracic malignancy and those suspected of having chest wall involvement on CT scans.

Objective: Video-assisted thoracoscopic surgery (VATS) represents at present the most suitable treatment of recurrent spontaneous pneumothorax. After three years we consider this interesting to draw up a trial balance of our VATS experience in comparison with the cases treated before 1991 with the classic thoracotomic approach., Methods: We have considered retrospectively the results obtained in a series of 30 consecutive patients with recurrent spontaneous pneumothorax treated with VATS between November 1991 and August 1994 in comparison with those obtained in a group of 30 patients previously treated with a traditional thoracotomy. The groups have been selected in such a way that surgical indications, sex ratio, age and number of episodes were homogeneous. The parameters we have compared were the postoperative complications, the duration of chest drainage and hospitalization, the operating times and the relapses. Besides these technical parameters we considered the economic data too., Results: On average drains removal occurred one day before in VATS-Group: the time spent in the Hospital was significantly shorter in VATS-Group, being on average 1 week. Short term complications may be considered similar in the two Groups. Prolonged air leaks occurred in 13% and 16% respectively. Emothorax requesting reoperation occurred in 1 case for each Group. One death occurred in thoracotomy-Group in an old patient presenting a severe chronic respiratory insufficience with exacerbation in postoperative time. We have registered 2 relapses after VATS and none after thoracotomy., Conclusions: The study has demonstrated the therapeutic efficacy of VATS and in the same time that in VATS the total economic cost is lower (22.7%) in comparison with traditional thoracotomy.

The current status of video-assisted thoracoscopic surgery (VATS) of the lung has been reviewed. The published data support the view that VATS pulmonary surgery is feasible and safe. It is associated with decreased perioperative pain and opiate requirement, better postoperative pulmonary function, and probable overall neutral cost impact. A VATS approach is functionally superior to open thoracotomy for wedge resection, pneumothorax surgery and bullous lung disease and may allow surgical intervention in patients with pulmonary function which is in adequate for open resection. Major VATS pulmonary resection with lobectomy and pneumonectomy can be performed for early malignant disease without compromising established surgical principles. Specific training is needed in VATS surgery and background skills in general thoracic surgery are necessary to underwrite major interventions. Decreased cytokine activation and enhanced post surgical immune function may prove to be long-term benefits of VATS surgery.

The authors have developed a technique of thoracoscopic closure of patent ductus arteriosus (PDA) that significantly reduces the surgical morbidity, recovery time, and hospital costs traditionally associated with the standard open procedure. Ten patients have undergone the procedure, with nine completed successfully. One patient required conversion to an open thoracotomy. There were no operative complications, and closure of the ductus was confirmed in all cases with a postoperative echocardiogram. Eight of ten patients were discharged in under 24 hours, and hospital charges were on the average 30% to 40% less.

The role of laparoscopy and thoracoscopy as diagnostic modalities in blunt and penetrating abdominal trauma was studied in 35 hemodynamically stable patients who otherwise would have undergone exploratory laparotomy because of equivocal diagnostic findings. Minimally invasive laparoscopic techniques (single 5 millimeter port) and minimal abdominal insufflation (8-10 millimeters mercury) were used with general anesthesia. Both laparoscopy and thoracoscopy appear to be safe (no complications), highly sensitive (100%), specific (88%), and accurate (91%) tools for determining the presence of surgically significant abdominal pathology and the need for therapeutic laparotomy. The appropriate application of these techniques, possibly under local anesthesia, offers potential cost savings.

Proliferation in the use of video-assisted thoracic surgery (VATS) has occurred without data demonstrating benefit. Few studies have critically compared VATS with limited thoracotomy (LT) in homogeneous patient populations undergoing standardized procedures. We retrospectively reviewed the hospital records of 37 consecutive patients referred for elective lung biopsy as part of an ongoing interstitial lung disease protocol to determine whether VATS improved outcome or reduced costs. Sixteen patients underwent VATS, and 21 patients underwent LT lung biopsy over a 31 month period. The two groups were homogeneous in regard to clinical symptoms, radiologic findings, age, sex, and preoperative pulmonary function. The operative mortality was not different between the two groups (VATS, 0/16, and LT, 1/21). The postoperative stay was 4.8 +/- 1.0 days for VATS and 5.0 +/- 0.5 days for LT (p = not significant). Operating time, number of specimens obtained, chest tube output, and day of chest tube removal did not differ. There was no difference in the amount of analgesics required during the postoperative period. Operating room cost for VATS was significantly greater than that for LT ($2,663 +/- $384 versus $1,801 +/- $94; p = 0.04) despite the use of nondisposable equipment. Anesthesia-related costs were also greater for VATS ($309 +/- $11 versus $244 +/- $15; p = 0.002). In conclusion, lung biopsy in patients with interstitial lung disease can be performed safely and efficiently with either VATS or LT, but VATS results in higher procedure-related costs.

Background: Video assisted thoracoscopic lung biopsies were compared with historical controls undergoing open lung biopsy to determine the diagnostic accuracy, effect on length of postoperative stay, and cost effectiveness of the new thoracoscopic technique., Methods: The first 25 video assisted thoracoscopic lung biopsies performed in the Edinburgh Thoracic Unit were compared with 25 historical controls for complications, diagnostic accuracy, and length of postoperative stay., Results: Statistical comparison showed equal diagnostic accuracy in both groups (96% v 92%), but mean (SD) inpatient stay was reduced in the video assisted thoracoscopic group (1.4 (0.7) days) compared with those undergoing open lung biopsy (3.1 (1.8) days). No postoperative complications were reported in the group which underwent video assisted thoracoscopic lung biopsies but three patients had postoperative complications in the open lung biopsy group., Conclusions: Video assisted thoracoscopic lung biopsy is as effective in providing histological diagnosis as is open lung biopsy. All postoperative complications were related to post thoracotomy pain and occurred only in patients undergoing open lung biopsy. Reduced postoperative disability in the video assisted thoracoscopic group decreased hospital stay, offsetting the increased cost in disposables. The overall cost of video assisted thoracoscopic and open lung biopsy was 712 pounds and 1114 pounds, respectively.

Video-assisted thoracic surgery (VATS) procedures are now being performed with increasing frequency. The instrumentation and video equipment continue to evolve and much of this new technology is expensive. We reviewed our experience with VATS in our most recent 150 cases for the purpose of cost analysis. The costs incurred in patients undergoing VATS wedge resection for nodules (n = 45) were compared with those in similar patients having wedge resection using open techniques (n = 31). We found that patients who undergo open resections were more likely to spend time in the intensive care unit after surgery. The anesthesia costs were similar in the two groups. Disposable instrument costs were $623 higher for VATS resection; however, the operative time was shorter (101.4 minutes for VATS versus 122.5 minutes for the open procedure), making the total operating room costs comparable. The length of hospital stay was shorter after VATS resection (4.4 days for VATS versus 6.5 days for the open procedure), resulting in lower total hospital charges in the VATS group; however, this difference was not statistically significant. The cost of a VATS wedge resection for removing peripheral nodules is competitive with that of open techniques. Additional benefits, such as reduced pain, shorter operating times, and decreased hospital stays, make thoracoscopy a valuable diagnostic tool. The length of hospital stay, operating room time, disposable instrument costs, complications, and patient acuity all have an impact on the total costs and vary for different procedures. The operative time has shortened and the use of disposable instrumentation has lessened as our experience with thoracoscopy has increased.(ABSTRACT TRUNCATED AT 250 WORDS)

Video-assisted thoracoscopy has recently evolved as an alternative to thoracotomy for several thoracic disorders. Spontaneous pneumothorax may be ideally suited for thoracoscopic management. Stapling of apical blebs and pleurodesis or pleurectomy can now be performed thoracoscopically in a fashion identical to the standard operation done through a lateral or axillary thoracotomy. We compared our results with thoracoscopic management of spontaneous pneumothorax in 26 patients (group I) with a group of 20 patients previously subjected to axillary thoracotomy (group II). Indications for operation, sex distribution, and average age (group I, 32.3 years; group II, 33.7 years) were comparable. Hospital stay was less in group I (2.88 +/- 0.99 days versus 4.47 +/- 1.07 days; p = 0.07), as was the use of parenteral narcotics after 48 hours (2/26 = 7.7% versus 14/20 = 70%; p = 0.01). There have been no recurrences to date (mean follow-up, 8 months) in the thoracoscopic group. Video-assisted thoracoscopic management of spontaneous pneumothorax allows performance of the standard surgical procedure while avoiding the thoracotomy incision. Video-assisted thoracoscopic management is safe and offers the potential benefits of shorter hospital stays and less pain.