A Retrospective Database Analysis

Transcription

1 CHEST Original Research LUNG CANCER In-hospital Clinical and Economic Consequences of Pulmonary Wedge Resections for Cancer Using Video-Assisted Thoracoscopic Techniques vs Traditional Open Resections A Retrospective Database Analysis John A. Howington, MD, FCCP ; Candace L. Gunnarsson, EdD ; Michael A. Maddaus, MD ; Robert J. McKenna, MD ; Bryan F. Meyers, MD, FCCP ; Daniel Miller, MD ; Matthew Moore, MHA ; John A. Rizzo, PhD ; and Scott Swanson, MD Objective: The objective of this study was to compare the safety, use, and cost profiles of open thoracotomy vs video-assisted thoracoscopic surgery (VATS) for wedge resection in lung cancer performed by thoracic surgeons in the United States. Methods: The Premier database, which contains complete patient billing, hospital cost, and coding histories from. 25 million inpatient discharges and. 175 million hospital outpatient visits, was used for this analysis. Eligible patients were those who underwent wedge resection by a thoracic surgeon for cancer diagnosis or treatment through open thoracotomy or VATS in 2007 or Multivariable logistic regression analyses were run for binary outcomes, and ordinary least squares regressions were used for continuous outcomes. All models were adjusted for patient demographics, comorbid conditions, and hospital characteristics. Results: Of 8,228 eligible procedures, 2,051 patients underwent wedge resections by a thoracic surgeon using the open technique (n 5 999) or VATS (n 5 1,052). Hospital costs remained significantly higher for open wedge resections than for VATS ($17,377 vs $14,795, P 5.000). Surgery time was significantly longer for open resections vs VATS (3.16 vs 2.82 h). Length of stay was 6.34 days for open vs 4.44 days for VATS. Adverse events were significant in the multivariable analysis, with an OR of 1.57 (95% CI, ) in favor of VATS. Conclusions: Although this retrospective database analysis could not address the issue of oncologic outcome equivalence, a clear advantage of VATS over open wedge lung cancer resection was found for both acute clinical outcomes and hospital costs. CHEST 2012; 141(2): Abbreviations: APR-DRG 5 all-patient refined diagnosis-related group; ICD-9-CM 5 International Classification of Diseases, Ninth Revision, Clinical Modification; VATS 5 video-assisted thoracoscopic surgery Lung surgery for purposes of diagnosis or treatment has evolved over the past 2 decades. Historically, surgery involving the lung was accomplished using one of two main procedures, depending on the clinical indication: by a thoracoscope inserted through a small incision or by an open thoracotomy involving a larger incision and rib spreading to improve visibility and access for control of the surgical field. Thoracotomy long predates thoracoscopy. The newer thoracoscopy approach gained appeal because it was less invasive and found increased indications for procedures that had been previously managed through a larger thoracic incision. Thoracoscopic procedures typically were reserved for obtaining diagnostic biopsy specimens, excisions of small solitary peripheral lesions, or pleurodesis for palliation of recurrent pleural effusions. In contrast, open thoracotomies were performed for more extensive procedures, such as wedge resection or lobectomy, often with therapeutic intent in severe emphysema or cancer. CHEST / 141 / 2 / FEBRUARY,

2 Thoracoscopic procedures have been transformed by the ongoing refinement of video-assisted thoracoscopic surgery (VATS) techniques and equipment, particularly high-definition cameras and monitors. Thoracoscopic procedures are now rarely performed without the aid of video assistance, 1 yet video-assisted techniques have been slower to adopt in traditional thoracotomy settings, such as deep wedge resections, segmentectomy, and lobectomy. For traditional thoracotomy indications, VATS is an evolving technique that is increasingly applied in situations where traditional open thoracotomy has long been used. There is a small, but growing amount of literature to support the use of VATS in this context. 2-6 Variations in the number of port incisions; incision length; use of ribspreaders; anatomic approach (posterolateral, anterior, axillary), with or without muscle sparing; use of staples alone vs buttressing with collagen or bovine pericardium; and use of robot enhancement all lack standardization in any definition of VATS. The literature published to date lists the purported benefits of VATS in lung surgery as smaller incisions, less pain, less blood loss, less respiratory compromise, and faster recovery times, all translating into shortened hospital lengths of stay and superior survival rates. 7 The downside of VATS includes high costs of equipment, longer operating room times, steep learning curves for surgeons and operating room personnel, and uncertain oncologic control when performed in cancer settings. 8 To assess the current use of VATS in wedge resections for lung cancer indications, we analyzed realworld data from a large, nationally representative database of hospital claims data. The primary objec- Manuscript received November 22, 2010; revision accepted July 1, Affiliations: From the Divisions of Thoracic Surgery and Surgical Quality (Dr Howington), NorthShore University Health System, Evanston, IL; S 2 Statistical Solutions, Inc (Dr Gunnarsson), Cincinnati, OH; Division of Thoracic Surgery (Dr Maddaus), University of Minnesota, Duluth, MN; Division of Thoracic Surgery (Dr McKenna), Cedars-Sinai Medical Center, Los Angeles, CA; Division of Cardiothoracic Surgery (Dr Meyers), Washington University, St. Louis, MO; Division of Thoracic Surgery (Dr Miller), Emory Clinic, Atlanta, GA; Healthcare Policy and Economics (Mr Moore), Ethicon Endo-Surgery, Inc, Cincinnati, OH; Departments of Preventive Medicine and Economics (Dr Rizzo), Stony Brook University, Stony Brook, NY; and Division of Minimally Invasive Thoracic Surgery (Dr Swanson), Brigham and Women s Hospital and the Dana Farber Cancer Institute, Boston, MA. Funding/support: Funding for this study was provided by Ethicon Endo-Surgery, Inc, Cincinnati, Ohio. Correspondence to: Candace L. Gunnarsson, EdD, S 2 Statistical Solutions, Inc, Main St, Cincinnati, OH 45241; Candaceg@s2stats.com. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians ( site/misc/reprints.xhtml ). DOI: /chest tives of our analysis were to assess and compare the safety, use, and cost profiles of VATS vs open thoracotomy for wedge resection in lung cancer performed by thoracic surgeons. Materials and Methods A protocol describing the analysis objectives, criteria for patient selection, data elements of interest, and statistical methods was submitted to the New England Institutional Review Board, and exemption was obtained on August 27, 2009 (approval number ). Data Source The Premier Perspective database, which contains clinical and utilization information on patients receiving care in. 600 US hospitals and ambulatory surgery centers across the nation was used. 9 Specifically, this database contains complete patient billing, hospital cost, and coding histories from. 25 million inpatient discharges and. 175 million hospital outpatient visits. Upon receiving data from participating hospitals, Premier performs an extensive sevenpart data validation and correction process with. 95 qualityassurance checks. Once all validations are complete, data are moved to the Perspective data warehouse to populate and maintain the databases for health services research. Patient diagnosis and procedures in the Premier database are coded using the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) classification system. Because VATS for lung cancer treatment is a newer technology, with VATS-specific codes available starting in 2007, only procedures from 2007 to 2008 were used, with all data anonymized by Premier with regard to patient identifiers. Patients and Procedures Eligible patients were those of any age undergoing wedge resection by a thoracic surgeon for cancer diagnosis or treatment through VATS methods or open thoracotomy. The rationale for these stringent inclusion criteria was to reduce variation in the sample. Brand of equipment was not a criterion for eligibility, and this level of detail is not available in the Premier Perspective database. ICD-9-CM diagnosis and procedure codes for identifying the wedge resection procedures, cancer diagnoses, comorbid conditions, and all adverse events are listed in e-appendixes 1 through 4. The patient selection process necessarily excluded patients who had a wedge resection by either method during this time period but in whom histology was benign. Statistical Analyses Initial counts, percentages, means, and SDs for patient demographics, comorbid conditions, hospital characteristics, and safety, utilization, and cost outcomes were summarized for open wedge resection and VATS groups using descriptive statistics. Safety outcomes of interest were selected from adverse events occurring during or up to 30 days after surgery. Procedure-specific complications grouped into six major categories can be found in e-appendix 3. Utilization outcomes were surgery time (hours) and hospital length of stay (days). Cost outcomes were total hospital costs per patient, both fixed and variable, but did not include initial capital cost or amortization of nondisposable equipment necessary for the VATS procedures. Univariate analyses were run using x 2 techniques to compare adverse event frequencies between the two comparison groups 430 Original Research

3 (open wedge resection vs VATS). Multivariable logistic regression analyses were run for binary outcomes, such as adverse events and categorical length of stay ( 14 days vs, 14 days). Ordinary least squares regressions were used for continuous outcomes, such as hospital costs, surgery time, and length of stay. For all models, the following explanatory variables were included for open and VATS wedge resection: age, sex, race, marital status, insurance type, diagnosis (metastasis vs primary cancer), comorbid conditions (eg, diabetes [see e-appendix 4 for a list of comorbidities]), allpatient refined diagnosis-related group (APR-DRG) severity index (an index of comorbidity unique to the Premier Perspective database), census region of hospital, rural vs urban hospitals, teaching vs nonteaching hospitals, and number of hospital beds. Using these explanatory variables, multivariable models were estimated to isolate the effects of open wedge resections vs VATS on hospital costs, surgery time, and length of stay. The precise control variables used in multivariable analyses are provided in Tables 1 through 3. Because the three dependent variables were right skewed, they were converted to natural logarithms to help normalize their distributions. Estimation was by ordinary least squares. Because of the logarithmic nature of the dependent variables, smearing estimates were used to obtain predicted values for hospital costs, surgery time, and length of stay. Furthermore, weights provided in the Premier database were used to transform the results in a manner that permitted generalizability to the US population. All analyses were performed using SAS, version 9.1 (SAS Institute, Inc) statistical software. Results Of 8,228 eligible procedures in the database with inpatient lung resections for lung cancer, 2,051 patients underwent wedge resections by a thoracic surgeon using either the open technique (n 5 999) or VATS (n 5 1,052). A patient attrition diagram is shown in Figure 1. As summarized in Table 1, characteristics of eligible patients show that there were slightly more women than men in both groups, and most patients in both groups were aged. 60 years and had Medicare insurance. Most patients in both groups were white, with primary (as opposed to metastatic) neoplasm of the lung and only minimal to moderate illness severity level according to the APR-DRG severity index. The groups appeared to be very well balanced overall, although in the open group there were slightly more primary cancers as well as Table 1 Patient Demographics Characteristics of Eligible Patients Open VATS P Value No. patients (% of N 52,051 ) 999 (0.48) 1,052 (0.51) Age, y Age group.513, 40 y y y y y y Race.002 White Black Hispanic Other Sex.680 Female Male Marital status.009 Married Unmarried Insurance type.096 Commercial Medicare Medicaid Managed Care Other Malignancy indication a Primary neoplasm of the lung Metastases from other primary malignancy Illness severity level.000 APR-DRG severity level 1, APR-DRG severity level 3, Data are presented as mean SD or percent. APR-DRG 5 all-patient refined diagnosis-related group; ICD-9-CM 5 International Classification of Diseases, Ninth Revision, Clinical Modification; VATS 5 video-assisted thoracic surgery. a All procedures are inpatient. Current Procedural Terminology and ICD-9-CM codes for lobectomies and resections are in e-appendix 1 and ICD-9-CM codes for lung cancer are in e-appendix 2. CHEST / 141 / 2 / FEBRUARY,

4 Figure 1. Attrition diagram. DB 5 database; Q3 5 quarter 3. slightly more patients with higher APR-DRG severity index scores. The distribution of specific patient comorbidities is shown in Table 2 and suggests that the higher APR- DRG severity index in the open group may be attributable to a slight excess of patients with cardiovascular disease (coronary artery disease and peripheral vascular disease) and COPD. These comorbid conditions were the most common in both groups along with diabetes mellitus. The pulmonary wedge resections studied were performed in 182 hospitals, with somewhat more performing open resections (n 5 170) than VATS resections (n 5 139) ( Table 3 ). Most procedures of both types, as well as most patients, derived from urban, nonteaching, moderate- to large-sized hospitals in the south. As noted previously, for patient distributions, hospital characteristics also were well balanced across comparison groups. Hospitals in the open group did not appear to differ from hospitals in the VATS group in terms of distribution of locations, size, or teaching status. Table 4 shows complication rates for each cohort. The most common complications in both groups were pulmonary, with significantly higher frequencies in the open group than in the VATS group. There were also more arrhythmias, bleeding episodes, and vascular/thromboembolic events in the open group than in the VATS group. Cardiac, neurologic, and wound complications were quite infrequent (, 2%) in both groups and did not differ significantly between them. Average hospital costs, surgery time, and length of hospital stay for each group were evaluated at the univariate level as well as group frequencies for all adverse events combined and particular events such as infections, persistent air leaks, RBC transfusions, and prolonged hospital stay. In all instances (ie, costs, time, and adverse events), the open group results exceeded those of the VATS group. Controlling for the observed differences in the VATS and open cohorts, multivariable analysis revealed operative technique (open vs VATS) to be an independent determinant of cost, operating room time, and length of stay. The results of these adjusted analyses as well as selected surgical complications are shown in Tables 5 and 6. Even after adjusting for the aforementioned variables, hospital costs remained significantly higher for open wedge resections than for VATS ($17,377 5,185 vs $14,795 4,415, P 5.000). Surgery time was significantly longer for open resections ( h) than for VATS ( h). The same was true for length of stay for open resections vs VATS ( days vs days). Table 2 Comorbid Conditions Existing for Patients Any Time During or Before Procedure Stay Comorbid Conditions Open VATS P Value No. patients 999 1,052 Myocardial infarction, acute or old Congestive heart failure Other chronic or unspecified heart failure Peripheral vascular disease Dementia Chronic pulmonary disease Connective tissue disease Liver disease Chronic viral hepatitis Renal insufficiency, chronic Diabetes mellitus Data are presented as percent, unless otherwise indicated. The present study only examined data from 2007 to 2008 due to the recent implementation of the VATS procedure-specific codes, which became available in ICD-9-CM codes for these variables are found in e-appendix 4. See Table 1 legend for expansion of abbreviation. 432 Original Research

5 Hospital Characteristics Table 3 Hospital Characteristics Hospitals (n 5 182) Adjusting for the multiple factors noted previously, the open technique was significantly associated with the composite of adverse events postoperatively (OR, 1.57; 95% CI, ) and, specifically, with increased RBC transfusion (OR, 1.88; 95% CI, ). However, adjusted differences in infections, air leaks, and prolonged lengths of stay were not significant. Discussion Patients (n 5 2,051) Open VATS Open VATS Total hospitals 170 (0.93) 139 (0.76) 999 (0.49) 1,052 (0.51) Census region Midwest Northeast South West Location Urban Not urban Type Teaching Nonteaching Bed count, Data are presented as percent, unless otherwise indicated. Note that the statistics test is only between patient data (between hospitals, overlapping sample). See Table 1 legend for expansion of abbreviation. In this retrospective analysis of a large, nationally representative database of hospitals and procedures, we observed that VATS wedge resections for lung cancer indications are now performed nearly as often as traditional open wedge resections. VATS wedge resections are associated with significantly shorter operative times, shorter lengths of stay, and lower hospital costs Table 4 Univariate Analysis for Adverse Event Categories Adverse Event Categories Open, % VATS, % P Valuea Arrhythmia Cardiac Hemorrhage Neurologic Pulmonary Wound Vascular/thromboembolic See e-appendix 3 for the individual definitions and ICD-9-CM diagnosis codes that make up each category of postoperative-specific compli cations. See Table 1 legend for expansion of abbreviation. a x 2 P value. than are open wedge resections for lung cancer indications. These differences persisted even after adjusting for potentially important differences in patient and hospital characteristics. Furthermore, for the composite and RBC transfusion categories of adverse events ( Table 6 ), the VATS group had significantly lower frequencies than the open group. Clinical Implications Today, thoracic surgeons have many choices in approach to diagnosing and treating lung cancer Thoracoscopy as a diagnostic tool for indeterminate pulmonary nodules has many advantages over open thoracotomy. The use of VATS has been proven to be highly sensitive, specific, and accurate in the diagnosis of indeterminate solitary lung nodules. The present study demonstrates an acute advantage of VATS but cannot address the issue of equivalence in terms of oncologic outcomes. Santambrogio and colleagues 13 performed a randomized trial comparing a VATS approach to the diagnosis of solitary pulmonary nodule with a musclesparing lateral thoracotomy in 44 patients treated between January 1991 and May The 22 patients in each arm of the trial were similar in age, comorbid conditions, and symptoms. All patients in each group had a final diagnosis made with no nondiagnostic results. The hospital stay was significantly shorter at days in the VATS group compared with days in the lateral thoracotomy group ( P,.01). These results match those seen in the current study. In addition, the visual analog pain score on postoperative day 6 was significantly less at in the VATS group compared with in the lateral thoracotomy group ( P,.05). Swanson and colleagues 14 confirmed the sensitivity and specificity of thoracoscopic resection of solitary pulmonary nodules approaches, reporting 100% in their prospective series of 65 patients. Chang and colleagues 15 reported on 62 ambulatory patients with indeterminate pulmonary nodules or interstitial lung disease undergoing thoracoscopic lung biopsy between June 2000 and June Forty-five patients (72.5%) were discharged home within 8 h of their operation. Fourteen patients (22.5%) were discharged within 23 h of their operation. Only three patients (5%) required admission for prolonged air leak (n 5 2) or conversion to a thoracotomy (n 51). One patient required readmission for a pneumothorax. There was no operative mortality in the study group. Outpatient thoracoscopic lung biopsy has become the procedure of choice in the diagnosis of interstitial or focal lung disease. Cardillo and colleagues 16 reported on the results of VATS biopsy for a solitary pulmonary nodule in 429 patients treated at a single CHEST / 141 / 2 / FEBRUARY,

6 Table 5 Multivariable Results for Cost and Utilization Dependent Variable No. Adjusted Outcome Hospital costs, $ Open , , , , Surgery time, h Open VATS Length of stay, d Open Data are presented as mean SD. All P values See Table 1 legend for expansion of abbreviation. institution from 1992 to No intraoperative complications were detected, and there were no perioperative deaths. Morbidity was low, and no wound infections were reported. The mean chest tube duration was 3.5 days, and the mean hospital stay was 4.6 days. Ninety-two percent of patients were able to return to work within 3 weeks following surgery. Over the past decade, more surgeons have become skilled in minimally invasive approaches to patients with lung cancer, and in turn, a greater percentage of lung cancer procedures have been approached with a minimally invasive technique. In the present cohort of patients in 2007 and 2008, the patient outcomes were better with VATS over open thoracotomy. Open thoracotomy has been in practice for a longer time than VATS approaches, suggesting that patient outcomes will improve further with increased experience and refinement of minimally invasive techniques and technologies. Clearly, patients with 1- to 2-cm lesions at the periphery of the lung should be approached with a minimally invasive technique for a wedge resection, and open thoracotomy should be reserved for those patients in whom the surgeon is unable to Table 6 Multivariable Results for Adverse Events Adverse Event Categories No. OR (95% CI) P Value Adverse event.000 Open ( ) Infections.051 Open ( ) Air leak.305 Open ( ) Transfusion.004 Open ( ) Length of stay 14 d.294 Open ( ) See Table 1 legend for expansion of abbreviation. identify the lesion or cleanly excise the lesion with a minimally invasive approach. Economic Implications The initial costs to hospitals to purchase and implement VATS equipment (eg, video and endoscopic equipment) have not been considered in this analysis. The cost of disposable instrumentation is presumably included in the total costs to the hospital per procedure and, thus, has been included in this analysis. It should be noted that soon after VATS was introduced, a study from the Mayo Clinic compared the cost of performing VATS pulmonary wedge resections with that of thoracotomy. 17 The VATS approach was associated not only with substantially shorter hospital stays but also with increased operating room costs. As a result, the use of VATS did not result in any significant overall savings. Since that study, however, as some VATS procedures (eg, pulmonary wedge resection) have become standard operations and more reusable instrumentation has become available, the cost of VATS has fallen. VATS techniques can be used in numerous types of surgical procedures, and to the extent that both clinical advantages and cost savings can be proven to accrue with VATS use across many different surgery types, the return on investment for hospitals is clear. The cost savings in the long run should be substantial for both hospitals and payers, and in this era of health-care reform, that is an important consideration. Limitations The present study has several limitations that must be recognized. One limitation is the nonexperimental study design. Multivariable analysis can control for a variety of confounding factors to help isolate clinical and cost differences between VATS and open procedures. However, in a nonexperimental study design, there is always the potential for unobserved differences between the two cohorts that one is unable to control for, thus resulting in selection bias. This analysis also was limited by the lack of more-detailed information about patients and procedures. For instance, it would have been of interest to examine the influence of additional patient characteristics, such as weight or BMI, and more procedure-related details. In the future, this may be possible as clinically rich data sets become available from greater use of electronic medical records in hospital settings, thereby facilitating analyses in these directions. In addition, because of the variations in VATS procedures, this study could only assess the average effects of these procedures, not the effects of specific types of VATS procedures. Finally, although the Premier 434 Original Research

7 database includes a large number of hospitals and its transactional data was used in this retrospective analysis, the results may not be applicable to all settings. Even without access to electronic medical records or information on the effects of specific types of VATS procedures, the use of the Premier database is an important strength of this analysis, given the very large numbers of patients and procedures that it provides, as well as the nationwide scope it represents. It would be of interest to use this database to examine next whether the clear advantages demonstrated with VATS wedge resections extend to lobectomies and to indications in addition to lung cancer. The present analysis of a large, nationally representative claims database provides strong evidence showing that VATS wedge resections for lung cancer indications have both clinical and economic advantages over traditional open wedge resections. Acknowledgments Author contributions: Dr Howington had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Dr Howington: contributed to the study concept and design, interpretation of data, and drafting and critical revision of the manuscript. Dr Gunnarsson : contributed to the study concept and design, acquisition of data, statistical analysis, interpretation of data, and drafting and critical revision of the manuscript. Dr Maddaus: contributed to the study concept and design, interpretation of data, and drafting and critical revision of the manuscript. Dr McKenna: contributed to the study concept and design, interpretation of data, and drafting and critical revision of the manuscript. Dr Meyers: contributed to the acquisition of data, interpretation of data, and drafting and critical revision of the manuscript. Dr Miller: contributed to the study concept and design, interpretation of the data, and drafting and critical revision of the manuscript. Mr Moore: contributed to the study concept and design, statistical analysis, interpretation of data, and drafting and critical revision of the manuscript. Dr Rizzo: contributed to the study concept and design, statistical analysis, interpretation of data, and drafting and critical revision of the manuscript. Dr Swanson: contributed to the study concept and design, interpretation of data, and drafting and critical revision of the manuscript. Financial/nonfinancial disclosures: The authors have reported to CHEST the following conflicts of interest: Drs Howington, Gunnarsson, Maddaus, McKenna, Meyers, Miller, Rizzo, and Swanson are consultants to Ethicon Endo-Surgery, Inc. Mr Moore is a full-time employee of Ethicon Endo-Surgery, Inc. Role of sponsors : Professional editing services were provided by Medical descriptions, Cincinnati, Ohio. Services were paid by S 2 Statistical Solutions, Inc, which is a paid consultant to Ethicon Endo-Surgery, Inc. Additional information: The e-appendixes can be found in the Online Supplement at 141/2/429/suppl/DC1. References 1. Flores RM, Park B, Rusch VW. Video-assisted thoracic surgery. In: Souba WW, Fink MP, Jurkovich GJ, et al, eds. ACS Surgery: Principles & Practice. Hamilton, Ontario, Canada: BC Decker; 2008 : Cheng D, Downey RJ, Kernstine K, et al. Video-assisted thoracic surgery in lung cancer resection. Innovations ; 2 (6 ): Sedrakyan A, van der Meulen J, Lewsey J, Treasure T. Video assisted thoracic surgery for treatment of pneumothorax and lung resections: systematic review of randomised clinical trials. BMJ ;329 (7473 ): Barker A, Maratos EC, Edmonds L, Lim E. Recurrence rates of video-assisted thoracoscopic versus open surgery in the prevention of recurrent pneumothoraces: a systematic review of randomised and non-randomised trials. Lancet ;370 (9584 ): Whitson BA, Groth SS, Duval SJ, Swanson SJ, Maddaus MA. Surgery for early-stage non-small cell lung cancer: a systematic review of the video-assisted thoracoscopic surgery versus thoracotomy approaches to lobectomy. Ann Thorac Surg ;86 (6 ): Flores RM, Alam N. Video-assisted thoracic surgery lobectomy (VATS), open thoracotomy, and the robot for lung cancer. Ann Thorac Surg ;85 (2 ):S710-S Mahtabifard A, Fuller CB, McKenna RJ Jr. Video-assisted thoracic surgery sleeve lobectomy: a case series. Ann Thorac Surg ;85 (2 ):S729-S Jones RO, Casali G, Walker WS. Does failed video-assisted lobectomy for lung cancer prejudice immediate and longterm outcomes? Ann Thorac Surg ;86 (1 ): Premier Perspective Database. Premier Research Services Web site. Accessed January 26, Carballo M, Maish MS, Jaroszewski DE, Holmes CE. Videoassisted thoracic surgery (VATS) as a safe alternative for the resection of pulmonary metastases: a retrospective cohort study. 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