# The Stapler Dilemma in VATS Wedge Resection: Are Sutures a Viable Alternative?

## TL;DR

A study compares using sutures versus staplers in lung surgery, finding sutures may be cheaper without worse outcomes.

## Contribution

The study suggests sutures could be a cost-effective alternative to staplers in VATS wedge resection for specific cases.

## Key findings

- Sutures reduced hospitalization costs compared to staplers after adjusting for confounders.
- Surgical time was slightly longer with sutures but did not significantly affect air leak or drainage duration.
- Clinical outcomes like complication rates and hospital stay were similar between the two methods.

## Abstract

Background: This single-center, retrospective, non-randomized observational study aims to explore the outcomes of video-assisted thoracoscopic surgery (VATS) wedge resection using the traditional clamp-and-suture technique versus staplers, with a focus on cost-effectiveness, operative time, and short-term postoperative outcomes. Methods: Data from 59 patients who underwent VATS wedge resection between 2018 and 2024 were retrospectively analyzed. Patients were divided into the stapler group (S-group, n = 27) and the clamp-and-suture group (C-group, n = 32). Technique selection was made intraoperatively by the surgeon based on lesion characteristics. Co-primary outcomes were total hospitalization cost and air leak duration > 2 days. Secondary outcomes included drainage time, complications, and hospital stay. The researchers conducted multivariable regression and sensitivity analyses to handle selection bias and confounding variables. Statistical analyses were performed with a significance level of p < 0.05. This study was approved by the Tekirdağ University Faculty of Medicine Ethics Committee (Approval No: 2024.22.02.06). Results: The C-group lesions showed proximity to the pleural surface at 5 mm compared to 8 mm (p = 0.048), indicating significant selection bias. Operation time was longer in the C-group (70 vs. 60 min, p = 0.115). Air leak duration and drainage time were similar between groups (p = 0.872, p = 0.176). Complication rates classified by Clavien–Dindo scale and hospital stay were comparable. The C-group showed reduced hospitalization expenses ($191.6 vs. $371.7) after adjusting for lesion characteristics and confounders while the clinical results between groups remained equivalent (adjusted OR for air leak: 0.68, 95% CI: 0.13–3.51, p = 0.645). The cost advantages persisted through sensitivity analysis which tested for selection bias effects. Conclusions: The clamp-and-suture method appears to offer a potentially cost-effective alternative to staplers for carefully selected peripheral lesions in VATS wedge resection, particularly in resource-limited settings. The preliminary results need to be treated as speculative because the study uses a non-randomized retrospective design with limited data from a small number of patients treated by one surgeon and shows evidence of selection bias. The obtained results do not qualify as practice-changing recommendations. The validation of these findings requires prospective randomized controlled trials with predetermined selection criteria and extended follow-up periods to establish clinical recommendations.