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VATS now a viable option for lung surgery

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BECAUSE of the high cost of some of the equipment needed, a surgical procedure touted to improve the quality of a patient’s life after surgery was rarely performed in the Philippines until recently — even though doctors around Asia came here for training and went on to perform the procedure in their home countries.

A VATS procedure
A VATS procedure

The procedure, called Video-assisted thorascopic surgery (VATS), is a minimally invasive technique used to diagnose and treat problems in the chest. This is done via small incisions through which a tiny camera called a thorascope is inserted alongside surgical instruments. The camera transmits the images onto a monitor which is then used by surgeons to perform the procedure.

It has been found that VATS have many benefits over open-chest surgery “such as smaller incisions, less pain, less blood loss, faster postoperative recovery, shortened hospital stay, and similar or superior survival rates,” said a study by Tunc Lacin and Scott Swanson published in the Journal of Thoracic Disease in August 2013, thus making it the preferred procedure for many patients.

“The joke is that nobody is looking at the patient anymore as everybody is looking at the screen,” said Dr. Antonio Ramos, a thoracic surgery specialist of the Lung Center of the Philippines in an interview with BusinessWorld on Nov. 10.

HIGH COST
VATS was first introduced in the Philippines in 1992, said Dr. Ramos, yet was hardly practiced here.

“This was the first time VATS was taught in Asia… so people from around the world came and trained [here] and when they went home they practiced it — and we did not,” Dr. Ramos said, before explaining that this was due to he cost of the procedure — in the Philippines, the costs were paid by patients, unlike, say, in Hong Kong were medical services were socialized.

“While we had the technology and equipment for it, the consumables were very expensive. It was very prohibitive,” he said. He pointed, in particular, to the surgical staples that had to be used in place of sutures or stitches. Each staple would cost P25,000-P30,000 locally as there was only one manufacturer, and up to half a dozen staples would be used in a procedure.

Some doctors resorted to “technical smuggling,” Dr. Ramos said. They would buy staples overseas and bring them into the Philippines because they were cheaper abroad.

“[VATS] did not take off until about five years ago,” he said, after the entry of another manufacturer which brought down the cost of staples to P8,000 each.

SINGLE INCISION
Aside from the lower cost, Dr. Ramos said that another breakthrough which is helping increase the popularity of VATS locally is the introduction of the “uniportal technique” which only requires a single incision (around two inches wide) through which the surgical implements, the thorascope, and the specimen can enter and exit with ease.

“We used to do three ports (incisions),” he said.

The technique was first introduced by Spanish surgeon Diego Gonzalez Rivas “five or six years ago,” he said.

“When we started [doing this operation] it was five hours [long] — it was the same time as when you do an open procedure,” he said. Mr. Lacin and Mr. Swanson had noted in their study that the downside of VATS were higher equipment costs and longer operating room times, “at least initially,” and a “learning curve of the team.”

This is no longer the case.

“The last case we did a few days ago, we were able to do a lobectomy (the removal of a portion of the lung) in less than three hours,” Dr. Ramos said, which is comparable to similar surgeries done in other countries.

100 PROCEDURES A YEAR
The Lung Center of the Philippines handles more than a hundred VATS procedures a year.

Currently, he estimates that the cost for VATS, which is mainly operating room fees (sans professional fees and hospital room costs) is around P150,000 to P160,000. The operating room fees of open-chest surgery can cost around P90,000.

While at first glance VATS is more expensive, the trade-offs may be worth it. These include:

• reduced number of days spent in the hospital — some VATS patients’ hospital stay is three days while open-chest surgery patients can stay for more than a week;

• better “quality of life,” which refers to the pain the patients feel before and after the surgery — open-chest surgery patients need stronger pain medications while VATS patients sometimes only require over-the-counter painkillers; and

• a reduced number of subsequent check-ups.

The only downside he sees with the procedure is that many younger surgeons are only trained to do VATS and are not trained in open-chest procedures, unlike veterans like Dr. Ramos who cut their teeth on open procedure and were introduced to the new method years into their practice. This is a problem since while many patients qualify for VATS, there are those who do not and require open surgery, something not many surgeons do nowadays — thus making it more of a specialization which is the opposite of when VATS was first introduced and open-chest surgery was the norm.

CHARITY
“We fund our charity patients from the profits we make from our paying patients, and while the government puts in money [for charity patients] we add to that,” he said when asked about patients who cannot afford the procedure. The Lung Center has around a dozen surgeons who can do VATS.

While the government currently allocates P180 million a year for charity patients, he said, the Center spends P250 million for these patients a year.

“The P70 million [difference] we generate ourselves… the reason we make profits is for our charity patients,” he said, noting that the hospital is a government-owned and -controlled corporation and thus allowed to generate its own revenues.

Depending on the case, a charity patient can receive a discount or even not pay at all.

“There’s no other place in the Philippines where a charity patient can go and have lung surgery — minimally invasive — and they don’t have to spend anything except here and we our mandate very seriously,” he said. — ZBC





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