Original ArticleNational Trends and Factors Predicting Outcomes Following Laser Interstitial Thermal Therapy for Brain Lesions: Nationwide Inpatient Sample Analysis
Introduction
Since the introduction of laser interstitial thermal therapy (LITT) in 1983,1 there has been tremendous interest in the utility of this technology for a variety of brain lesions, deep-seated in particular.2, 3, 4, 5, 6 The advent of magnetic resonance thermography further provided an opportunity to monitor the extent of thermal ablation in real time7,8 and therefore opened up the horizons for the widespread use of this technology. This led to U.S. Food and Drug Administration clearance of 2 major LITT devices: Visualase System (Medtronic Inc., Minneapolis, Minnesota, USA) in 2007 and NeuroBlate System (Monteris Medical Corporation, Plymouth, Minnesota, USA) in 2009. In 2013, Sloan et al9 reported the successful application of LITT in phase I clinical trial in patients with deep hemispheric recurrent glioblastoma. Since then, LITT has shown favorable outcomes in patients with a variety of brain lesions (primary or recurrent tumors, radiation necrosis)10, 11, 12, 13, 14, 15, 16 and epilepsy.17, 18, 19, 20 In addition, LITT has been shown to disrupt the blood-brain barrier, which provides an opportunity to deliver chemotherapeutic agents or macromolecules for therapeutic purposes.21,22
Given the minimally invasive nature of this technology, there are several advantages of LITT such as shorter length of hospital stay, lower intraoperative blood loss, and smaller incision compared with traditional open approaches.23,24 Also, LITT is associated with lower rates of major complications compared with open approaches (5.7% vs. 13.8%).23 Cost-effectiveness analysis also showed that LITT offers survival advantage with minimal additional cost, which is well below the current standard for life-years gained.24 Kamath et al14 reported overall complication/readmission rates of 6% each, and mortality was noted in 2.2% of patients following LITT for a variety of brain lesions (n = 120 patients with 133 lesions). Another large series (n = 102 patients and 133 lesions) reported complication rates of 26.5% with complete resolution of symptoms in 64.3% of these patients (9/14 patients), and 2 patients died in this series. The majority of published literature is from single-center studies and therefore reflects the experience of a single surgeon or center with low sample size. Recently, Wu et al25 reported an overall complication rate of 15% (42 complications in 35 patients) in a multicenter series of 234 patients following LITT for mesial temporal lobe epilepsy.
In light of this background, we aimed to query the National Inpatient Sample (NIS) database to identify the practice patterns and outcomes associated with LITT throughout the United States using a large administrative database. We hypothesize that LITT is increasingly being used for a variety of indications with low morbidity and the majority of patients are likely to be discharged home after the procedure.
The objective of our retrospective cohort study was to report the national trends in LITT procedures across the United States using the NIS. We also aimed at evaluating the factors predicting the clinical outcomes following LITT using this database.
Section snippets
Registration, Study Design, and Setting
We used the administrative database NIS for this retrospective case series. NIS is part of the Healthcare Cost and Utilization Project, by the Agency for Healthcare Research and Quality. The NIS is an approximately 20% stratified sample of all inpatient data from U.S. community hospitals, excluding rehabilitation and long-term acute care hospitals. It contains all patients regardless of payer, including individuals covered by Medicare, Medicaid, private insurance, and uninsured. These data
Results
We identified a cohort of 1768 patients who underwent LITT procedure during the study period. LITT is increasing being performed since 2011, with more than half of the cases (58%) being done in 2015 and 2016 (Figure 1).
Discussion
LITT has been increasingly performed for a variety of brain lesions since 2011. LITT was primarily performed as an elective procedure at teaching hospitals in the South and Midwest. Mean LOS was 3.2 days; 82% of patients were discharged to home and in-hospitalization charges were $124,225. Overall, complication rate was 12.9% and mortality was 2.5% after LITT. Cerebrovascular complications were the most common, followed by pulmonary and infection. Non-Caucasian patients, those with 4+
Conclusion
LITT is increasingly being performed for a variety of brain lesions in the United States with a low incidence of complications. Most LITT procedures were performed at large-size teaching hospitals in the South and Midwest. Patient-related (non-Caucasian race, higher comorbidity index, noncommercial insurance) and nonelective LITT procedures were predictors of higher complication rates and less likelihood of being discharged home. In-hospitalization charges were higher in patients with higher
CRediT authorship contribution statement
Mayur Sharma: Conceptualization, Methodology, Investigation, Writing - review & editing. Beatrice Ugiliweneza: Methodology, Formal analysis, Writing - review & editing. Dengzhi Wang: Methodology, Formal analysis, Writing - review & editing. Maxwell Boakye: Writing - review & editing. Norberto Andaluz: Writing - review & editing. Joseph Neimat: Writing - review & editing. Alireza Mohammadi: Writing - review & editing. Gene H. Barnett: Writing - review & editing. Brian J. Williams: Supervision,
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Conflict of interest statement: Drs. Williams, Mohammadi, and Barnett are consultants for Monteris Medical Company. The rest of the authors have no conflicts of interest or financial disclosures.