OPERATIVE TIME FOR ESOPHAGECTOMY IN ESOPHAGEAL CANCER: DOES TIME REALLY MATTER? A NSQIP STUDY
Brandon W. Nuckles*, Ayobami Fatunmbi, Shengxuan Wang, Joseph Blansfield
Geisinger Medical Center, Danville, PA
Background
Esophagectomy is one of the most technically complex surgical procedures. Over the past two decades, there has been a shift from an open approach to minimally invasive esophagectomy (MIE). There is increasing literature focusing on comparing oncological outcomes with MIE vs open approaches. It is well known that operative times play a role in peri-operative outcomes, however few studies regarding esophagectomies. Our aim is to determine how operative times between the open vs. MIE approach impacts peri-operative outcomes.
Methods
This is a retrospective study utilizing the National Surgical Quality Improvement Program (NSQIP) database. We analyzed patients who were diagnosed with esophageal cancer and subsequently underwent esophagectomy between 2016-2018. Patients were grouped by MIE and open procedures and then by operative duration quintiles. Multivariate analysis compared quintiles for operative and peri-operative outcomes.
Results
A total of 1,659 patients were included in this study. There were 875 patients in the planned open group and 784 (47%) in the MIE group. Median operative time was 293 minutes for the open group and 399 minutes for the minimally invasive (MIS) group. The open approach had faster operative times across all quintiles compared to the MIS approach. The difference between open and MIE was statistically significant (p<0.0001). The demographics for the two groups were well matched but the open approach tumors had higher T stage (p<0.001) and higher N stage (p<0.0012).
On univariate analysis, The MIE approach had statistically significant improvement in inpatient mortality, hospital duration >30 days, superficial surgical site infection, pneumonia, unplanned intubation, and ventilator duration>48 hours when compared to the open approach (all p<0.05).
Associations with operative time where studied on multivariate analysis. Patient's race had the largest impact on operative time in both the MIS and open group. Black patients' operations were 46 minutes slower than their white counterparts. The type of tumor was also associated with increased operative time with squamous cell cancer operations taking longer than operations for adenocarcinoma.
For open procedures, longer operative times led to an increase in unplanned reoperation, unplanned readmission, and anastomotic leak (p<0.003). In the MIE group, only unplanned reoperation was affected by increased operative times.
CONCLUSION
Prolonged operative time combined with surgical approach plays a significant role in peri-operative outcomes. Even though operative time was overall increased in MIS group, there were less adverse outcomes as compared to the open group. Further investigation is needed to assess the balance between increased operative time and the minimally invasive approaches.
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