PROGRESSIVE IMPROVEMENTS IN POSTOPERATIVE OUTCOMES WITH OVER 500 ROBOTIC ASSISTED MINIMALLY INVASIVE ESOPHAGECTOMIES AT A SINGLE INSTITUTION
Andrew J. Sinnamon*, Samir Saeed, Justin A. Drake, Rutika Mehta, Russell F. Palm, Shaffer Mok, Jobelle Joyce Anne Baldonado, Jacques-Pierre Fontaine, Jose M. Pimiento
Gastrointestinal Oncology, Moffitt Cancer Center, Tampa, FL
Background
Transthoracic esophagectomy has historically been characterized as an operation with substantial postoperative morbidity. The application of the robotic surgical platform to enable robotic-assisted minimally invasive esophagectomy (RAMIE) has been prospectively shown to reduce postoperative complications when compared to open resection with thoracotomy. However, RAMIE requires significant institutional investment to fully realize postoperative benefits of minimally invasive resection. We sought to describe improvements in postoperative outcomes over time in our high-volume single-center experience of over 500 RAMIEs.
Methods
Patients undergoing robotic-assisted transthoracic two-field esophagectomy were identified from a prospectively-maintained institutional database (2010-2021). Patients were included if the abdominal portion of the operation was performed open or minimally invasive; all thoracic portions were performed robotically. Primary postoperative outcomes of interest included length of stay (LOS), 30-day pulmonary complication, and 30-day cardiac complication. Cases were separated into cumulative volume quintile (CVQ) by surgical date. Associations between outcomes and CVQ were assessed using regression analysis, as appropriate, with adjustment for clinical factors (age, sex, receipt of neoadjuvant therapy), tumor factors (site, histology, clinical stage), and open vs minimally invasive abdominal portion.
Results
In all, there were 504 RAMIEs identified for study. Median patient age was 66 years (IQR 58-72) and the majority were male (81.9%), were performed for adenocarcinoma (88.1%), and received neoadjuvant therapy (83.9%). Median operative time was 415 minutes, which did not vary by CVQ (p=0.24). Median operative blood loss decreased with increasing CVQ, but not after adjustment for other factors (p=0.79).
The rate of 30-day respiratory complication was lowest (7.0%) in the highest CVQ (cases 404-504), compared to CVQ1 27.7%, CVQ2 16.8%, CVQ3 27.7%, and CVQ4 17.8%, (p=0.001). The association between higher CVQ and reduced rate of respiratory complication remained significant after adjustment for other factors (OR 0.71, p<0.001). Exploratory analysis revealed LOS decreased steadily with cumulative volume (Figure). Median LOS was 10, 10, 9, 9, and 7 days by increasing CVQ (p<0.001) which remained significant in multivariable adjustment (mean -1.2 days per CVQ, p<0.001). No significant association between rate of 30-day cardiac complication and CVQ was observed (CVQ1 28.7%, CVQ2 24.8%, CVQ3 38.6%, CVQ4 27.7, CVQ5 25.0%, p=0.20).
Conclusions
LOS and postoperative respiratory complication decreased significantly over our experience with 500 RAMIEs. The well-established benefits of minimally invasive resection are likely maximized when performed in a high-volume center with experience in optimization of postoperative care.
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