Outcomes of robotic esophagectomies for esophageal cancer by hospital volume: an analysis of the national cancer database.

Hue JJ, Bachman KC, Worrell SG, Gray KE, Linden PA, Towe CW. Outcomes of robotic esophagectomies for esophageal cancer by hospital volume: an analysis of the national cancer database. Surgical endoscopy. 2021 Jul 1; 35(7):3802-3810.

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Abstract:

BACKGROUND: Robotic minimally invasive esophagectomies (RMIE) have been associated with superior outcomes; however, it is unclear if these are specific to robotic technique or are present only at high-volume institutions. We hypothesize that low-volume RMIE centers would have inferior outcomes. METHODS: The National Cancer Database (NCDB) identified patients receiving RMIE from 2010 to 2016. Based on the total number of RMIE performed by each hospital system, the lowest quartile performed? = 9 RMIE over the study period. Ninety-day mortality, number of lymph nodes evaluated, margins status, unplanned readmissions, length of stay (LOS), and overall survival were compared. Regression models were used to account for confounding. RESULTS: 1565 robotic esophagectomies were performed by 212 institutions. 173 hospitals performed? = 9 RMIE (totaling 478 operations over the study period, 30.5% of RMIE) and 39 hospitals performed? > 9 RMIE (1087 operations, 69.5%). Hospitals performing? > 9 RMIE were more likely to be academic centers (90.4% vs 66.2%, p? < 0.001), have patients with advanced tumor stage (65.3% vs 59.8%, p? = 0.049), andadministered preoperative radiation (72.8% vs 66.3%, p? = 0.010). There were no differences based on demographics, nodal stage, or usage of preoperative chemotherapy. On multivariable regressions, hospitals performing? = 9 RMIE were associated with a greater likelihood of experiencing a 90-day mortality, a reduced number of lymph nodes evaluated, and a longer LOS; however, there was no association with rates of positive margins or unplanned readmissions. Median overall survival was decreased at institutions performing? = 9 RMIE (37.3 vs 51.5 months, p? < 0.001). Multivariable Cox regression demonstrated an association with poor survival comparing hospitals performing? = 9 to? > 9 RMIE (HR 1.327, p? = 0.018). CONCLUSION: Many robotic esophagectomies occur at institutions which performed relatively few RMIE and were associated with inferior short- and long-term outcomes. These data argue for regionalization of robotic esophagectomies or enhanced training in lower volume hospitals.