Combined robotic approach and enhanced recovery after surgery pathway for optimization of costs in patients undergoing proctectomy

Modified enhanced recovery after surgery protocol in octogenarians undergoing minimally invasive colorectal cancer surgery

BACKGROUND

Colorectal cancer (CRC) is a major health issue worldwide. As the population ages, more older patients including octogenarians will require CRC treatment. However, this vulnerable group has decreased functional reserves and increased surgical risks. Enhanced recovery after surgery (ERAS) pathways aim to reduce surgical stress and complications, but concerns remain about applying ERAS protocols to older patients. We assessed whether a modified ERAS (mERAS) protocol combined would improve outcomes in octogenarian CRC patients undergoing minimally invasive surgery.

METHODS

In this retrospective cohort study, we compared 360 non-octogenarians aged 50-64 years and 114 octogenarians aged 80-89 years before and after mERAS protocol implementation. Outcomes including postoperative functionary recovery, length of stay, complications, emergency department visits, and readmissions were analyzed.

RESULTS

Despite comparable tumor characteristics, octogenarians had poorer nutrition, American Society of Anesthesiologists status, and more comorbidities. After mERAS, octogenarians had reduced complications, faster return of bowel function, and shorter postoperative length of stay, similar to non-octogenarians. mERAS implementation improved recovery in both groups without increasing emergency department visits or readmissions.

CONCLUSION

Although less remarkable than in non-octogenarians, mERAS protocols mitigated higher complication rates and improved recovery in octogenarians after minimally invasive surgery for CRC, confirming protocol feasibility and safety in this vulnerable population.

Integrating a tumour appropriate transanal or robotic assisted approach to total mesorectal excision in high-volume rectal cancer practice is safe and cost-effective

Total mesorectal excision (TME) is accepted as the gold standard for oncological resection in rectal cancer. The best approach to TME is debated and often surgeons will select a preferred approach. In this study, we aimed to describe how both robotic (R-TME) and transanal (TaTME) TME can be integrated into high-volume rectal cancer surgeon practice with a comparison of clinical and oncological outcomes and cost analysis. A prospective comparative cohort study was performed in a high-volume rectal cancer centre comparing the previous 50 R-TME and 50 TaTME performed by the same surgeon. A comparison of tumour characteristics was performed to highlight a specific role for each technique. Clinical outcomes (operative duration, length of stay (LOS) and perioperative morbidity), cancer quality indicators (resection margin and completeness of TME) and cost analysis were compared. Statistical analysis was performed using IBM SPSS, version 20. R-TME was preferred in mid-rectal cancer, compared to TaTME preferred in low rectal cancer (9 cm vs. 5 cm, p < 0.001). Operative duration was longer in R-TME compared to TaTME (265 vs. 179 min, p < 0.001). Major complications (CD III-IV complications) were experienced in 10% of R-TME and 14% of TaTME (p = 0.476). A 98% (n = 49) clear R0 resection margin was achieved with both R-TME and TaTME and mesorectum quality defined as 'complete' in 86% (n = 43) in R-TME and 82% (n = 41) in TaTME. Length of hospital stay was shorter in R-TME (5 vs. 7 days, p = 0.624). An overall difference of €131 was observed favouring TaTME. In high-volume rectal cancer surgery practice, both R-TME and TaTME can be practised and tailored according to patients and tumour characteristics, with comparable clinical and cancer outcomes and is cost-effective.

Can Colorectal Surgery Be Performed as an Outpatient Surgery?

The potential to discharge patients safely within the same day after colorectal surgery has developed over time with concurrent advances in concepts of enhanced recovery pathways, along with minimally invasive techniques available to surgeons. The advent of planned same-day discharges after elective colectomy is made possible by research establishing improved length of stay with minimal morbidity in patients undergoing minimally invasive surgery and especially minimally invasive surgery in the setting of an enhanced recovery after surgery (ERAS) protocol. In tracing the timeline of research and development of knowledge in this setting, the safety of outpatient colorectal surgery can be established.

Economic analysis of open versus laparoscopic versus robot-assisted versus transanal total mesorectal excision in rectal cancer patients: A systematic review

OBJECTIVES

Minimally invasive total mesorectal excision is increasingly being used as an alternative to open surgery in the treatment of patients with rectal cancer. This systematic review aimed to compare the total, operative and hospitalization costs of open, laparoscopic, robot-assisted and transanal total mesorectal excision.

METHODS

This systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement (PRISMA) (S1 File) A literature review was conducted (end-of-search date: January 1, 2023) and quality assessment performed using the Consensus Health Economic Criteria.

RESULTS

12 studies were included, reporting on 2542 patients (226 open, 1192 laparoscopic, 998 robot-assisted and 126 transanal total mesorectal excision). Total costs of minimally invasive total mesorectal excision were higher compared to the open technique in the majority of included studies. For robot-assisted total mesorectal excision, higher operative costs and lower hospitalization costs were reported compared to the open and laparoscopic technique. A meta-analysis could not be performed due to low study quality and a high level of heterogeneity. Heterogeneity was caused by differences in the learning curve and statistical methods used.

CONCLUSION

Literature regarding costs of total mesorectal excision techniques is limited in quality and number. Available evidence suggests minimally invasive techniques may be more expensive compared to open total mesorectal excision. High-quality economical evaluations, accounting for the learning curve, are needed to properly assess costs of the different techniques.

Robotic approach together with an enhanced recovery programme improve the perioperative outcomes for complex hepatectomy

Objective

Robotic surgery has more advantages than traditional surgical approaches to complex liver resection; however, the robotic approach is invariably associated with increased cost. Enhanced recovery after surgery (ERAS) protocols are beneficial in conventional surgeries.

Methods

The present study investigated the effects of robotic surgery combined with an ERAS protocol on perioperative outcomes and hospitalization costs of patients undergoing complex hepatectomy. Clinical data from consecutive robotic and open liver resections (RLR and OLR, respectively) performed in our unit in the pre-ERAS (January 2019-June 2020) and ERAS (July 2020-December 2021) periods were collected. Multivariate logistic regression analysis was performed to determine the impact of ERAS and surgical approaches-alone or in combination-on LOS and costs.

Results

A total of 171 consecutive complex liver resections were analyzed. ERAS patients had a shorter median LOS and decreased total hospitalization cost, without a significant difference in the complication rate compared with the pre-ERAS cohort. RLR patients had a shorter median LOS and decreased major complications, but with increased total hospitalization cost, compared with OLR patients. Comparing the four combinations of perioperative management and surgical approaches, ERAS + RLR had the shortest LOS and the fewest major complications, whereas pre-ERAS + RLR had the highest hospitalization costs. Multivariate analysis found that the robotic approach was protective against prolonged LOS, whereas the ERAS pathway was protective against high costs.

Conclusions

The ERAS + RLR approach optimized postoperative complex liver resection outcomes and hospitalization costs compared with other combinations. The robotic approach combined with ERAS synergistically optimized outcome and overall cost compared with other strategies, and may be the best combination for optimizing perioperative outcomes for complex RLR.

A cost analysis of robotic vs. video-assisted thoracic surgery: The impact of the learning curve and the COVID-19 pandemic

Introduction

Robot-assisted thoracoscopic surgery (RATS) is an alternative to video-assessed thoracoscopic surgery (VATS) for the treatment of lung cancer but concern exists regarding the high associated costs. The COVID-19 pandemic added further financial pressure to healthcare systems. This study investigated the impact of the learning curve on the cost-effectiveness of RATS lung resection and the financial impact of the COVID-19 pandemic on a RATS program.

Methods

Patients undergoing RATS lung resection between January 2017 and December 2020 were prospectively followed. A matched cohort of VATS cases were analyzed in parallel. The first 100 and most recent 100 RATS cases performed at our institution were compared to assess the learning curve. Cases performed before and after March 2020 were compared to assess the impact of the COVID-19 pandemic. A comprehensive cost analysis of multiple theatre and postoperative data points was performed using Stata statistics package (v14.2).

Results

365 RATS cases were included. Median cost per procedure was £7,167 and theatre cost accounted for 70%. Major contributing factors to overall cost were operative time and postoperative length of stay. Cost per case was £640 less after passing the learning curve (p < 0.001) largely due to reduced operative time. Comparison of a post-learning curve RATS subgroup matched to 101 VATS cases revealed no significant difference in theatre costs between the two techniques. Overall cost of RATS lung resections performed before and during the COVID-19 pandemic were not significantly different. However, theatre costs were significantly cheaper (£620/case; p < 0.001) and postoperative costs were significantly more expensive (£1,221/case; p = 0.018) during the pandemic.

Discussion

Passing the learning curve is associated with a significant reduction in the theatre costs associated with RATS lung resection and is comparable with the cost of VATS. This study may underestimate the true cost benefit of passing the learning curve due to the effect of the COVID-19 pandemic on theatre costs. The COVID-19 pandemic made RATS lung resection more expensive due to prolonged hospital stay and increased readmission rate. The present study offers some evidence that the initial increased costs associated with RATS lung resection may be gradually offset as a program progresses.

Robotic colorectal resection in combination with a multimodal enhanced recovery program - results of the first 100 cases

PURPOSE

In Germany, colorectal robot-assisted surgery (RAS) has found its way and is currently used as primary technique in colorectal resections at our clinic. We investigated whether RAS can be extensively combined with enhanced recovery after surgery (ERAS®) in a large prospective patient group.

METHODS

Using the DaVinci Xi surgical robot, all colorectal RAS from 09/2020 to 01/2022 were incorporated into our ERAS® program. Perioperative data were prospectively recorded using a data documentation system. The extent of resection, duration of the operation, intraoperative blood loss, conversion rate, and postoperative short-term results were analyzed. We documented the postoperative duration of Intermediate Care Unit (IMC) stay and major and minor complications according to the Clavien-Dindo classification, anastomotic leak rate, reoperation rate, hospital-stay length, and ERAS® guideline adherence.

RESULTS

One hundred patients (65 colon and 35 rectal resections) were included (median age: 69 years). The median durations of surgery were 167 min (colon resection) and 246 min (rectal resection). Postoperatively, four patients were IMC-treated (median stay: 1 day). In 92.5% of the colon and 88.6% of the rectum resections, no or minor complications occurred postoperatively. The anastomotic leak rate was 3.1% in colon and 5.7% in rectal resection. The reoperation rate was 7.7% (colon resection) and 11.4% (rectal resection). The hospital stay length was 5 days (colon resection) and 6.5 days (rectal resection). The ERAS® guideline adherence rate was 88% (colon resection) and 82.6% (rectal resection).

CONCLUSION

Patient perioperative therapy per the multimodal ERAS® concept is possible without any problems in colorectal RAS, leading to low morbidity and short hospital stays.

Should minimally invasive approaches in rectal surgery be regarded as a key element of modern enhanced recovery perioperative care?

INTRODUCTION

The aim of study was to assess the impact of an enhanced recovery after surgery (ERAS) protocol and minimally invasive approaches on short-term outcomes in rectal surgery.

PATIENTS AND METHODS

A consecutive series of patients that underwent open or minimally invasive rectal resections in a single institution between January 2015 and April 2020 were included in the study. An ERAS program was introduced in April 2016. The study cohort was divided into three groups: open surgery without ERAS, open surgery with ERAS, and minimally invasive surgery with ERAS. Outcome measures compared were recovery parameters, surgical stress parameters, 30-day morbidity and mortality, oncological radicality and length of hospital stay.

RESULTS

A total of 202 patients were included: 43 in the open non-ERAS group, 92 in the open ERAS group and 67 in the minimally invasive ERAS group. All recovery parameters apart from postoperative nausea and vomiting were significantly improved in both ERAS groups. Surgical stress parameters, prolonged postoperative ileus, and hospital stay were significantly reduced in the minimally invasive ERAS group. The overall 30-day morbidity and mortality and oncological radicality did not significantly differ among the three groups.

CONCLUSIONS

Minimally invasive approaches and enhanced recovery care in rectal surgery improve short-term outcomes. Their combination leads to an improvement in recovery parameters and a reduction of prolonged postoperative ileus and hospital stay.

Nurse-led coordinated surgical care pathways for cost optimization of robotic-assisted partial nephrectomy: medico-economic analysis of the UroCCR-25 AMBU-REIN study

PURPOSE

Robot-assisted partial nephrectomy (RAPN) reduces morbidity, enabling development of Enhanced Recovery After Surgery (ERAS) and day-case protocols. Additional financial costs limit its integration into clinical practice. We evaluated the medico-economic impact of RAPN using a nurse-led coordinated pathway of care (NLC-RAPN).

METHODS

All tumor RAPNs performed in 2017 were prospectively included in nurse-led protocols: NP-RAAC (ERAS) or Ambu-Rein (day case). Clinico-biological and pathological data were prospectively collected within the French Research Network for Kidney Cancer database (NCT03293563). Estimated costs were compared to "average" patients at the national level operated by open partial nephrectomy (OPN) or RAPN, using data from the 2017 French hospital discharge database and the national cost scale.

RESULTS

The NLC-RAPN cohort (n = 151) included 27 (18%) outpatients and the average hospital length of stay (LOS) was 2.4 days. In the national control cohorts for OPN (n = 2475) and RAPN (n = 3529), the average LOS were 8.0 and 5.2 days, respectively. The mean incomes per group were €7607 for NLC-RAPN, €9813 for OPN, and €8215 for RAPN. The mean daily cost of stay was €659 for NLC-RAPN, €838 for OPN, and €725 for RAPN. The overall cost for NLC-RAPN was €6594, €8733 for OPN, and €8763 for RAPN. The best operational margin was obtained for day-case NLC-RAPN (€1967).

CONCLUSION

Combining RAPN with nurse-led coordinated pathways of care led to a shorter hospital stay and reduced costs versus OPN. This may facilitate the economic sustainability of robotic assistance for hospitals where the extra cost is not covered by the healthcare system.

Enhanced Recovery after Uterine Corpus Cancer Surgery: A 10 Year Retrospective Cohort Study of Robotic Surgery in an NHS Cancer Centre

Simple Summary

Surgical and survival outcomes for uterine corpus cancer following the introduction of robotic surgery to Royal Surrey NHS Foundation Trust; a large volume United Kingdom teaching hospital and cancer centre. Introduction of the Da Vinci^TM robot was associated with enhanced recovery after surgery with low 30-day mortality (0.1%), low return to theatre (0.5%), a low use of blood transfusion and intensive care (1.8% & 7.2% respectively), low conversion to open surgery (0.5%) and a reduction in median length of stay, with comparable survival to published data, and a three to four fold increase in cases treated. This increased productivity was associated with a highly predicable patient pathway of care, for high-risk patients, with reduced demands on health services.

Abstract

Royal Surrey NHS Foundation Trust introduced robotic surgery for uterine corpus cancer in 2010 to support increased access to minimally invasive surgery, a central element of an enhanced recovery after surgery (ERAS) pathway. More than 1750 gynaecological oncology robotic procedures have now been performed at Royal Surrey NHS Foundation Trust. A retrospective cohort study was performed of patients undergoing surgery for uterine corpus cancer between the 1 January 2010 and the 31 December 2019 to evaluate its success. Data was extracted from the dedicated gynaecological oncology database and a detailed notes review performed. During this time; 952 patients received primary surgery for uterine corpus cancer; robotic: n = 734; open: n = 164; other minimally invasive surgery: n = 54. The introduction of the Da Vinci^TM robot to Royal Surrey NHS Foundation Trust was associated with an increase in the minimally invasive surgery rate. Prior to the introduction of robotic surgery in 2008 the minimally invasive surgery (MIS) rate was 33% for women with uterine corpus cancer undergoing full surgical staging. In 2019, 10 years after the start of the robotic surgery program 91.3% of women with uterine corpus cancer received robotic surgery. Overall the MIS rate increased from 33% in 2008 to 92.9% in 2019. Robotic surgery is associated with a low 30-day mortality (0.1%), low return to theatre (0.5%), a low use of blood transfusion and intensive care (1.8% & 7.2% respectively), low conversion to open surgery (0.5%) and a reduction in median length of stay from 6 days (in 2008) to 1 day, regardless of age/BMI. Robotic survival is consistent with published data. Introduction of the robotic program for the treatment of uterine cancer increased productivity and was associated with a highly predicable patient pathway of care, for high-risk patients, with reduced demands on health services. Future health care commissioning should further expand access to robotic surgery nationally for women with uterine corpus cancer.

Pediatric robotic surgery: issues in management-expert consensus from the Italian Society of Pediatric and Neonatal Anesthesia and Intensive Care (SARNePI) and the Italian Society of Pediatric Surgery (SICP)

BACKGROUND

Pediatric robotic-assisted surgeries have increased in recent years; however, guidance documents are still lacking. This study aimed to develop evidence-based recommendations, or best practice statements when evidence is lacking or inadequate, to assist surgical teams internationally.

METHODS

A joint consensus taskforce of anesthesiologists and surgeons from the Italian Society of Pediatric and Neonatal Anesthesia and Intensive Care (SARNePI) and the Italian Society of Pediatric Surgery (SICP) have identified critical areas and reviewed the available evidence. The taskforce comprised 21 experts representing the fields of anesthesia (n = 11) and surgery (n = 10) from clinical centers performing pediatric robotic surgery in the Italian cities of Ancona, Bologna, Milan, Naples, Padua, Pavia, Perugia, Rome, Siena, and Verona. Between December 2020 and September 2021, three meetings, two Delphi rounds, and a final consensus conference took place.

RESULTS

During the first planning meeting, the panel agreed on the specific objectives, the definitions to apply, and precise methodology. The project was structured into three subtopics: (i) preoperative patient assessment and preparation; (ii) intraoperative management (surgical and anesthesiologic); and (iii) postoperative procedures. Within these phases, the panel agreed to address a total of 18 relevant areas, which spanned preoperative patient assessment and patient selection, anesthesiology, critical care medicine, respiratory care, prevention of postoperative nausea and vomiting, and pain management.

CONCLUSION

Collaboration among surgeons and anesthesiologists will be increasingly important for achieving safe and effective RAS procedures. These recommendations will provide a review for those who already have relevant experience and should be particularly useful for those starting a new program.

Implementation of an enhanced recovery after surgery program with robotic surgery in high-risk patients obtains optimal results after colorectal resections

Enhanced recovery after surgery programs reduce postoperative complications and length of stay after laparoscopic colorectal surgery, but are still under evaluation after robotic colorectal surgery. To evaluate potential benefits in terms of length of stay and complications of an Enhanced recovery after surgery program in colorectal surgery. A subanalysis was performed to assess what combination of surgical approach and perioperative care had better outcomes. Prospective observational cohort study. 300 consecutive colorectal surgery patients: 150 were prospectively included in the enhanced recovery after Surgery program group and 150 retrospectively in the traditional care group, and subdivided according to the type of surgery, in Hospital Marques de Valdecilla, between 2013 and 2016. Postoperative complications decreased significantly (p = 0.002) from 46 to 28% (traditional care vs program group). The length of stay was decreased by 2 days (p < 0.001). Multivariate analysis indicated similar effect sizes after adjusting for age, gender, Charlson score, and type of surgery. Type of surgery was an independent predictive factor for postoperative complications and length of stay. Compared to open surgery, postoperative complications decreased by 50% (p < 0.001) after robotic surgery and by 40% (p = 0.01) after laparoscopic surgery, while the median length of stay decreased by three days (p < 0.001) after minimally invasive surgery. Enhanced recovery after surgery program and minimally invasive surgery were associated with decreased morbidity and length of stay after colorectal surgery compared to open surgery and traditional care. An enhanced recovery after surgery program with robotic surgery in high-risk patients might be beneficial.

The feasibility of implementing an enhanced recovery programme in patients undergoing pelvic exenteration

BACKGROUND

Pelvic exenteration (PE) is a complex operative procedure, reserved for patients with locally advanced and recurrent pelvic malignancies. PE is associated with a high index of post-operative morbidity. Enhanced Recovery After Surgery (ERAS) programmes have been successful in improving postoperative outcomes, however, its application in PE has not been studied. The aim of our study is to assess the feasibility and short-term impact of ERAS on PE.

METHODS

A dedicated PE ERAS programme was developed reflecting the complexity of differing subtypes of PE. A prospective cohort study was undertaken to evaluate the feasibility of implementing our PE ERAS between 2016 and 2020. The primary endpoint of this study was overall compliance with the ERAS programme.

RESULTS

145 patients were enrolled into our PE ERAS programme, with 86 (56.2%) patients undergoing a soft tissue PE, 27 (17.6%) a vascular PE and 32 (20.9%) a bony PE. The median overall compliance to the PE ERAS programme was 70% (IQR 55.5-88.8). There were no observed differences between overall compliance to the PE ERAS programme between different subtypes of PE (p = 0.60). Patients with higher compliance with the PE ERAS programme had a shorter LoS (p < 0.001), less post-operative morbidity (p < 0.001), reduced severity of Clavien-Dindo grade of morbidity (p < 0.001) and fewer readmissions (p = 0.03).

CONCLUSIONS

The principles of ERAS can be readily applied to patients undergoing PE, with high adherence to the ERAS programme associated with improved clinical outcomes.

Does Timing of Robotic Esophagectomy Adoption Impact Short-Term Postoperative Outcomes?

BACKGROUND

Robotic esophagectomies are increasingly common and are reported to have superior outcomes compared with an open approach; however, it is unclear if all institutions can achieve such outcomes. We hypothesize that early adopters of robotic technique would have improved short-term outcomes.

METHODS

The National Cancer Database (2010-2016) was used to identify robotic esophagectomies. Early adopters were defined as programs which performed robotic esophagectomies in 2010-2011, late adopters in 2012-2013. Outcomes of esophagectomies performed between 2014 and 2016 were compared and included length of stay, number of lymph nodes evaluated, readmission, conversion rate, and 90-day mortality. Multivariable regressions, accounting for robotic esophagectomy volume, were used to control for confounding factors.

RESULTS

There were 37 early adopters and 35 late adopters. Between 2014 and 2016, 683 robotic esophagectomies were performed: 446 (65.3%) by early adopters and 237 (34.7%) by late adopters. Early adopters were more likely to be academic programs (96.2 versus 72.8%, P < 0.01). Other clinical and demographic variables were similar. Late adopters were found to have decreased a number of lymph nodes evaluated (coefficient -2.407, P = 0.004) compared with early adopters. There were no significant differences in length of stay, readmissions, rate of positive margins, conversion from robotic to open, or 90-day mortality.

CONCLUSIONS

When accounting for robotic esophagectomy volume, late adoption of robotic esophagectomy was associated with a reduced lymph node harvest, but other postoperative outcomes were similar. These data suggest that programs can safely start new robotic esophagectomy programs, but must ensure an adequate case load.

Robotic surgery for colorectal cancer

Minimally invasive surgery has demonstrated many benefits in general surgery, particularly in colon and rectal procedures. On the other hand, it has some limitations that must be taken into account, especially technical drawback. Robotic surgery has incorporated many improvements to overcome this disadvantage, such as 3D visualization, articulating instruments assisting complex and precise movements. As a result, robotic colorectal surgery shows less intraoperative blood loss, shorter time to oral tolerance and initial flatus (particularly associated with "Enhanced Recovery After Surgery" protocol), less conversion rate to open surgery, shortened hospital stay, and longer distal margins compared to laparoscopic and open surgery. This approach also shows a shorter learning curve. Some studies suggest that it could decrease perioperatively or 30 days after the intervention's mortality, raise overall survival, reduce wound infection, and improve functional results, while others show no significant difference. However, it lengthens surgical time. Otherwise, the studies included do not show statistically significant changes in the number of resected lymph nodes and anastomotic leaks. Economic costs remain one of the major concerns, although to date there are no large-scale studies that have evaluated this aspect from a global point of view. Robotic surgery represents a qualitative leap in surgical instruments and, although there is no strong evidence in favor of the use of robotic surgery over laparoscopic or open surgery, there is enough evidence to support its use in colorectal surgery, with potential advantages for patients.