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Rayman S, Ross SB, Sucandy I, Syblis C, Pattilachan TM, Christodoulou M, Rosemurgy A. Weighing the outcomes: the role of BMI in complex robotic esophageal and hepatobiliary operations. Updates Surg 2024; 76:1031-1039. [PMID: 38460102 DOI: 10.1007/s13304-024-01757-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Accepted: 01/08/2024] [Indexed: 03/11/2024]
Abstract
BACKGROUND The correlation between body mass index (BMI) and surgical outcomes has emerged as a critical consideration in complex abdominal operations. While elevated BMI is often associated with increased perioperative risk, its specific effects on the outcomes of robotic surgeries remain inadequately explored. This study assesses the impact of BMI on perioperative variables of complex esophageal and hepatopancreaticobiliary (HPB) robotic operations. METHODS Following IRB approval, we prospectively followed 607 patients undergoing pancreaticoduodenectomy, trans-hiatal esophagectomy (THE), major liver resection or distal pancreatectomy with splenectomy, all performed robotically. Perioperative data retrieved included operative duration, estimated blood loss (EBL), intraoperative and postoperative complications, conversions to an 'open' operation and length of stay (LOS). Z scores were assigned to each variable to standardize operations, and the variables were then regressed against BMI. For illustrative purposes, data are presented as median(mean ± standard deviation). RESULTS Between 2012 and 2020, surgeries included 71 THE, 122 distal pancreatectomies with splenectomies, 129 major hepatectomies and 285 pancreaticoduodenectomies. Median age was 67(65 ± 12.5) years old, and BMI was 27(28 ± 5.5) kg/m2. Operative duration for all operations was 349(355 ± 124.5) min and had a positive correlation with increasing BMI (p = 0.004), specifically for robotic THE and robotic pancreaticoduodenectomy, with both operative durations having positive correlation with increasing BMI (p = 0.02 and p = 0.05). No significant correlation with BMI was found for EBL, intraoperative or postoperative complications, conversion to 'open' surgery, or LOS. CONCLUSION Elevated BMI is associated with longer operative durations in select robotic surgeries, such as trans-hiatal esophagectomy and pancreaticoduodenectomy, and highlights the need for strategic planning in these patients.
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Affiliation(s)
- Shlomi Rayman
- Digestive Health Institute, AdventHealth, 3000 Medical Park Drive, Suite #500, Tampa, FL, 33613, USA
- Department of General Surgery, Assuta Medical Center, Ashdod, Israel
- Affiliated to the Faculty of Health and Science, Ben-Gurion University, Beer-Sheba, Israel
| | - Sharona B Ross
- Digestive Health Institute, AdventHealth, 3000 Medical Park Drive, Suite #500, Tampa, FL, 33613, USA.
| | - Iswanto Sucandy
- Digestive Health Institute, AdventHealth, 3000 Medical Park Drive, Suite #500, Tampa, FL, 33613, USA
| | - Cameron Syblis
- Digestive Health Institute, AdventHealth, 3000 Medical Park Drive, Suite #500, Tampa, FL, 33613, USA
- University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Tara M Pattilachan
- Digestive Health Institute, AdventHealth, 3000 Medical Park Drive, Suite #500, Tampa, FL, 33613, USA
| | - Maria Christodoulou
- Digestive Health Institute, AdventHealth, 3000 Medical Park Drive, Suite #500, Tampa, FL, 33613, USA
| | - Alexander Rosemurgy
- Digestive Health Institute, AdventHealth, 3000 Medical Park Drive, Suite #500, Tampa, FL, 33613, USA
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Rayman S, Ross S, Sucandy I, Mikhail K, Christodoulou M, Pattilachan T, Rosemurgy A. The effects of smoking history on robotic transhiatal esophagectomy patient outcomes. J Robot Surg 2024; 18:76. [PMID: 38353887 DOI: 10.1007/s11701-024-01829-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Accepted: 01/14/2024] [Indexed: 02/16/2024]
Abstract
Esophageal resection for the treatment of esophageal cancer generally entails high rates of morbidity and mortality. Patients with a smoking history have increased post-operative complications following esophagectomy. This study was undertaken to determine how smoking or a history of smoking can affect perioperative outcomes and morbidity following robotic transhiatal esophagectomy. 75 patients were prospectively followed and divided; 44 patients actively smoking or with a history of significant smoking were classified as 'smokers', while the other 31 patients were classified as 'non-smokers'. Significance was determined at a p-value of ≤ 0.05 and data are presented as median (mean ± SD). 'Smokers' averaged 70(70 ± 7.8) years, 89% male, with 82% undergoing neoadjuvant therapy. 'Nonsmokers' averaged 68(69 ± 7.8) years, 74% male, and 74% receiving neoadjuvant therapy. BMI and ASA class showed no significant difference between the cohorts. 'Smokers' had an operative time of 341(343 ± 91.0) minutes and a blood loss of 150(191 ± 140.0) mL; 'nonsmokers' had 291(298 ± 65.9) minutes and 100(140 ± 120.9) mL, respectively (p = 0.02 for operative time). Tumor size and AJCC staging were similar for both cohorts. No significant differences were noted in postoperative complications, Clavien-Dindo score ≥ III, in-hospital mortality, length of stay, or 30-day readmissions. Survival rates were comparable. Hospital costs for 'smokers' were $33,131(41,091 ± 23,465.17) and $34,896 (62,154 ± 65,839.53) for 'nonsmokers' (p = 0.05). Profit/loss was $-23,155 (- 15,137 ± 35,819.29) for smokers and $-23,720 (- 16,716 ± 50,864.64) for nonsmokers. Current or past 'smokers' had longer operative times and lower costs following robotic transhiatal esophagectomy, with no significant difference in postoperative complications or survival compared to 'non-smokers'.
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Affiliation(s)
- Shlomi Rayman
- Digestive Health Institute, AdventHealth Tampa, 3000 Medical Park Drive, Suite#500, Tampa, FL, 33613, USA
- Department of General Surgery, Assuta Ashdod Public Hospital, Ashdod, Israel
- Affiliated with the Faculty of Health and Science, Ben-Gurion University, Beer-Sheba, Israel
| | - Sharona Ross
- Digestive Health Institute, AdventHealth Tampa, 3000 Medical Park Drive, Suite#500, Tampa, FL, 33613, USA.
| | - Iswanto Sucandy
- Digestive Health Institute, AdventHealth Tampa, 3000 Medical Park Drive, Suite#500, Tampa, FL, 33613, USA
| | - Katherine Mikhail
- Digestive Health Institute, AdventHealth Tampa, 3000 Medical Park Drive, Suite#500, Tampa, FL, 33613, USA
| | - Maria Christodoulou
- Digestive Health Institute, AdventHealth Tampa, 3000 Medical Park Drive, Suite#500, Tampa, FL, 33613, USA
| | - Tara Pattilachan
- Digestive Health Institute, AdventHealth Tampa, 3000 Medical Park Drive, Suite#500, Tampa, FL, 33613, USA
| | - Alexander Rosemurgy
- Digestive Health Institute, AdventHealth Tampa, 3000 Medical Park Drive, Suite#500, Tampa, FL, 33613, USA
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Dugan MM, Ross SB, Sucandy I, Slavin M, Pattilachan TM, Christodoulou M, Rosemurgy A. Cost comparison between medicare and private insurance for robotic transhiatal esophagectomy. J Robot Surg 2024; 18:30. [PMID: 38231356 DOI: 10.1007/s11701-023-01762-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Accepted: 12/01/2023] [Indexed: 01/18/2024]
Abstract
Esophageal cancer is a significant health concern, with the robotic platform being increasingly adopted for transhiatal esophagectomy (THE). While literature exists regarding the cost of robotic THE and its benefits, there is limited data analyzing cost and concurrent hospital reimbursement based on payor or provider. This study aimed to compare hospital reimbursement after robotic THE for patients with Medicare versus private insurance. With IRB approval, a prospective study of 85 patients from 2012 to 2022 who underwent robotic THE was conducted. Private insurance was defined as coverage excluding Medicare, Medicaid, or self-pay. Statistical analyses involved Student's t test, Chi-square test, and Fisher's exact test, with p ≤ 0.05 considered statistically significant. Data are presented as median (mean ± standard deviation). Among the 85 patients, 64 had Medicare, and 21 had private insurance. Medicare patients exhibited more frequent history of prior abdominal or thoracic surgeries (41% vs 10%, p < 0.01). Both groups showed no differences in factors like sex, body mass index, ASA classification, operative duration, estimated blood loss, conversions to 'open', tumor size, and major postoperative complications (Clavien-Dindo ≥ III). Similarly, metrics such as hospital stay duration, in-hospital mortality, 30-day readmission, and various financial components including total and variable costs, hospital reimbursement, and net margin were consistent across both. Despite Medicare patients being older and often having a broader operative history, hospital costs and reimbursements did not differ from patients with private insurance post-robotic THE. The robotic platform appears to mitigate potential disparities in hospitalization costs and hospital reimbursement for THE between Medicare and private insurance.
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Affiliation(s)
- Michelle M Dugan
- Florida Atlantic University Schmidt College of Medicine, Boca Raton, FL, USA
- Digestive Health Institute, AdventHealth Tampa, University of Central Florida (UCF), 3000 Medical Park Drive, Suite #500, Tampa, FL, 33613, USA
| | - Sharona B Ross
- Digestive Health Institute, AdventHealth Tampa, University of Central Florida (UCF), 3000 Medical Park Drive, Suite #500, Tampa, FL, 33613, USA.
| | - Iswanto Sucandy
- Digestive Health Institute, AdventHealth Tampa, University of Central Florida (UCF), 3000 Medical Park Drive, Suite #500, Tampa, FL, 33613, USA
| | - Moran Slavin
- Digestive Health Institute, AdventHealth Tampa, University of Central Florida (UCF), 3000 Medical Park Drive, Suite #500, Tampa, FL, 33613, USA
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Tara M Pattilachan
- Digestive Health Institute, AdventHealth Tampa, University of Central Florida (UCF), 3000 Medical Park Drive, Suite #500, Tampa, FL, 33613, USA
| | - Maria Christodoulou
- Digestive Health Institute, AdventHealth Tampa, University of Central Florida (UCF), 3000 Medical Park Drive, Suite #500, Tampa, FL, 33613, USA
| | - Alexander Rosemurgy
- Digestive Health Institute, AdventHealth Tampa, University of Central Florida (UCF), 3000 Medical Park Drive, Suite #500, Tampa, FL, 33613, USA
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Jacoby H, Ross S, Sucandy I, Syblis C, Crespo K, Johnson L, Rosemurgy A. The Effect of Body Mass Index on Robotic Transhiatal Esophagectomy for Esophageal Adenocarcinoma. Am Surg 2022; 88:2204-2209. [PMID: 35694911 DOI: 10.1177/00031348221086786] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Ross SB, Rayman S, Thomas J, Peek G, Crespo K, Syblis C, Sucandy I, Rosemurgy A. Evaluating the Cost for Robotic vs "Non-Robotic" Transhiatal Esophagectomy. Am Surg 2021; 88:389-393. [PMID: 34794333 DOI: 10.1177/00031348211046885] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION This study was undertaken to analyze and compare the cost of robotic transhiatal esophagectomy (THE) to "non-robotic" THE (ie, "open" and laparoscopic). METHODS With IRB approval, we prospectively followed 82 patients who underwent THE. We analyzed clinical outcomes and perioperative charges and costs associated with THE. To compare profitability, the robotic approach was analyzed against "non-robotic" approaches of THE using F-test, Mann-Whitney U test/Student's t-test, and Fisher's exact test. Statistical significance was reported as P ≤0.05. Data are presented as median (mean ± SD). RESULTS 67 patients underwent the robotic approach, and 15 patients underwent "non-robotic" approach; 4 were "open" and 11 were laparoscopic. 79 patients had adenocarcinoma. Operative duration for robotic THE was 327 (331 ± 82.8) vs 213 (225 ± 62.0) minutes (P = 0.0001) and estimated blood loss was 150 (184 ± 136.1) vs 300 (476 ± 708.7) mL (P = 0.0001). Length of stay was 7 (11 ± 11.8) vs 8 (12 ± 10.6) days (P = 0.76). 16 patients had post-operative complications with a Clavien-Dindo score of three or more. Hospital charges for robotic THE were $197,405 ($259,936 ± 203,630.8) vs "non-robotic" THE $159,588 ($201,565 ± $185,763.5) (P = 0.31). Cost of care for robotic THE was $34,822 ($48,844 ± $45,832.8) vs "non-robotic" THE was $23,939 ($39,386 ± $44,827.2) (P = 0.47). Payment received for robotic THE was $14,365 ($30,003 ± $40,874.7) vs "non-robotic" THE was $28,080 ($41,087 ± $44,509.1) (P = 0.41). 15% of robotic operations were profitable vs 13% of "non-robotic" operations. CONCLUSIONS Patients were predominantly older overweight men who had adenocarcinoma of the esophagus. The robotic approach had increased operative time and minimal blood loss. More than a fourth of operations included concomitant procedures. Patients were discharged approximately one week after THE. Overall, the robotic approach has no apparent significant differences in charges, cost, or profitability.
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Affiliation(s)
| | - Shlomi Rayman
- Department of General Surgery, 64850Assuta Medical Center, Ashdod, Israel.,4422Affiliated to the Faculty of Health and Science, Ben-Gurion University, Beer-Sheba, Israel
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Williams AM, Kathawate RG, Zhao L, Grenda TR, Bergquist CS, Brescia AA, Kilbane K, Barrett E, Chang AC, Lynch W, Lin J, Wakeam E, Lagisetty KH, Orringer MB, Reddy RM. Similar Quality of Life After Conventional and Robotic Transhiatal Esophagectomy. Ann Thorac Surg 2021; 113:399-405. [PMID: 33745901 DOI: 10.1016/j.athoracsur.2021.03.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Revised: 02/08/2021] [Accepted: 03/09/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Patient-reported outcomes (PROs) for minimally invasive esophagectomy (MIE) have demonstrated benefits compared to open transthoracic or 3-hole esophagectomy. PROs including quality of life (QoL) and fear of recurrence (FoR) comparing open transhiatal esophagectomy (THE) and transhiatal robotic-assisted MIE (Th-RAMIE) have been limited. METHODS At a single, high-volume academic center, patients undergoing THE and Th-RAMIE with gastric conduit for clinical stage I-III esophageal cancer from 2013 to 2018 were evaluated. The European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire (QLQ-C30), EORTC Quality of Life Questionnaire in Esophageal Cancer (QLQ-OES18), and FoR survey were administered preoperatively, and at 1, 6- and 12-months post-operatively. Linear mixed-effects models were used for QoL and FoR score comparisons. Perioperative outcomes were also compared. RESULTS 309 patients (212 THE and 97 Th-RAMIE) were included. The Th-RAMIE cohort had a significantly higher number of lymph nodes harvested (14 ±0.8 vs. 11.2 ±0.4; p = 0.01), shorter length of stay (days, 10.0 ± 6.7 vs. 12.1 ±7.0; p = 0.03), lower rates of postoperative ileus (5% vs. 15%; p = 0.02), and had fewer opioids prescribed at discharge (71% vs. 85%; p = 0.03). After adjustment, there were no significant differences in QLQ-C30, QLQ-OES18, and FoR scores between groups out to 1 year following surgery. CONCLUSIONS There were no clear patient-reported benefits of Th-RAMIE over THE for esophageal cancer. However, Th-RAMIE conferred a number of perioperative benefits.
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Affiliation(s)
- Aaron M Williams
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Ranganath G Kathawate
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA; University of Michigan Medical School, Ann Arbor, MI, USA
| | - Lili Zhao
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Tyler R Grenda
- Department of Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | | | | | - Keara Kilbane
- University of Michigan Medical School, Ann Arbor, MI, USA
| | - Emily Barrett
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Andrew C Chang
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA; University of Michigan Medical School, Ann Arbor, MI, USA; Section of Thoracic Surgery, University of Michigan, Ann Arbor, MI, USA
| | - William Lynch
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA; University of Michigan Medical School, Ann Arbor, MI, USA; Section of Thoracic Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Jules Lin
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA; University of Michigan Medical School, Ann Arbor, MI, USA; Section of Thoracic Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Elliot Wakeam
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA; University of Michigan Medical School, Ann Arbor, MI, USA; Section of Thoracic Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Kiran H Lagisetty
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA; University of Michigan Medical School, Ann Arbor, MI, USA; Section of Thoracic Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Mark B Orringer
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA; University of Michigan Medical School, Ann Arbor, MI, USA; Section of Thoracic Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Rishindra M Reddy
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA; University of Michigan Medical School, Ann Arbor, MI, USA; Section of Thoracic Surgery, University of Michigan, Ann Arbor, MI, USA.
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