ROBOtic Care Outcomes Project for acute gallbladder pathology

BACKGROUND

Robotic cholecystectomy is being increasingly used for patients with acute gallbladder disease who present to the emergency department, but clinical evidence is limited. We aimed to compare the outcomes of emergent laparoscopic and robotic cholecystectomies in a large real-world database.

METHODS

Patients who received emergent laparoscopic or robotic cholecystectomies from 2020 to 2022 were identified from the Intuitive Custom Hospital Analytics database, based on deidentified extraction of electronic health record data from US hospitals. Conversion to open or subtotal cholecystectomy and complications were defined using ICD10 and/or CPT codes. Multivariate logistic regression with inverse probability treatment weighting (IPTW) was performed to compare clinical outcomes of laparoscopic versus robotic approach after balancing covariates. Cost analysis was performed with activity-based costing and adjustment for inflation.

RESULTS

Of 26,786 laparoscopic and 3,151 robotic emergent cholecystectomy patients being included, 64% were female, 60% were ≥45 years, and 24% were obese. Approximately 5.5% patients presented with pancreatitis, and 4% each presenting with sepsis and biliary obstruction. After IPTW, distributions of all baseline covariates were balanced. Robotic cholecystectomy decreased odds of conversion to open (odds ratio, 0.68; 95% confidence interval, 0.49-0.93; p = 0.035), but increased odds of subtotal cholecystectomy (odds ratio, 1.64; 95% confidence interval, 1.03-2.60; p = 0.037). Surgical site infection, readmission, length of stay, hospital acquired conditions, bile duct injury or leak, and hospital mortality were similar in both groups. There was no significant difference in hospital cost.

CONCLUSION

Robotic cholecystectomy has reduced odds of conversion to open and comparable complications, but increased odds of subtotal cholecystectomy compared with laparoscopic cholecystectomy for acute gallbladder diseases. Further work is required to assess the long-term implications of these differences.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level IV.

A retrospective study of laparoscopic, robotic-assisted, and open emergent/urgent cholecystectomy based on the PINC AI Healthcare Database 2017-2020

BACKGROUND

Robotic-assisted cholecystectomy (RAC) is becoming increasingly common, but the outcomes of emergent/urgent robotic-assisted cholecystectomies compared to emergent laparoscopic (LC) and open cholecystectomies (OC) remain understudied.

METHODS

The PINC AI Healthcare Database was queried to identify adults who underwent emergent or urgent (Em-Ur) cholecystectomy between January 1, 2017, and December 31, 2020. Immediate postoperative and 30-day outcomes were identified including intraoperative complications, transfusion, conversion, postoperative complication, and hospital length of stay. Propensity score matching was done to compare outcomes between Em-Ur robotic-assisted, laparoscopic, and open cholecystectomies Subgroup analyses were performed comparing RAC done with and without fluorescent imaging as well as comparing RAC and LC performed for patients with class 3 obesity (BMI ≥ 40 kg/m2).

RESULTS

RAC Em-Ur cholecystectomies are being performed with increasing frequency and is the most utilized modality for patients with class 3 obesity. There was no difference in intraoperative complications (0.3%), bile duct injury (0.2%), or postoperative outcomes between RAC and LC. LC had significantly shorter operating room times (96 min (75,128)) compared to RAC (120 min (90,150)). There was a significant lower rate of conversion to open in RAC (1.9%) relative to LC (3.2%) in both the overall population and the class 3 obesity sub-analysis (RAC-2.6% vs. LC-4.4%). There was no difference in outcomes in robotic-assisted cholecystectomies done with and without fluorescent imaging.

CONCLUSIONS

A comparison of propensity score-matched cohorts of emergent/urgent robotic-assisted and laparoscopic cholecystectomy indicates that robotic-assisted cholecystectomy is a safe alternative to laparoscopic cholecystectomy, and that both have superior outcomes to open cholecystectomies.

Analysis of Oncological Outcomes After Robotic Liver Resection for Intrahepatic Cholangiocarcinoma

BACKGROUND

Concerns regarding minimally invasive liver resection of intrahepatic cholangiocarcinoma (IHCC) include inadequate resection margins and inferior long-term overall survival (OS) when compared to an "open" approach. Limited data exists to address these issues. We aimed to compare perioperative variables, tumor distance to margin, and long-term outcomes after IHCC resection based on surgical approach (robotic vs open) in our hepatobiliary center to address these concerns.

METHODS

With IRB approval, 34 patients who underwent robotic or open hepatectomy for IHCC were prospectively followed. Patients were stratified by tumor distance to resection margin (≤1 mm, 1.1-9.9 mm, ≥10 mm) for illustrative purposes and by approach (robotic vs open). Where appropriate, regression analysis and cox model of proportional hazards were utilized. Survival was stratified by margin distance and approach utilizing Kaplan-Meier curves. Data are presented as median (mean ± SD).

RESULTS

Patients undergoing robotic vs open hepatectomy had similar demographics. Patients undergoing the robotic approach had significantly lower estimated blood loss (EBL). Tumor distance to margin between the two approaches were similar (P = .428). Median OS between the two approaches was similar in patients of any margin distance.In the subgroup analysis by margin distance, the robotic approach yielded less EBL for patients in the 1.1-9.9 mm and ≥10 mm margin groups, and a shorter ICU length of stay for patients with ≥10 mm margin.

DISCUSSION

Similar margins were attained via either approach, translating into oncological non-inferiority of robotic IHCC resection. Robotic approach for the treatment of IHCC should be considered an alternative to an open approach.

National Trends in Cholecystectomy and Endoscopic Retrograde Cholangiopancreatography During Index Hospitalization for Mild Gallstone Pancreatitis

BACKGROUND

Guidelines call for cholecystectomy during the index hospitalization for patients with gallstone pancreatitis. Therefore, the study sought to determine the trends for cholecystectomy and Endoscopic Retrograde Cholangiopancreatography (ERCP) for mild gallstone pancreatitis.

METHODS

A retrospective analysis of the 2010-2018 Nationwide Readmission Database (NRD) was performed to identify patients with mild gallstone pancreatitis. The primary aim was to identify the trends in the use of cholecystectomy in these patients, and the secondary aim was to assess if ERCP alone was protective against readmission.

RESULTS

A total of 510,470 patients with mild gallstone pancreatitis were identified. There has been an increasing trend in ERCP use (25% in 2018 vs. 22% in 2010; p-0.001) and a decline in cholecystectomy (37% in 2018 vs. 46% in 2010; p-0.001) prior to discharge. Multivariate analysis revealed higher 30-day readmission for patients who underwent ERCP without cholecystectomy (odds ratio1.3; 95% confidence interval, 1.1-3.5) during the index admission.

CONCLUSIONS

There has been a decline in the use of cholecystectomy during index hospitalization for mild gallstone pancreatitis. In addition, ERCP was not protective against 30-day readmission from mild gallstone pancreatitis.

Assessing the perioperative complications and outcomes of robotic pancreaticoduodenectomy using the National Cancer Database: is it ready for prime time?

Robotic pancreaticoduodenectomy has generated significant interest in recent years. Our study aimed to evaluate the difference in surgical, oncological, and survival outcomes after pancreaticoduodenectomy (PD) by either a robotic (RPD) or open approach (OPD). Using the National Cancer Database, we identified patients from 2010 and 2017 diagnosed with pancreatic adenocarcinoma and underwent pancreaticoduodenectomy by either robotic PD or open approach. Patients who underwent robotic PD during 2010 were compared to patients receiving the same procedure in 2017. In addition, a secondary analysis was performed to assess outcomes of robotic PD to open PD for the 2017 patient cohorts. Our primary outcomes included 30-day and 90-day mortality, length of stay, as well as 30-day readmission. Secondary outcome measures were surgical margins, lymph node yield, and adjuvant chemotherapy initiation within 12 weeks of surgery. When we compared the 2017 data to 2010 data, we found that robotic pancreaticoduodenectomy had lower 30- and 90-day mortality rates in 2017 compared to 2010. Additionally, we found that the lymph node yield in robotic PD increased during the study period. When we compared robotic PD to open PD for 2017, we found no statistically significant differences in readmission rates (10.1% vs. 9.7%: p-0.4), lymph node yield, or negative margin between the groups. Outcomes of robotic PD have improved over the years. In 2017, outcomes of robotic PD were similar to open PD.

Comprehensive analysis of laparoscopic, robotic, and open hepatectomy outcomes using the nationwide readmissions database

Although open resections have been the most prevalent method of hepatectomies in the United States, laparoscopic and robotic methods of liver resection have since gained significant traction. Given the augmenting role of minimally invasive techniques in liver resection, a study that explores and analyzes the surgical outcomes of the approaches mentioned above to liver resection on a national basis is warranted. A retrospective analysis was performed in this study using the 2016-2018 Nationwide Readmissions Database (NRD). Patients who underwent liver resections via one of the following methods were selected and grouped: open, laparoscopic, or robotic. Our primary outcome variable of interest was the 45-day readmission rate. 11,186 patients were included in the analysis. The 45-day readmission rate was 13.5%, 12.9%, and 8.7% in the open, laparoscopic, and robotic groups, respectively (p < 0.001). A significantly lower complication rate (7.3%) was seen in the robotic group than its counterparts (11.4% in open vs. 9.1% in the laparoscopic group). Patients undergoing hepatectomies may benefit from the robotic approach given that it is associated with a shorter hospital length of stay and lower readmission rates.

Hospitalization Costs and Outcomes of Open, Laparoscopic, and Robotic Liver Resections

INTRODUCTION

Most liver resections performed in the United States are open. With the ever-increasing role of robotic surgery, our study's role is to assess national outcomes based on the surgical approach.

METHODS

We performed a retrospective analysis of the 2015 National Readmission Database (NRD). We selected patients undergoing open, laparoscopic, and robotic hepatectomy. Propensity score matching was performed to match the three groups in terms of demographics, hospital characteristics, and resection type. Our primary outcome was 6-month readmission rates and associated costs.

RESULTS

3,872 patients were included in the analysis (open = 3,420, laparoscopic = 343, and robotic = 109). Robotic liver resection has lower 6-month readmission rates (18.3%) than the laparoscopic (26.7%) and open (30%) counterparts. The robotic approach was more cost-effective ($127,716.56 ± 12,567.31) than the open ($157,880.82 ± 18,560.2) and laparoscopic approach ($152,060.78 ± 8,890.13) in terms of the total cost which includes cost per readmission.

CONCLUSIONS

There is a financial benefit of using robotics in terms of cost, hospital length of stay, and readmission rates in patients undergoing liver resection, cost.