Evaluating the Cost for Robotic vs "Non-Robotic" Transhiatal Esophagectomy

Clinical Outcomes and Costs of Robotic-assisted vs Conventional Mitral Valve Repair: A National Analysis

BACKGROUND

Robotic approaches have been increasingly utilized for cardiothoracic operations, though concerns regarding costs remain. We evaluated short-term outcomes and costs of robotic-assisted and conventional mitral valve repair (MV-repair), hypothesizing that cost differences would be mitigated at high-volume programs.

METHODS

Adults undergoing elective MV-repair from 2016 to 2020 were identified in the Nationwide Readmissions Database. Patients with rheumatic heart disease, mitral stenosis, and those undergoing concomitant operations were excluded. Generalized linear models were utilized to evaluate the association between approach and in-hospital mortality, complications, length of stay, costs, and 90-day readmissions. Annual institutional MV-repair volume was modeled using restricted cubic splines, and cost differences subsequently evaluated by volume tertile.

RESULTS

Of 40,738 patients, 9.8% underwent robotic-assisted MV-repair. Risk-adjusted outcomes including mortality, stroke, reoperation, respiratory complications, postoperative infection, and readmission were comparable between the 2 groups, while those undergoing robotic-assisted MV-repair had lower rates of nonhome discharge. The median cost of robotic-assisted MV-repair was greater than conventional surgery ($46,800 vs $38,500, P < .001). Despite a 1.3-day decrement (95% CI, 1.1-1.6) in length of stay, robotic-assisted MV-repair was associated with greater risk-adjusted costs by $10,500 (95% CI, $5800-$15,200). Programs in the highest volume tertile exhibited comparable costs for robotic-assisted and conventional MV-repair (cost difference, $5900; 95% CI, -$1200 to $12,200; P > .05).

CONCLUSIONS

Robotic-assisted MV-repair had comparable short-term outcomes relative to conventional surgery. Despite increased costs of robotic-assisted MV-repair overall, high-volume programs had similar risk-adjusted costs by approach. These findings support the designation and performance of robotic MV-repair at centers of excellence in the United States.

A comparative assessment of ACS NSQIP-predicted and actual surgical risk outcomes of robotic transhiatal esophagectomy for esophageal adenocarcinoma resection at a high volume institution

Esophageal adenocarcinoma incidence is increasing in Western nations. There has been a shift toward minimally invasive approaches for transhiatal esophagectomy (THE). This study compares the outcomes of robotic THE for esophageal adenocarcinoma resection at our institution with the predicted metrics from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP). With Institutional Review Board (IRB) approval, we prospectively followed 83 patients who underwent robotic THE from 2012 to 2023. Predicted outcomes were determined using the ACS NSQIP Surgical Risk Calculator. Our outcomes were compared with these predicted outcomes and with general outcomes for transhiatal esophagectomy reported in ACS NSQIP, which includes a mix of surgical approaches. The median age of patients was 70 years, with a body mass index (BMI) of 26.4 kg/m2 and a male prevalence of 82%. The median length of stay was 7 days. The rates of any complications and in-hospital mortality were 16% and 5%, respectively. Seven patients (8%) were readmitted within a 30-day postoperative window. The median survival is anticipated to surpass 95 months. Our outcomes were generally aligned with or surpassed the predicted ACS NSQIP metrics. The extended median survival of over 95 months highlights the potential effectiveness of robotic THE in the resection of esophageal adenocarcinoma. Further exploration into its long-term survival benefits and outcomes is warranted, along with studies that provide a more direct comparison between robotic and other surgical approaches.

Is Robotic Surgery the Future for Resectable Esophageal Cancer?: A Systematic Literature Review of Oncological and Clinical Outcomes

BACKGROUND

Radical esophagectomy for resectable esophageal cancer is a major surgical intervention, associated with considerable postoperative morbidity. The introduction of robotic surgical platforms in esophagectomy may enhance advantages of minimally invasive surgery enabled by laparoscopy and thoracoscopy, including reduced postoperative pain and pulmonary complications. This systematic review aims to assess the clinical and oncological benefits of robot-assisted esophagectomy.

METHODS

A systematic literature search of the MEDLINE (PubMed), Embase and Cochrane databases was performed for studies published up to 1 August 2023. This review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocols and was registered in the PROSPERO database (CRD42022370983). Clinical and oncological outcomes data were extracted following full-text review of eligible studies.

RESULTS

A total of 113 studies (n = 14,701 patients, n = 2455 female) were included. The majority of the studies were retrospective in nature (n = 89, 79%), and cohort studies were the most common type of study design (n = 88, 79%). The median number of patients per study was 54. Sixty-three studies reported using a robotic surgical platform for both the abdominal and thoracic phases of the procedure. The weighted mean incidence of postoperative pneumonia was 11%, anastomotic leak 10%, total length of hospitalisation 15.2 days, and a resection margin clear of the tumour was achieved in 95% of cases.

CONCLUSIONS

There are numerous reported advantages of robot-assisted surgery for resectable esophageal cancer. A correlation between procedural volume and improvements in outcomes with robotic esophagectomy has also been identified. Multicentre comparative clinical studies are essential to identify the true objective benefit on outcomes compared with conventional surgical approaches before robotic surgery is accepted as standard of practice.

The Implications of Readmission on Cost and Patient Outcomes Following Distal Pancreatectomy and Splenectomy

BACKGROUND

Robotic platform usage for distal pancreatectomy and splenectomy has grown exponentially in recent years. This study aims to identify the impact of readmission following robotic distal pancreatectomy and splenectomy and to analyze the financial implications of these readmissions.

METHODS

We prospectively followed 137 patients after robotic distal pancreatectomy and splenectomy. Readmission was defined as rehospitalization within 30 days post-discharge. Total cost incorporated initial and readmission hospital costs, when applicable. Outcomes were analyzed using chi-square/Fisher's exact test and Student's t test. Data are presented as median (mean ± SD).

RESULTS

Of 137 patients, 20 (14%) were readmitted. Readmitted patients were 67 (66 ± 10.3) years old and had a BMI of 30 (30 ± 7.0) kg/m2; 9 (45%) had previous abdominal operations. Non-readmitted patients were 67 (62 ± 14.7) years old and had a BMI of 28 (28 ± 5.7) kg/m2; 37 (32%) had previous abdominal operations (P = NS, for all). Readmitted patients vs non-readmitted patients had operative durations of 327 (363 ± 179.1) vs 251 (293 ± 176.4) minutes (P = .10), estimated blood loss (EBL) of 90 (159 ± 214.6) vs 100 (244 ± 559.4) mL (P = .50), and tumor diameter of 3 (4 ± 2.0) vs 3 (4 ± 2.9) cm (P = 1.00). Initial length of stay (LOS) for readmitted patients vs patients who were not readmitted was 5 (5 ± 2.7) vs 4 (5 ± 3.0) days (P = 1.00); total hospital cost of those readmitted, including both admissions, was $29,095 (32,324 ± 20,227.38) vs $24,663 (25,075 ± 10,786.45) (P = .018) for those not readmitted.

DISCUSSION

Despite a similar perioperative course, readmissions were associated with increased costs. We propose thorough consideration before readmission and increased patient education initiatives will reduce readmissions after robotic distal pancreatectomy and splenectomy.

Cost comparison between medicare and private insurance for robotic transhiatal esophagectomy

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.

Robotic-Assisted Ivor Lewis Esophagectomy Is Safe and Cost Equivalent Compared to Minimally Invasive Esophagectomy in a Tertiary Referral Center

In recent decades, robotic-assisted minimally invasive esophagectomy (RAMIE) has been increasingly adopted for patients with esophageal cancer (EC) or cancer of the gastroesophageal junction (GEJ). However, concerns regarding its costs compared to conventional minimally invasive esophagectomy (MIE) have emerged. This study examined outcomes and costs of RAMIE versus total MIE in 128 patients who underwent Ivor Lewis esophagectomy for EC/GEJ at our department between 2017 and 2021. Surgical costs were higher for RAMIE (EUR 12,370 vs. EUR 10,059, p < 0.001). Yet, median daily (EUR 2023 vs. EUR 1818, p = 0.246) and total costs (EUR 30,510 vs. EUR 29,180, p = 0.460) were comparable. RAMIE showed a lower incidence of postoperative pneumonia (8% vs. 25%, p = 0.029) and a trend towards shorter hospital stays (15 vs. 17 days, p = 0.205), which may have equalized total costs. Factors independently associated with higher costs included readmission to the intensive care unit (hazard ratio [HR] = 7.0), length of stay (HR = 13.5), anastomotic leak (HR = 17.0), and postoperative pneumonia (HR = 5.4). In conclusion, RAMIE does not impose an additional financial burden. This suggests that RAMIE may be considered as a valid alternative approach for esophagectomy. Attention to typical cost factors can enhance postoperative care across surgical methods.

A Single-Institution Comparison of Robot-Assisted and Conventional Laparoscopic Colorectal Surgeries

There has been ongoing discussion regarding the superiority of robotic laparoscopic surgery (RLS) over conventional laparoscopic surgery (CLS) in many surgical subspecialties. We therefore sought to elucidate if RLS is associated with more favorable clinical outcomes than CLS among patients who underwent colorectal surgery. Using data from a high-volume single institution in New Jersey, we identified 145 patients who underwent an elective RLS or CLS sigmoid resection for colon cancer or diverticulitis in 2019 and 2020. We analyzed operation time, hospitalization cost, complications, readmissions, reoperations, and lymph node retrieval. Operation time and operation to discharge time were not significantly different among patients undergoing surgery for colon cancer (P > .05), but operation time was found to be longer in diverticulitis patients (P = .03). Additionally, RLS was significantly more costly ($86,003 ± $3520 vs. $68,277 ±$1,168, P < .001) for patients with diverticulitis. Our data demonstrate that the benefit of RLS over CLS in colon resections for diverticulitis and colon cancer is not evident due to the increased costs associated with RLS procedures.