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

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.

Automated summary

The study found that robotic minimally invasive esophagectomies (RMIE) performed at low-volume institutions have higher mortality rates, lower number of lymph nodes evaluated, longer length of stay, and lower overall survival rates. These results support regionalization of RMIE or enhanced training in lower volume hospitals.