M. C. Mason1,2, H. S. Tran Cao2, S. S. Awad1,2, F. Farjah3, G. J. Chang4, C. Chai2, N. N. Massarweh1,2 1Michael E. DeBakey VA Medical Center,Houston VA Center For Innovations In Quality, Effectiveness, And Safety,Houston, TX, USA 2Baylor College Of Medicine,Michael E. DeBakey Department Of Surgery,Houston, TX, USA 3University Of Washington,Department Of Surgery And Surgical Outcomes Reseach Center,Seattle, WA, USA 4The University Of Texas MD Anderson Cancer Center,Department Of Surgical Oncology And Health Services Research,Houston, TX, USA
Introduction: Laparoscopic and robotic techniques are applied across surgical specialties. However, the extent to which these minimally invasive surgery (MIS) techniques are applied for gastrointestinal (GI) cancer resection has not been well defined and the impact of receiving care at high MIS utilizing hospitals is unclear.
Methods: Retrospective cohort study of 137,581 surgically resected esophageal, gastric, pancreatic, hepatobiliary, colon, and rectal cancer patients within the National Cancer Data Base (2010-2013). Disease-specific, reliability-adjusted MIS utilization and conversion to open rates were calculated for each hospital and used to stratify hospitals into quartiles. Among gastric, pancreatic, and colon patients for whom AC was indicated, the association between days to AC and hospital MIS utilization was examined using generalized estimating equations. The association with risk of death was evaluated with multivariable Cox regression.
Results: While disease-specific MIS use increased significantly (42.0-68.3% increase; trend test, p<0.001 for all but hepatobiliary [p=0.007]), most hospitals remained low MIS-utilizers. High MIS utilization is associated with increased lymph nodes examined (p<0.001 for all) and shorter LOS (p<0.001 for all). Among colon and rectal patients, mortality at 30 days (colon—0.7% lowest MIS quartile vs 0.4% highest quartile; trend test, p<0.001; rectal—1.1% vs 0.8%; trend test, p=0.018) and 90 days (colon—2.6% vs 2.0%; trend test, p=0.002; rectal—2.4% vs 1.6%; trend test, p=0.002) was lower at higher MIS utilizing hospitals. Except for colon, case volume was highest at hospitals in the lowest and highest conversion to open quartiles. However, hospital conversion rates were not clearly associated with worse perioperative outcomes. For gastric cancer, each 10% increase in hospital MIS utilization is associated with 3.3[95% CI, 1.2-5.3] fewer days to AC initiation. While this association was not observed for pancreatic or colon patients overall, time-to-AC was decreased by 3.3[0.7-5.8] days for gastric and 1.1 [0.3-2.0] days for colon patients who had open resection. Relative to the lowest quartile hospitals, care at higher MIS utilizing hospitals was associated with a lower risk of death for colon (Q2–Hazard Ratio 0.96[0.89-1.02]; Q3–HR 0.91[0.86-0.98]; Q4–HR 0.87[0.82-0.93]) and rectal cancer patients (Q2–Hazard Ratio 0.89[0.76-1.05]; Q3–HR 0.84[0.72-0.97]; Q4–HR 0.86[0.74-0.98]).
Conclusions: Although MIS use for GI cancer has increased, most hospitals remain low utilizers. Shorter LOS at high utilizing hospitals and the lack of a clear association between hospital conversion rates and perioperative outcomes potentially reflect the real world effectiveness of MIS. As data regarding MIS for GI cancer resection evolve, MIS utilization may help identify hospitals with infrastructure and care processes that can be used to facilitate multimodality cancer care.