A. M. Villano1, A. Zeymo2, M. Bayasi1, W. Al-Refaie1, K. Chan1 1Georgetown University Medical Center,General Surgery,Washington, DC, USA 2MedStar Health Research Institute,Washington, DC, USA
Introduction: Minimally invasive surgery (MIS) for colorectal cancer (CRC) has increasingly gained attention as a result of level one evidence supporting equivalent oncologic outcomes versus the open approach. The adoption of minimally invasive techniques has not been universal. We examined temporal trends of MIS (both laparoscopic and robotic approaches) for CRC and tested for differences in utilization and surgical outcomes amongst hospital types.
Methods: The National Cancer Database was queried for patients who underwent colon (n=218,138) and rectal (n=46,263) cancer surgery between 2011-2015. Time-trend analysis was performed to assess differences in uptake of MIS approaches (laparoscopic, robotic) by hospital type across the study period. Comparison of MIS use amongst hospital types (community, comprehensive community, integrated network, and academic) was performed with unadjusted and multivariable, adjusted logistic analyses controlling for covariates (age, comorbidities, income, education, rurality of treating center, tumor stage, tumor grade), to identify differences in case severity and surgical outcomes.
Results: Across the study period, community hospitals had the lowest overall rate of laparoscopic (38.1%) and robotic (3.6%) procedures for CRC as compared to comprehensive community (46.9% laparoscopic; 6.14% robotic), integrated network (48.1% laparoscopic; 7.14% robotic), and academic (47.3% laparoscopic; 7.15% robotic) (p<0.001). Community hospitals exhibited a significant lag in adoption rates of robotic surgery per year for CRC across the study period as compared to the mean rate of change amongst all other hospital types (colon= 0.93% vs. 1.52%; rectum= 2.12% vs. 4.14%). However, these centers adopted laparoscopic rectal surgery the quickest, closing a large disparity gap in utilization by 2015. As compared to laparoscopic colon surgery at academic centers, community centers treated lower grade tumors (OR 0.786) in less comorbid patients (OR 0.947), however more frequently produced margin-positive resections (OR 1.446) with higher 30-day (OR 1.384) and 90-day mortality (OR 1.292)(for all p<0.05, Table 1). A similar relationship existed for robotic colon and laparoscopic rectal surgery at community hospitals, whereby margins were more frequently positive despite treating lower grade tumors (p<0.05, Table 1).
Conclusion:The application of MIS to colorectal cancer lags at the community level and suffers from worse post-operative mortality, an effect which is pronounced in the laparoscopic approach to colon cancer. As utilization of MIS approaches in CRC continues to grow, these observations suggest that centralization to academic centers is paramount in providing safe and effective care.
