Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve School of Medicine, 11100 Euclid Avenue, Cleveland, OH, 44106-5011, USA.
Surg Endosc. 2021 Jul;35(7):3802-3810. doi: 10.1007/s00464-020-07875-z. Epub 2020 Aug 12.
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.
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.
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).
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.
机器人微创食管切除术（RMIE）与更好的结果相关；然而，目前尚不清楚这些结果是特定于机器人技术还是仅存在于高容量机构。我们假设低容量 RMIE 中心的结果较差。
国家癌症数据库（NCDB）从 2010 年至 2016 年确定接受 RMIE 的患者。根据每个医院系统实施的 RMIE 总数，最低四分位数在研究期间实施的 RMIE 数量≤9。比较 90 天死亡率、评估的淋巴结数量、切缘状态、非计划再入院、住院时间（LOS）和总生存率。使用回归模型来解释混杂因素。
1565 例机器人食管切除术由 212 个机构完成。173 家医院实施了≤9 例 RMIE（研究期间共进行了 478 例手术，占 RMIE 的 30.5%），39 家医院实施了>9 例 RMIE（1087 例手术，占 69.5%）。实施>9 例 RMIE 的医院更有可能是学术中心（90.4% vs 66.2%，p<0.001），患者肿瘤分期较晚（65.3% vs 59.8%，p=0.049），且接受术前放疗（72.8% vs 66.3%，p=0.010）。基于人口统计学、淋巴结分期或术前化疗的使用，没有差异。在多变量回归中，实施≤9 例 RMIE 的医院与更高的 90 天死亡率、评估的淋巴结数量减少和更长的 LOS 相关；然而，与阳性切缘或非计划再入院率无关。在实施≤9 例 RMIE 的机构中，中位总生存期降低（37.3 与 51.5 个月，p<0.001）。多变量 Cox 回归显示，与实施>9 例 RMIE 的医院相比，实施≤9 例 RMIE 的医院与较差的生存相关（HR 1.327，p=0.018）。
许多机器人食管切除术在实施相对较少 RMIE 的机构进行，并且与短期和长期结果较差相关。这些数据表明需要对机器人食管切除术进行区域化或在低容量医院加强培训。
