Evaluating the Cost for Robotic vs “Non-Robotic” Transhiatal Esophagectomy

Abstract

Introduction

This study was undertaken to analyze and compare the cost of robotic transhiatal esophagectomy (THE) to “non-robotic” THE (ie, “open” and laparoscopic).

Methods

With IRB approval, we prospectively followed 82 patients who underwent THE. We analyzed clinical outcomes and perioperative charges and costs associated with THE. To compare profitability, the robotic approach was analyzed against “non-robotic” approaches of THE using F-test, Mann-Whitney U test/Student’s t-test, and Fisher’s exact test. Statistical significance was reported as P ≤0.05. Data are presented as median (mean ± SD).

Results

67 patients underwent the robotic approach, and 15 patients underwent “non-robotic” approach; 4 were “open” and 11 were laparoscopic. 79 patients had adenocarcinoma. Operative duration for robotic THE was 327 (331 ± 82.8) vs 213 (225 ± 62.0) minutes (P = 0.0001) and estimated blood loss was 150 (184 ± 136.1) vs 300 (476 ± 708.7) mL (P = 0.0001). Length of stay was 7 (11 ± 11.8) vs 8 (12 ± 10.6) days (P = 0.76). 16 patients had post-operative complications with a Clavien-Dindo score of three or more. Hospital charges for robotic THE were $197,405 ($259,936 ± 203,630.8) vs “non-robotic” THE $159,588 ($201,565 ± $185,763.5) (P = 0.31). Cost of care for robotic THE was $34,822 ($48,844 ± $45,832.8) vs “non-robotic” THE was $23,939 ($39,386 ± $44,827.2) (P = 0.47). Payment received for robotic THE was $14,365 ($30,003 ± $40,874.7) vs “non-robotic” THE was $28,080 ($41,087 ± $44,509.1) (P = 0.41). 15% of robotic operations were profitable vs 13% of “non-robotic” operations.

Conclusions

Patients were predominantly older overweight men who had adenocarcinoma of the esophagus. The robotic approach had increased operative time and minimal blood loss. More than a fourth of operations included concomitant procedures. Patients were discharged approximately one week after THE. Overall, the robotic approach has no apparent significant differences in charges, cost, or profitability.

Keywords

minimally invasive surgery esophagus/foregut robotic surgery cancer

Introduction

The American Cancer Society estimates that over 19,000 Americans will develop esophageal cancer and over 15,000 deaths will occur as a consequence of it in 2021; national statistics purport a 20% 5-year survival after esophagectomy, which can only be undertaken for the healthiest patients with the earlier stages of disease.¹ Esophageal cancer is a bad thing.

Highest risk patients are obese older white men with gastroesophageal reflux disease, for which they take proton pump inhibitors.^2,3 Diagnosis of esophageal cancer has improved over the past few decades, with improved radiologic imaging, endoscopic ultrasound, and wide-spread availability of scanning positron emission tomography. The treatment of esophageal cancer has evolved similarly for both neoadjuvant and adjuvant therapy; who gets it, for how long, and what does it constitute remain questions at the core of adjunctive nonoperative therapy (ie, radiation and chemotherapy).^4-6 The most recent perceived, yet unproven, advancement in esophagectomy is the application of minimally invasive esophagectomy, generally utilizing the robotic platform as a robotic transhiatal esophagectomy (THE). Robotic THE may potentially reduce post-operative complications and length of stay compared to the traditional “open” esophagectomy, without compromising oncological control.^5,7-9 Transhiatal esophagectomy and Ivor-Lewis thoraco-abdominal esophagectomy carry a high rate of post-operative morbidity and mortality, allowing tremendous room for improvement.¹⁰ With annual health care costs rising to four trillion dollars in the United States during the last year, there is a constant need for reducing health care costs of major abdominal and thoracic operations and utilizing the robotic platform may assist in this.^11,12

As with any innovative procedure, especially undertaken with novel technology, robotic THE will have its feasibility, safety, and clinical outcomes scrutinized. Robotic THE will also have its costs scrutinized and compared to more traditional approaches, such as “open” transhiatal esophagectomy.

The aim of this study was to assess the costs of robotic THE and to compare these costs to those associated “non-robotic” transhiatal esophagectomies. We hypothesized that the overall costs of robotic THE and “non-robotic” THE are similar; however, the outcomes after robotic THE are superior.

Methods

With Institutional Review Board approval, we prospectively followed all patients who underwent esophagectomy between January 2012 and December 2020. Data retrieved included demographics, tumor characteristics, neoadjuvant treatment, perioperative variables, adjuvant therapy, type and severity of complications, and costs incurred.

Patients undergoing robotic THE were compared to patients undergoing “non-robotic” esophageal resections which included “open” esophagectomy, laparoscopic Ivor-Lewis, and laparo-endoscopic single-site esophagectomy. Analysis of clinical outcomes, perioperative charges, and costs incurred associated with esophagectomy included lab services, radiologic studies, consultations, operating room services, materials, endoscopy, pharmacy, anesthesiology, bed cost, respiratory services, Length of stay (LOS), intensive care unit (ICU) stay, physical therapy, occupational therapy, speech therapy, and room cost for recovery. Severity of post-operative complications were graded according to the Clavien-Dindo Classification, with a score of ≥ III, which was considered a major complication.¹³ Costs of neoadjuvant and adjuvant therapy were not considered because they were stage dependent and not procedure dependent.

Surgical technique for THE was performed as previously described.⁵

The duration and constituents of neoadjuvant and adjuvant therapy were not defined by protocol.

Costs of all perioperative parameters were calculated from the institutional financial database identified by Current Procedural Terminology codes and dispersed into hospital cost, hospital charge, and payments received. Calculation of profitability was made by subtracting the payment received from the cost of the procedure.

To compare profitability, the robotic approach was analyzed against “non-robotic” approaches of THE using F-test, Mann-Whitney U test/Student’s t-test, and Fisher’s exact test where appropriate. Statistical significance was reported as P ≤ .05. For illustrative purposes, data are presented as median (mean ± SD).

Results

Over nine years, 82 patients underwent esophagectomy. Median age and body mass index were without differences between robotic or non-robotic approaches (Table 1). The majority of patients were men (n = 70, 85%), and the most common operation undertaken was robotic THE (n = 67, 82%) (Table 1). Among the “non-robotic” operations were four “open” and 11 laparoscopic THE. The most common pathology was adenocarcinoma, which was found in 79 patients (96%) (Table 1).

Table 1.

Patient Demographics.

Variable	Robotic THE	“Non-Robotic” THE	Total/P-Value
Patients (N)	67	15	82
Sex (M/W)	55 M/12W	15 M/0W	P = .11
Age (years)	69 (68 ± 8.1)	67 (63 ± 12.9)	P = .06
BMI (kg/m²)	26 (27 ± 5.0)	27 (27 ± 4.6)	P = 1.00
ASA class	II (18) III (46) IV(3)	II (2) III (13)	—

Abbreviations: BMI, body mass index; ASA, American Society of Anesthesiologists Class.

Neoadjuvant treatment was administered in 58 patients [n = 48 (72%) prior to robotic THE vs 10 (66%) for “non-robotic” THE, P = NS]. Twenty-four patients (30%) underwent an up-front operation without neoadjuvant treatment. The most common neoadjuvant treatment protocol involved carboplatin and paclitaxel.

Median operative duration was 311 minutes, with a significantly longer operative time for robotic THE vs “non-robotic” THE (Table 2; P = .0001). Median estimated blood loss (EBL) was significantly lower with robotic THE vs “non-robotic” THE (Table 2; P = .0001) with no difference in LOS [Table 3, P = .76]. Conversions from robotic THE occurred in five (8%) patients, which was less frequent than with laparoscopic THE (Table 2; n = 5/11, 46%, P = .004). There was no difference in the amount of lymph nodes excised [8 (10 ± 5.8) vs 6 (10 ± 7.4), P = 1.00] or involved with tumor [0 (1 ± 1.3) vs 0 (1 ± 2.2), P = 1.00] for robotic THE vs “non-robotic” THE, respectively. All but one patient received R0 resection with negative margins for robotic THE. Major post-operative complications occurred in 16 patients (19%) with no difference between approaches (n = 11/67, 16% for robotic THE vs n = 5/15, 33% for “non-robotic” THE, P = .16; Table 3). The nature of complications is depicted in Table 3. There were no significant differences in hospital charges between robotic THE vs “non-robotic” THE (Table 4), or in cost of care and payment received (Table 4). There was no difference in the number of patients for which the hospital experienced profitability for robotic (n = 10/67, n = 15% vs n = 2/15, 13%) for “non-robotic” THE (Table 4).

Table 2.

Intra-Operative Variables.

Variable	Robotic THE N = 67	“Non-Robotic” THE N = 15	Total/P-Value N = 82
EBL (mL)	150 (184 ± 136.1)	300 (476 ± 708.7)	P = .002
Operative duration (mins)	327 (331 ± 82.8)	213 (225 ± 62.0)	P = .0001
T criteria (%)	T0 (28%) T1 (38%) T2 (15%) T3 (18%) T4 (1%)	T0 (13%) T1 (27%) T2 (33%) T3 (27%) T4 (0%)	T0 (26%) T1 (35%) T2 (18%) T3 (20%) T4 (1%)
N criteria (%)	N0 (73%) N1 (21%) N2 (3%) N3 (1%)	N0 (67%) N1 (20%) N2 (13%) N3 (0%)	N0 (73%) N1 (21%) N2 (5%) N3 (1%)
Pathology (N)	64 Adenocarcinoma 1 GIST 1 Neuroendocrine tumor 1 Squamous cell carcinoma	15 Adenocarcinoma	79 Adenocarcinoma /3 other
Conversion (%)	5 (8%)	5 (46%)	P = .004
Tumor size (cm)	2 (2 ± 1.7)	2 (2 ± 2.7)	P = 1.00

Abbreviation: EBL, estimated blood loss.

Table 3.

Post-Operative Course.

Variable	Robotic THE N = 67	“Non-Robotic” THE N = 15	Total/P-Value N = 82
CD ≥ III (%)	11 (16%)	5 (33%)	P = .16
Complications	3 respiratory failure 2 capnothoraces 1 pneumonia	1 wound dehiscence 2 respiratory failure	9 (11%)/P = .35
In-hospital mortality	5 (8%)	2 (13%)	7 (9%)/P = .61
Average LOS (days)	7 (11 ± 11.8)	8 (12 ± 10.6)	P = .76

Abbreviation: CD, Clavien-Dindo classification.

Table 4.

Costs.

Variable	Robotic THE N = 67	“Non-Robotic” THE N = 15	Total/P-Value N = 82
Hospital cost	$34,822 ($48,844 ± $45,832.8)	$23,939 ($39,386 ± $44,827.2)	P = .47
Hospital charge	$197,405 ($259,936 ± 203,630.8)	$159,588 ($201,565 ± $185,763.5)	P = .31
Payments received	$14,365 ($30,003 ± $40,874.7)	$28,080 ($41,087 ± $44,509.1)	P = .35
Adjustments (charge-payment)	$171,999 ($234,384 ± $200,793.3)	$124,614 ($187,869 ± $162,628.2)	P = .41
Profit (payment-cost)	−$23,720 (−$23,319 ± $55,426.1)	−$19,997 (−$25,691 ± $26,510.1)	P = .87
Profitable Encounters (N)	10/67 (15%)	2/15 (13%)	12/82 (15%)

Discussion

Robotic THE is an innovative technique of esophageal resection. As with any innovative technique that challenges traditional operations, the toll (ie, learning curve, operative duration, LOS, EBL, morbidity, and mortality) of its adoption will be evaluated, in part, with the financial implications of its utilization. Our study examines the financial aspects of undertaking robotic THE relative to non-robotic esophagectomy, with considerations of prominent perioperative morbidities which influence overall health care costs. To our knowledge, this is the first study that assesses both cost and profitability of robotic THE and “non-robotic” THE while taking in account intra- and post-operative variables that directly affect costs and patient wellbeing.

Patients in this report were generally overweight older men with moderate operative candidacy. Almost all patients had adenocarcinoma in the distal esophagus and the significant majority underwent neoadjuvant therapy. Robotic THE was a significantly longer operation with less EBL, but LOS was not less after robotic THE. Our results show increased conversions to “open” procedures with “non-robotic” esophagectomies relative to robotic THE; the rate of conversions to “open” operations from robotic THE occurred in less than one in ten, most often early in our experience and generally as a consequence of failing to make progress for 15 minutes. We have found no significant differences in blood products, given post-operative course and overall costs between robotic THE and “non-robotic” esophagectomies.

This study shows that comparable lymph nodes harvests occur with both robotic and “other” approaches to THE. One patient who underwent robotic THE received an R0 resection with negative margins. Focal residual adenocarcinoma was found at the resection margin which exhibited near complete response to neoadjuvant chemoradiation.

In a retrospective study of over 700 esophagectomies by Geller et al,¹⁴ the authors reported a 76% increased incremental cost per major post-operative complication following esophagectomy, regardless of surgical approach. The most significant post-operative complication leading to a 200% increase in incremental cost per event was due to anastomotic complications requiring re-operation.¹⁴ Another retrospective study, utilizing the Surveillance, Epidemiology, and End-Results-Medicare database for esophagectomy cost, showed higher 90-day median cost in patients having a post-operative complication. Complications were predicted by women undergoing a transthoracic approach for mid esophageal stage I or III+ squamous cell carcinoma without receiving neoadjuvant treatment.¹⁵ Therein, overall cost was $45,471 with a $13,659 cost increase with any complication.¹⁵ Multivariate analysis showed that wound and pulmonary complications significantly increased costs.¹⁵ A prospectively collected database by Liu et al¹⁶ compared the cost of minimally invasive esophagectomy (MIE) to “open” esophagectomy and determined that overall costs were higher for patients undergoing MIE due to higher surgical costs, despite having higher ICU and hospitalization costs for “open” esophagectomy. A case series by Mori et al¹⁷ showed increased pulmonary complication in transthoracic vs transhiatal esophagectomies, both utilizing a robotic approach. While arguments about the superiority of transthoracic vs transhiatal esophagectomy has raged for decades and is beyond this report, this study of our robotic experience is notable for our data on costs and outcomes.¹⁸

While esophagectomy has been traditionally performed via a “non-robotic” approach, robotic THE stands out as a novel and intriguing approach for esophageal resection. Robotic THE harnesses the advantages of the robotic platform and negates the need for thoracic incisions, with potentially lowering EBL, pulmonary complications, LOS, and shortening recovery time.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Author Biography

Iswanto Sucandy, Shlomi Rayman, Ja’Karri Thomas, Kaitlyn Crespo, Cameron Syblis, and George Peek have no conflicts of interest to declare. Each author has contributed to the concept and design of the study, the analysis of data, revision of content, and acceptance of final version. The authors agree to be accountable to this manuscript’s contents. Sharona Ross and Alexander Rosemurgy both have an educational and research relationship with Intuitive Surgical Inc (Intuitive Corporation, Sunnyvale, CA). Both authors have contributed to the concept and design of the study, the analysis of data, revision of content, and acceptance of final version. The authors agree to be accountable to this manuscript’s contents.

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