National Trends In Operative Approach To Esophagectomy: Utilization Rates, Disparities And Overall Survival
Akbarshakh Akhmerov, Andrew R. Brownlee, Justin Watson, Shruthi Nammalwar, Amirhossein Mahfoozi, Harmik Soukiasian.
Cedars-Sinai Medical Center, Los angeles, CA, USA.
Background: Although open esophagectomies (OE) have traditionally been favored, minimally invasive approaches are increasingly utilized and associated with improved outcomes. We investigated the adoption rates of robotic-assisted minimally invasive esophagectomy (RAMIE) and minimally invasive esophagectomy (MIE) compared with OE. Factors impacting the surgical approach, perioperative outcomes, and overall survival were analyzed.
Methods: The NCDB was queried for patients who underwent OE, MIE, and RAMIE for esophageal cancer from 2010-2020. Adoption rates of RAMIE, MIE and OE were determined for all patients. Patients with primary cervical esophageal cancer, stage 4 disease, unknown staging, or missing 30-day follow-up data were excluded. Propensity matched cohorts were created for each surgical approach and compared. Results: A total of 14,467 patients underwent an esophagectomy for stage I, II, and III disease (OE: n=8,445; MIE: n=4,506; RAMIE: n=1,516). Between 2010 and 2020, OE decreased by 39%, while MIE and RAMIE increased by 88% and 918%, respectively (Figure 1A). At non-academic centers, OE was performed more frequently (42%) than MIE (35%) or RAMIE (36%) (p<0.001), and uninsured patients were more likely to undergo OE (1.9%) than MIE (1.4%) or RAMIE (0.7%) (p=0.012). In the propensity matched cohort, the number of sampled lymph nodes was higher in RAMIE, compared with OE (16 [11,23] vs 14 [9, 20]; p<0.001). The length-of-stay (LOS) was shorter in the RAMIE group compared with OE (9 [7, 13] days vs 10 [8, 15], p<0.001). Long-term survival was significantly better in the RAMIE group, compared with OE (p<0.001; Figure 1B), while RAMIE had comparable lymph node harvest (p=0.212) and overall survival (p=0.076) with MIE (Figure 1C). Conclusion: This contemporary review of a national cohort demonstrates the rapid adoption of minimally invasive esophagectomy techniques, without compromise in short-term or long-term outcomes. However, the adoption of minimally invasive technology has not been uniform, highlighting the need to expand access to minimally invasive esophageal procedures. 
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