Adoption of Minimally Invasive Lung Resection: A National Cancer Database Study.

INTRODUCTION: Minimally invasive lung resection has been associated with improved outcomes; however, institutional characteristics associated with utilization are unclear. We hypothesized that the presence of surgical robots at institutions would be associated with increased utilization of minimally invasive techniques . METHODS: Patients with cT1/2N0M0 non-small cell lung cancer who underwent lung lobectomy between 2010 and 2020 in the National Cancer Database were identified. Patients were categorized by operative approach as minimally invasive surgery (MIS) versus open. Institutions were categorized as "high utilizers" of MIS technique if their proportion of MIS lobectomies was >50%. Multivariate logistic regressions were used to determine factors associated with proportion of procedures performed minimally invasively. Further multivariate models were used to evaluate the association of proportion of MIS procedures with 90-d mortality, hospital length of stay, and hospital readmission. RESULTS: In multivariate analysis, passage of time by year (odds ratio [OR] 1.26; confidence interval [CI] 1.22-1.30) and presence of a robot at the facility (OR 3.48; CI 2.84-4.24) were associated with high MIS-utilizing facilities. High utilizers of MIS were associated with lower 90-d mortality (OR 0.89; CI 0.83-0.97) and hospital length of stay (coeff -0.88; CI -1.03 to -0.72). Hospital readmission was similar between high and low MIS-utilizing facilities (compared to low MIS-utilizing facilities: OR 1.06; CI 0.95-1.09). CONCLUSIONS: Passage of time and the presence of surgical robots were independently associated with increased utilization of MIS lobectomy. In addition to being associated with improved patient-level outcomes, robotic surgery is correlated with a higher proportion of procedures being performed minimally invasively.

Gender Disparities in Surgical Subspecialties: A CMS Data Analysis.

INTRODUCTION: The persistent under-representation of women in surgery remains a critical concern within the medical profession, prompting a need for a nuanced analysis of gender distribution. Despite advancements in medical education, historical gender disparities in surgery persist, necessitating an exploration of the specific realms where gaps are most pronounced. Leveraging the 2023 Center for Medicare & Medicaid Services National Downloadable Database, this study aims to contribute insights into the multifaceted dynamics of gender representation within surgical disciplines. METHODS: Data from 1,168,064 physicians in the 2023 Center for Medicare & Medicaid Services National Downloadable Database were analyzed to distinguish between surgeons and physicians in medicine subspecialties. Univariable and multivariable logistic regression explored demographic variables, practice settings, and temporal trends to comprehensively understand factors contributing to the observed gender gap. RESULTS: The analysis revealed a statistically significant gender difference, with only 16.7% of surgeons identified as female. Temporal trends indicated a slow increase in female surgeon representation, and specialty-specific analysis unveiled variations, such as lower likelihoods of females in cardiac surgery and higher likelihoods in colorectal surgery. Multivariable logistic regression emphasized factors influencing the odds of physicians practicing surgery, with female physicians exhibiting a lower likelihood. Regional and graduation year variations also played roles in surgical practice. CONCLUSIONS: This study provides evidence-based insights into the persistent gender gap within surgical specialties, emphasizing the need for targeted interventions to enhance inclusivity and equity in the surgical workforce. The findings highlight intricate interplays of demographic, temporal, and specialty-specific factors, laying a foundation for future initiatives promoting a more diverse and inclusive surgical environment.

Risk Factors for Chronic Atrial Fibrillation Following Lung Lobectomy.

INTRODUCTION: Postoperative atrial fibrillation (POAF) is a common complication following lung lobectomy and is associated with increased risk of stroke, mortality, and prolonged hospital length of stay. The purpose of this study was to define the risk factors for POAF after lobectomy, hypothesizing that operative approach would be associated with risk of chronic POAF. METHODS: The TriNetX database was used to identify adult patients with no history of arrythmia receiving elective lung lobectomy for cancer from 7/6/2003-7/6/2023. Patients were categorized by approach: video-assisted thoracoscopic surgery (VATS) or open. The outcome of interest was the presence of POAF occurring at 1-3 months ("early") and 12-24 months postop ("chronic"). Propensity matching was performed to reduce bias between cohorts. RESULTS: We identified 22,998 patients: 8472 (36.8%) who received open and 14,526 (63.2%) VATS lobectomy. The rate of early POAF was 3.7% of VATS and 5.3% of open patients. The rate of chronic POAF was 5.5 % of VATS patients and 6.2% of open lobectomy patients. Propensity matching decreased bias between the approach groups, creating 7942 pairs for analysis. After matching, the risk of early POAF was greater in the open approach (5.5% open vs 3.4% VATS, risk ratio 1.607 (95% confidence interval 1.385-1.865), P < 0.001). Chronic POAF was (also) higher in the open approach (6.3% open vs 5.2% VATS, Risk Ratio 1.211 (95%CI 1.067-1.374), P = 0.003). CONCLUSIONS: Postoperative atrial fibrillation (POAF) occurs more commonly after open lobectomy, both acutely and chronically. Providers should counsel patients about the risk of chronic arrythmia after lung resection.

Early Repair of Rib Fractures Is Associated with Superior Length of Stay and Total Hospital Cost: A Propensity Matched Analysis of the National Inpatient Sample.

Background and Objectives: Previous studies have suggested that early scheduling of the surgical stabilization of rib fractures (SSRF) is associated with superior outcomes. It is unclear if these data are reproducible at other institutions. We hypothesized that early SSRF would be associated with decreased morbidity, length of stay, and total charges. Materials and Methods: Adult patients who underwent SSRF for multiple rib fractures or flail chest were identified in the National Inpatient Sample (NIS) by ICD-10 code from the fourth quarter of 2015 to 2016. Patients were excluded for traumatic brain injury and missing study variables. Procedures occurring after hospital day 10 were excluded to remove possible confounding. Early fixation was defined as procedures which occurred on hospital day 0 or 1, and late fixation was defined as procedures which occurred on hospital days 2 through 10. The primary outcome was a composite outcome of death, pneumonia, tracheostomy, or discharge to a short-term hospital, as determined by NIS coding. Secondary outcomes were length of hospitalization (LOS) and total cost. Chi-square and Wilcoxon rank-sum testing were performed to determine differences in outcomes between the groups. One-to-one propensity matching was performed using covariates known to affect the outcome of rib fractures. Stuart-Maxwell marginal homogeneity and Wilcoxon signed rank matched pair testing was performed on the propensity-matched cohort. Results: Of the 474 patients who met the inclusion criteria, 148 (31.2%) received early repair and 326 (68.8%) received late repair. In unmatched analysis, the composite adverse outcome was lower among early fixation (16.2% vs. 40.2%, p < 0.001), total hospital cost was less (USD114k vs. USD215k, p < 0.001), and length of stay was shorter (6 days vs. 12 days) among early SSRF patients. Propensity matching identified 131 matched pairs of early and late SSRF. Composite adverse outcomes were less common among early SSRF (18.3% vs. 32.8%, p = 0.011). The LOS was shorter among early SSRF (6 days vs. 10 days, p < 0.001), and total hospital cost was also lower among early SSRF patients (USD118k vs. USD183k late, p = 0.001). Conclusion: In a large administrative database, early SSRF was associated with reduced adverse outcomes, as well as improved hospital length of stay and total cost. These data corroborate other research and suggest that early SSRF is preferred. Studies of outcomes after SSRF should stratify analyses by timing of procedure.

Is Sarcomatoid Lung Cancer Associated With Inferior Overall Survival? A National Cancer Database Analysis.

INTRODUCTION: Sarcomatoid lung cancer has mainly been described in case series and single institution reviews. Although often associated with a poor prognosis, the overall survival compared to other forms of nonsmall cell lung cancer (NSCLC) is unknown. We hypothesize that sarcomatoid lung cancers have worse overall survival relative to other forms of NSCLC. MATERIALS AND METHODS: In this retrospective cohort study, we identified adult patients with nonmetastatic NSCLC from 2004 to 2018 in the National Cancer Database. Patients were categorized by histology as sarcomatoid, adenocarcinoma, or squamous cell carcinoma. We compared clinical and demographic characteristics between the groups. The primary outcome of overall survival was analyzed using Kaplan-Meier analysis. Multivariable Cox analysis was used to analyze factors associated with overall survival in sarcomatoid patients undergoing surgery. RESULTS: Among 1,259,109 patients with lung cancer, there were 5223 (0.4%) sarcomatoid cancers. Sarcomatoid patients were more likely to be male, of Hispanic ethnicity, have fewer comorbidities, and receive treatment at an academic program. Despite higher cT- and M-stages, patients with sarcomatoid cancer were more likely to undergo surgical resection in multivariate analysis (odds ratio = 1.8 [confidence interval 1.60-2.11]; P < 0.001). Among nonmetastatic patients, overall survival was lower for sarcomatoid cancer relative to other histologies in Kaplan-Meier analysis (median survival sarcomatoid 17.6 mo versus nonsarcomatoid 31.5 mo, P < 0.001). CONCLUSIONS: This National Cancer Database study confirms the findings of smaller studies that sarcomatoid cancer is associated with inferior overall survival compared to other NSCLCs. Given the inferior prognosis, further studies regarding optimal staging practices are appropriate.

Evaluating the Optimal Time Between Diagnosis and Surgical Intervention for Early-Stage Lung Cancer.

INTRODUCTION: There is no consensus on the optimal timing for lung cancer surgery. We aim to evaluate the impact of timing of surgical intervention. We hypothesize delay in intervention is associated with worse overall survival and higher pathologic upstaging in early-stage lung cancer. METHODS: We identified patients with cT1/2N0M0 nonsmall cell lung cancer in the National Cancer Database from 2004 to 2018. Patients were categorized by time to surgery groups: early (<26 d), average (26-60 d), and delayed (61-365 d). Primary outcome was overall survival and secondary outcome was pathologic upstaging. Multivariate models and survival analyses were used to determine factors associated with time from diagnosis to surgery, pathologic upstaging, and overall survival. RESULTS: In multivariate model, advanced age, non-Hispanic Black patients, nonprivate insurance, low median income and education, and treatment at low-volume facilities were less likely to undergo early intervention and compared to the average group were more likely to receive delayed intervention. Pathologic upstaging was more likely in the delayed group (odds ratio 1.11, 1.07-1.14) compared to early group (odds ratio 0.96, 0.93-0.99). Early intervention was associated with improved overall survival (hazard ratio 0.93, 0.91-0.95), while delayed intervention was associated with inferior survival (hazard ratio 1.11, 1.09-1.14). CONCLUSIONS: Expeditious surgical intervention is associated with lower rates of pathologic upstaging and improved overall survival in early-stage lung cancer. Delays in surgery are associated with social and economic factors, suggesting disparities in access to surgery. Lung cancer surgery should be performed as quickly as possible to maximize oncologic outcomes.

Modeling the COVID Pandemic: Do Delays in Surgery Justify Using Stereotactic Radiation to Treat Low-Risk Early Stage Non-Small Cell Lung Cancer?

INTRODUCTION: It was suggested that stereotactic radiation (SBRT) is an "alternative if no surgical capacity is available" for non-small cell lung cancer (NSCLC) care during the COVID-19 pandemic. The purpose of this study was to compare the oncologic outcomes of delayed surgical resection and early SBRT among operable patients with early stage lung cancer. METHODS: The National Cancer Database was queried for patients with cT1aN0M0 NSCLC who underwent surgery or SBRT (2010-2016) with no comorbidity. Patients with any comorbidities or age >80 were excluded. The outcome of interest was overall survival. Delays in surgical care were modeled using different times from diagnosis to surgery. A 1:1 propensity match was performed and survival was analyzed using multivariable Cox regression. RESULTS: Of 6720 healthy cT1aN0M0 NSCLC patients, 6008 (89.4%) received surgery and 712 (10.6%) received SBRT. Among surgery patients, time to surgery >30 d was associated with inferior survival (HR > 1.4, P ≤ 0.013) compared with patients receiving surgery ≤14 d. Relative to SBRT, surgery demonstrated superior survival at all time points evaluated: 0-30 d, 31-60 d, 61-90 d, and >90 d (all P < 0.001). Among a propensity-matched cohort of 256 pairs of patients, delayed surgery (>90 d) remained association with better overall survival relative to early SBRT (5-year survival 76.9% versus 32.3%, HR = 0.266, P < 0.001). CONCLUSIONS: Although longer time to surgery is associated with inferior survival among surgery patients, delayed surgery is superior to early SBRT. Surgical resection should remain the standard of care to treat operable early stage lung cancer despite delays imposed by the COVID-19 pandemic.

Contemporary outcomes of esophageal and gastroesophageal junction neuroendocrine tumors.

Adenocarcinoma and squamous cell esophageal cancers have been extensively studied in the literature. Esophageal neuroendocrine (NET)/carcinoid tumors are less commonly studied and have only been described in small series. The purpose of this study was to describe the demographics and natural history of esophageal NETs, as well as optimal treatments. We hypothesized that surgical resection would be the best treatment of esophageal NETs. The National Cancer Database was used to identify adult patients with esophageal or gastroesophageal junction (GEJ) cancer from 2004 to 2018. Patients were characterized as carcinoid/NET, adenocarcinoma, or squamous cell cancer. Clinical and demographic characteristics were compared between the histology groups. The primary outcome was overall survival, which was assessed by multivariable Cox analysis. Multivariable Cox analysis was also used to analyze factors associated with survival among NET patients who underwent surgery. Among 206,321 patients with esophageal cancer, 1,563 were NETs (<0.01%). Relative to the other two histologies, NETs were associated with younger age, female sex, and advanced clinical stage at diagnosis. Multivariate analysis suggested that NETs were less likely to be treated with surgical resection (OR 0.51, P < 0.001). Nonetheless, surgical resection was associated with improved survival (HR 0.64, P = 0.003). Among patients with NETs who received surgery, neoadjuvant therapy was associated with improved overall survival (HR 0.38, P = 0.013). NET of the esophagus presents with more advanced disease than other common histologies. Among patients with nonmetastatic cancer, surgical resection appears to be the best treatment. Neoadjuvant systemic therapy may offer survival benefit, but future studies are necessary.

Disparities and access to thoracic surgeons among esophagectomy patients in the United States.

Esophagectomy is a complex operation with significant morbidity and mortality. Previous studies have shown that sub-specialization is associated with improved esophagectomy outcomes. We hypothesized that disparities would exist among esophagectomy patients regarding access to thoracic surgeons based on demographic, geographic, and hospital factors. The Premier Healthcare Database was used to identify adult inpatients receiving esophagectomy for esophageal and gastric cardia cancer, Barrett's esophagus, and achalasia from 2015 to 2019 using ICD-10 codes. Patients were categorized as receiving their esophagectomy from a thoracic versus non-thoracic provider. Survey methodology was used to correct for sampling error. Backwards selection from bivariable analysis was used in a survey-weighted multivariable logistic regression to determine predictors of esophagectomy provider specialization. During the study period, 960 patients met inclusion criteria representing an estimated population size of 3894 patients. Among them, 1696 (43.5%) were performed by a thoracic surgeon and 2199 (56.5%) were performed by non-thoracic providers. On multivariable analysis, factors associated with decreased likelihood of receiving care from a thoracic provider included Black (OR 0.41, p < 0.001), Other (OR 0.21, p < 0.001), and Unknown race (OR 0.22, p = 0.04), and uninsured patients (OR 0.53, p = 0.03). Urban hospital setting was associated with an increased likelihood of care by a thoracic provider (OR 4.43, p = 0.001). In this nationally representative study, Nonwhite race, rural hospital setting, and lower socioeconomic status were factors associated with decreased likelihood of esophagectomy patients receiving care from a thoracic surgeon. Efforts to address these disparities and provide appropriate access to thoracic surgeons is warranted.

Motor Vehicle Protective Device Usage Associated with Decreased Rate of Flail Chest: A Retrospective Database Analysis.

Background and Objectives: Protective equipment, including seatbelts and airbags, have dramatically reduced the morbidity and mortality rates associated with motor vehicle collisions (MVCs). While generally associated with a reduced rate of injury, the effect of motor vehicle protective equipment on patterns of chest wall trauma is unknown. We hypothesized that protective equipment would affect the rate of flail chest after an MVC. Materials and Methods: This study was a retrospective analysis of the 2019 iteration of the American College of Surgeons Trauma Quality Program (ACS-TQIP) database. Rib fracture types were categorized as non-flail chest rib fractures and flail chest using ICD-10 diagnosis coding. The primary outcome was the occurrence of flail chests after motor vehicle collisions. The protective equipment evaluated were seatbelts and airbags. We performed bivariate and multivariate logistic regression to determine the association of flail chest with the utilization of vehicle protective equipment. Results: We identified 25,101 patients with rib fractures after motor vehicle collisions. In bivariate analysis, the severity of the rib fractures was associated with seatbelt type, airbag status, smoking history, and history of cerebrovascular accident (CVA). In multivariate analysis, seatbelt use and airbag deployment (OR 0.76 CI 0.65-0.89) were independently associated with a decreased rate of flail chest. In an interaction analysis, flail chest was only reduced when a lap belt was used in combination with the deployed airbag (OR 0.59 CI 0.43-0.80) when a shoulder belt was used without airbag deployment (0.69 CI 0.49-0.97), or when a shoulder belt was used with airbag deployment (0.57 CI 0.46-0.70). Conclusions: Although motor vehicle protective equipment is associated with a decreased rate of flail chest after a motor vehicle collision, the benefit is only observed when lap belts and airbags are used simultaneously or when a shoulder belt is used. These data highlight the importance of occupant seatbelt compliance and suggest the effect of motor vehicle restraint systems in reducing severe chest wall injuries.

Concurrent diagnosis of anxiety increases postoperative length of stay among patients receiving esophagectomy for esophageal cancer.

OBJECTIVE: Psychiatric comorbidities disproportionately affect patients with cancer. While identified risk factors for prolonged length of stay (LOS) after esophagectomy are primarily medical comorbidities, the impact of psychiatric comorbidities on perioperative outcomes is unclear. We hypothesized that psychiatric comorbidities would prolong LOS in patients with esophageal cancer. METHODS: The 2016 National Inpatient Sample (NIS) was used to identify patients with esophageal cancer receiving esophagectomy. Concurrent psychiatric illness was categorized using Clinical Classifications Software Refined for ICD-10, creating 34 psychiatric diagnosis groups (PDGs). Only PDGs with >1% prevalence in the cohort were included in the analysis. The outcome of interest was hospital LOS. Bivariable testing was performed to determine the association of PDGs and demographic factors on LOS using rank sum test. Multivariable regression analysis was performed using backward selection from bivariable testing (α ≤ 0.05). RESULTS: We identified 1,730 patients who underwent esophagectomy for esophageal cancer in the 2016 NIS. The median LOS was 8 days (IQR 5-12). In bivariable testing, a concurrent diagnosis of anxiety was the only PDG associated with LOS (9 days (IQR 6-14) with anxiety diagnosis versus 8 days (IQR 5-12) with no anxiety diagnosis, p = 0.022). Multivariable modeling showed an independent association between anxiety diagnosis and increased LOS (OR 4.82 (1.25-25.23), p = 0.022). Anxiety was not associated with increased hospital cost or in-hospital mortality. CONCLUSIONS: This analysis demonstrates an independent effect of anxiety prolonging postoperative LOS after esophagectomy in the United States. These findings may influence perioperative care, patient expectations, and resource allocation.

Palliative Surgery Outcomes for Patients with Esophageal Cancer: An National Cancer Database Analysis.

INTRODUCTION: Many patients with esophageal cancer are not candidates for surgical resection with curative intent, given the advanced stage of disease at presentation. Palliative surgery is one treatment option, but relative survival of palliative surgery has not been described. This study aims to describe the outcomes of palliative surgery in patients with esophageal cancer. METHODS: We used the National Cancer Database to identify patients with esophageal cancer who received palliative surgery or non-surgical palliation-which consisted of palliative radiation and palliative chemotherapy without any surgery. The outcome of interest was overall survival. Characteristics of patients were compared between the palliative surgery group and the non-surgical group using rank sum test or chi square test. Survival differences between groups were compared using Kaplan Meier estimate and log rank test, and Cox proportional hazards model. RESULTS: A total of 14,589 patients were included in the analysis, including 2,812 (19.2%) receiving palliative surgery and 11,777 (80.7%) receiving non-surgical palliation (6,512 palliative radiation and 5,265 palliative chemotherapy). Median overall survival in palliative surgery patients was 5.5 mo, shorter than non-surgical palliation (6.4 mo, P = 0.004). However, when correcting for age, sex, nodal status, metastases, Charlson score, histology, academic center, and private insurance, there was no difference in survival between palliative surgery and non-surgical palliation in Cox proportional hazard modeling (HR 1.03 (0.975-1.090), P = 0.281). CONCLUSIONS: Palliative surgery in advanced esophageal cancer is associated with poor overall survival but is similar to other palliative modalities. Palliative Surgery for esophageal cancer patients should be used sparingly given these poor outcomes.

Does Timing of Robotic Esophagectomy Adoption Impact Short-Term Postoperative Outcomes?

BACKGROUND: Robotic esophagectomies are increasingly common and are reported to have superior outcomes compared with an open approach; however, it is unclear if all institutions can achieve such outcomes. We hypothesize that early adopters of robotic technique would have improved short-term outcomes. METHODS: The National Cancer Database (2010-2016) was used to identify robotic esophagectomies. Early adopters were defined as programs which performed robotic esophagectomies in 2010-2011, late adopters in 2012-2013. Outcomes of esophagectomies performed between 2014 and 2016 were compared and included length of stay, number of lymph nodes evaluated, readmission, conversion rate, and 90-day mortality. Multivariable regressions, accounting for robotic esophagectomy volume, were used to control for confounding factors. RESULTS: There were 37 early adopters and 35 late adopters. Between 2014 and 2016, 683 robotic esophagectomies were performed: 446 (65.3%) by early adopters and 237 (34.7%) by late adopters. Early adopters were more likely to be academic programs (96.2 versus 72.8%, P < 0.01). Other clinical and demographic variables were similar. Late adopters were found to have decreased a number of lymph nodes evaluated (coefficient -2.407, P = 0.004) compared with early adopters. There were no significant differences in length of stay, readmissions, rate of positive margins, conversion from robotic to open, or 90-day mortality. CONCLUSIONS: When accounting for robotic esophagectomy volume, late adoption of robotic esophagectomy was associated with a reduced lymph node harvest, but other postoperative outcomes were similar. These data suggest that programs can safely start new robotic esophagectomy programs, but must ensure an adequate case load.

Are We Underestimating the Morbidity of Single Rib Fractures?

PURPOSE: Previous studies suggest that patients with multiple rib fractures have poor outcomes, but it is unknown how isolated single rib fractures (SRF) are associated with morbidity or mortality. We hypothesized that patients with poor outcomes after SRF can be identified by demographics and comorbidities. The purpose of this study was to model adverse outcome after single rib fractures. MATERIALS AND METHODS: We used the 2016 National Inpatient Sample to identify patients with SRF associated with blunt trauma using ICD-10 coding. Comorbidities and abbreviated injury score (AIS) were also extracted. Patients with non-chest trauma were excluded. The primary outcome was an adverse composite outcome of death, pneumonia, tracheostomy, or hospitalization longer than twelve days. One-third of the cohort was reserved for validation. Backward selection multivariable modeling identified factors associated with adverse composite outcome. The model was used to create a nomogram to predict adverse composite outcome. The nomogram was then tested using the validation cohort. RESULTS: 2,398 patients with isolated SRF were divided into training (n = 1,598) and validation sets (n = 800). The average age was 69 and the majority were male (66%) and received care at academic institutions (61.6%). The adverse composite outcome occurred in 20.8%: 61 deaths (2.5%), 67 tracheostomies (2.8%), 319 pneumonias (13.3%), and 165 patients with hospital length of stay greater than twelve days (6.9%). Results of stepwise multivariable modeling had a C-statistic of 0.700. The multivariable model was used to create a nomogram which had a c-statistic of 0.672 in the validation cohort. CONCLUSION: 20% of isolated SRF patients had an adverse outcome. Demographics and comorbidities can be used to identify and triage high-risk patients for specialized care and proper counseling.

Outcomes of robotic esophagectomies for esophageal cancer by hospital volume: an analysis of the national cancer database.

BACKGROUND: 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. METHODS: 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. RESULTS: 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). CONCLUSION: 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.

Robotic minimally invasive esophagectomy provides superior surgical resection.

INTRODUCTION: Robotic minimally invasive esophagectomy (RMIE) and "traditional" minimally invasive esophagectomy techniques (tMIE) have reported superior outcomes relative to open techniques. Differences in the outcomes of these two approaches have not been examined. We hypothesized that short-term outcomes of RMIE would be superior to tMIE. METHODS AND PROCEDURES: The National Cancer Database was used to analyze outcomes of patients undergoing RMIE and tMIE from 2010 to 2016. Patients with clinical metastatic disease were excluded. Trends in the number of procedures performed with each approach were described using linear regression testing. Primary outcome of interest was 90-day mortality rate. Secondary outcomes of interest were positive surgical margin rate, number of lymph nodes (LN) removed, adequate lymphadenectomy (> 15 LNs), length of hospitalization (LOS), readmission rate, and conversion to open rate. Outcomes of RMIE and tMIE were compared using Wilcoxon rank sum test and chi square test as appropriate. Multivariable regression was also performed to reduce the impact of differences in the cohorts of patients receiving RMIE and tMIE. RESULTS: 6661 minimally invasive esophagectomies were performed from 2010 to 2016 (1543/6661 (23.2%) RMIE and 5118/6661 (76.8%) tMIE). Over the study period, the proportion of RMIE increased from 10.4% (64/618) in 2010 to 27.2% (331/1216) in 2016 (p < 0.001) (Fig. 1). The primary outcome of 90-day mortality was similar between RMIE and tMIE (92/1170 (7.4%) vs 305/4148 (7.9%), p = 0.558) (Table 2). RMIE and tMIE also had similar readmission rate (6.3 vs 7%, p = 0.380). There was no difference between the cohorts based on sex, age, race, insurance, and tumor size. The cohorts of patients receiving RMIE and tMIE differed in that RMIE patients had lower rates of elevated Charlson scores, were more likely to be treated at an academic institution, had a higher rate of advanced clinical T-stage and clinical nodal involvement, and had received neoadjuvant therapy. In a univariate analysis, RMIE had a lower rate of positive margin (3.9 vs 6.1%, p = 0.001), more mean lymph nodes evaluated (16.6 ± 9.74 vs 16.1 ± 10.08 p = 0.018), lower conversion to open rate (5.4 vs 11.4%, p < 0.001), and a shorter mean length of stay (12.1 ± 10.39 vs 12.8 ± 11.18 days, p < 0.001). In multivariable analysis, RMIE was associated with lower risk of conversion to open (OR 0.51, 95% CI: 0.37-0.70, p < 0.001) and lower rate of positive margin (OR 0.62, 95% CI: 0.41-0.93, p = 0.021).). Additionally, in a multivariable logistic regression, RMIE demonstrated superior adequate lymphadenectomy (> 15 LNs) (OR 1.18, 95% CI 1.02-1.37, p < 0.032). CONCLUSION: In the National Cancer Database, robotic esophagectomy is associated with superior rate of conversion to open and positive surgical margin status. We speculate enhanced dexterity and visualization of RMIE facilitates intraoperative performance leading to improvement in these outcomes.

Surgery following neoadjuvant chemoradiation therapy in clinical N3 esophageal cancer results in improved survival: a propensity-matched analysis.

Esophageal cancer patients with extensive nodal metastases have poor survival, and benefit of surgery in this population is unclear. The aim of this study is to determine if surgery after neoadjuvant chemoradiotherapy (nCRT) improves overall survival (OS) in patients with clinical N3 (cN3) esophageal cancer relative to chemoradiation therapy (CRT) alone. The National Cancer Database was queried for all patients with cN3 esophageal cancer between 2010 and 2016. Patients who met inclusion criteria (received multiagent chemotherapy and radiation dose ≥30 Gy) were divided into two cohorts: CRT alone and nCRT + surgery. 769 patients met inclusion criteria, including 560 patients who received CRT alone, and 209 patients who received nCRT + surgery. The overall 5-year survival was significantly lower in the CRT alone group compared to the nCRT + surgery group (11.8% vs 18.0%, P < 0.001). A 1:1 propensity matched cohort of CRT alone and nCRT + surgery patients also demonstrated improved survival associated with surgery (13.11 mo vs 23.1 mo, P < 0.001). Predictors of survival were analyzed in the surgery cohort, and demonstrated that lymphovascular invasion was associated with worse survival (HR 2.07, P = 0.004). Despite poor outcomes of patients with advanced nodal metastases, nCRT + surgery is associated with improved OS. Of those with cN3 disease, only 27% underwent esophagectomy. Given the improved OS, patients with advanced nodal disease should be considered for surgery. Further investigation is warranted to determine which patients with cN3 disease would benefit most from esophagectomy, as 5-year survival remains low (18.0%).

Higher Doses of Neoadjuvant Radiation for Esophageal Cancer Do Not Affect the Pathologic Complete Response Rate or Survival: A Propensity-Matched Analysis.

BACKGROUND: Traditional neoadjuvant therapy for esophageal cancer has used chemoradiation doses greater than 45 Gy. This study aimed to examine the dose of preoperative radiation in relation to the pathologic complete response (pCR) rate and overall survival (OS) for patients with resectable esophageal cancer. METHODS: The National Cancer Database was queried for all patients with esophageal or gastroesophageal junction cancer who received neoadjuvant chemoradiation (CRT) followed by esophagectomy between 2006 and 2015. The radiation doses were divided into four ranges based on Grays (Gy) received: less than 39.6 Gy, 39.60-44.99 Gy, 45-49.99 Gy, and 50 Gy or more. RESULTS: The inclusion criteria were met by 10,293 patients. All patients received neoadjuvant CRT, with 689 patients (6.7%) receiving less than 39.6 Gy, 973 patients (9.5%) receiving 39.6-44.9 Gy, 3837 patients (37.3%) receiving 45-49.9 Gy, and 4794 patients (46.6%) receiving 50 Gy or more. The overall pCR rate was 17.2% (1769/10,293) and was significantly lower for those who received less than 39.6 Gy of radiation than for those who received 39.6 Gy or more (13.9% [96/689] vs. 17.4% [1673/9604]; p = 0.017). The median OS of 37.2 months was significantly better for those who received 39.6 Gy or more than for those who received less than 39.6 Gy (38 vs. 29.6 months (p < 0.0001). The pCR and OS did not differ between the three higher radiation doses (39.6-44.9 vs. 45-49.9 Gy vs. ≥ 50 Gy; pCR [p = 0.1] vs. OS [p = 0.097]). The patients who received 39.6-44.9 Gy were propensity matched with those who received 45 Gy or more of radiation. There remained no difference in pCR (p = 0.375) or OS (p = 0.957). CONCLUSIONS: In the United States, the heterogeneity in neoadjuvant CRT dosing is significant, with 84% of patients receiving more than 45 Gy. The benefit of neoadjuvant CRT in terms of pCR and overall  survival is seen with doses of 39.6 Gy or more, but not with doses higher than 45 Gy.

Conventional Computed Tomographic Calcium Scoring vs full chest CTCS for lung cancer screening: a cost-effectiveness analysis.

BACKGROUND: Conventional CTCS images the mid/lower chest for coronary artery disease (CAD). Because many CAD patients are also at risk for lung malignancy, CTCS often discovers incidental pulmonary nodules (IPN). CTCS excludes the upper chest, where malignancy is common. Full-chest CTCS (FCT) may be a cost-effective screening tool for IPN. METHODS: A decision tree was created to compare a FCT to CTCS in a hypothetical patient cohort with suspected CAD. (Figure) The design compares the effects of missed cancers on CTCS with the cost of working up non-malignant nodules on FCT. The model was informed by results of the National Lung Screening Trial and literature review, including the rate of malignancy among patients receiving CTCS and the rate of malignancy in upper vs lower portions of the lung. The analysis outcomes are Quality-Adjusted Life Year (QALY) and incremental cost-effectiveness ratio (ICER), which is generally considered beneficial when <$50,000/QALY. RESULTS: Literature review suggests that rate of IPNs in the upper portion of the lung varied from 47 to 76%. Our model assumed that IPNs occur in upper and lower portions of the lung with equal frequency. The model also assumes an equal malignancy potential in upper lung IPNs despite data that malignancy occurs 61-66% in upper lung fields. In the base case analysis, a FCT will lead to an increase of 0.03 QALYs comparing to conventional CTCS (14.54 vs 14.51 QALY, respectively), which translates into an QALY increase of 16 days. The associated incremental cost for FCT is $278 ($1027 vs $748, FCT vs CTCS respectively. The incremental cost-effectiveness ratio (ICER) is $10,289/QALY, suggesting significant benefit. Sensitivity analysis shows this benefit increases proportional to the rate of malignancy in upper lung fields. CONCLUSION: Conventional CTCS may be a missed opportunity to screen for upper lung field cancers in high risk patients. The ICER of FCT is better than screening for breast cancer screening (mammograms $80 k/QALY) and colon cancer (colonoscopy $6 k/QALY). Prospective studies are appropriate to define protocols for FCT.

Minimally invasive esophagectomy is associated with superior survival, lymphadenectomy and surgical margins: propensity matched analysis of the National Cancer Database.

Despite excellent short-term outcomes of minimally invasive esophagectomy (MIE), there is minimal data on long-term outcomes compared to open esophagectomy. MIE's superior visualization may have improved lymphadenectomy and complete resection rate and therefore improved long-term outcomes. We hypothesized that MIE would have superior long-term survival. Patients undergoing an esophagectomy for cancer between 2010 and 2016 were identified in the National Cancer Database. MIE included laparoscopic/robotic approach, and conversions were categorized as open. A 1:1 propensity match was performed. Lymphadenectomy and margin status were compared between MIE and open using Stuart Maxwell marginal homogeneity and Wilcoxon matched-pair signed-rank test. Survival was compared using log-rank test. 13,083 patients were identified: 8,906 (68%) open and 4,177 (32%) MIE. Propensity matching identified 3,659 'pairs' of MIE and open esophagectomy patients. Among them, MIE was associated with higher number lymph nodes examined (16 vs. 14, P < 0.001) and similar number of positive lymph nodes (0 vs. 0, P = 0.33). MIE had higher rate of negative pathologic margin (95 vs. 93.5%, P < 0.001). MIE was also associated with shorter hospitalization (9 vs. 10 days, P < 0.001). Survival was improved among MIE patients (46.6 vs. 41.4 months for open, P = 0.003) and among pathologic node-negative patients (71.4 vs. 61.5 months, P = 0.005). These data suggest that MIE has improved short-term outcomes (improved lymphadenectomy, pathologic margins, and length of stay) and also associated improved overall survival. The etiology of superior overall survival is likely secondary to many factors related and unrelated to surgical approach.