Safe surgery in the elderly: A review of outcomes following robotic proctectomy from the Nationwide Inpatient Sample in a cross-sectional study.

Carly R Richards,Scott R Steele,Robert B Lim,Ali R Althans,Suzanne M Gillern,Michael B Lustik,Justin T Brady,Andrew T Schlussel

doi:10.1016/j.amsu.2019.06.004

Abstract

BackgroundAs our nation's population ages, operating on older and sicker patients occurs more frequently. Robotic operations have been thought to bridge the gap between a laparoscopic and an open approach, especially in more complex cases like proctectomy.MethodsOur objective was to evaluate the use and outcomes of robotic proctectomy compared to open and laparoscopic approaches for rectal cancer in the elderly. A retrospective cross-sectional cohort study utilizing the Nationwide Inpatient Sample (NIS; 2006–2013) was performed. All cases were restricted to age 70 years old or greater.ResultsWe identified 6740 admissions for rectal cancer including: 5879 open, 666 laparoscopic, and 195 robotic procedures. The median age was 77 years old. The incidence of a robotic proctectomy increased by 39%, while the open approach declined by 6% over the time period studied. Median (interquartile range) length of stay was shorter for robotic procedures at 4.3 (3–7) days, compared to laparoscopic 5.8 (4–8) and open at 6.7 (5–10) days (p < 0.01), while median total hospital charges were greater in the robotic group compared to laparoscopic and open cases ($64,743 vs. $55,813 vs. $50,355, respectively, p < 0.01). There was no significant difference in the risk of total complications between the different approaches following multivariate analysis.ConclusionRobotic proctectomy was associated with a shorter LOS, and this may act as a surrogate marker for an overall improvement in adverse events. These results demonstrate that a robotic approach is a safe and feasible option, and should not be discounted solely based on age or comorbidities.

Highlights

As the nation's population ages, the volume of surgical interventions on older patients has continued to grow
We identified 6740 admissions for patients receiving a proctectomy for rectal cancer
The open approach declined from 16% to 10%, and the laparoscopic approach increased from 9% to 16% over time

Summary

Introduction

As the nation's population ages, the volume of surgical interventions on older patients has continued to grow. The United States census data has shown that from 1980 to 2010, the age of citizens 65–89 years old has doubled, and those greater than 90 years old has almost tripled [1] This increase in life expectancy presents the challenge of continuing to deliver safe and effective health care to the elderly, but those with a significant number of medical comorbidities [2]. With a decreased physiologic reserve and an increased number of comorbidities, the application of laparoscopy has become important to this population This technique is associated with a decreased length of stay (LOS), decreased morbidity rate, earlier return of bowel function, and equivalent oncologic outcomes as compared to open surgery for patients greater than 70 years old [5,6,7,8]. These results demonstrate that a robotic approach is a safe and feasible option, and should not be discounted solely based on age or comorbidities

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