Robotic Right Colectomy for Colon Cancer: Comparison of Outcomes from a Single Institution with the ACS-NSQIP Database

Abstract

Background:

Robotic surgery has increased in recent years for the treatment of colorectal cancer; however, it is not yet the standard of care. This study aims to compare the 30-day outcomes after robotic colectomy for right-sided colon cancer from our institution with those from a national dataset, the targeted colectomy American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database.

Methods:

Patients undergoing elective, robotic, right colon resection for stage I, II, and III colon cancer were identified within the targeted colectomy ACS-NSQIP database from 2012 to 2014. Patients meeting the same criteria were identified within a prospectively maintained institutional database from 2009 to 2015. Univariate analyses using chi-square tests and Student's t-tests were done where appropriate to compare baseline characteristics and outcomes between the two groups.

Results:

Patients at our institution had a significantly higher average number of lymph nodes retrieved (24.4 versus 20.1, P = .046). There was no statistically significant difference between the two groups regarding the incidence of wound infections, anastomotic leaks, blood transfusions, unplanned return to the operating room, or prolonged length of hospital stay. There were no 30-day mortalities at our institution and only one in the ACS-NSQIP database.

Conclusions:

Our institutional experience with robotic right colon resection is equivalent to that of a national sample. This study demonstrates the safety of performing robotic right hemicolectomy for the treatment of colon cancer.

Introduction

Robotic surgery has become increasingly more prevalent in the field of colorectal surgery. Although laparoscopic colectomy is currently the preferred surgical approach to colon resection for cancer, the benefits of the robotic technique have begun to challenge this standard.^1–6 Recent studies have shown that the robotic surgery platform is not only equivalent to the laparoscopic approach for all types of elective colon resections, including those for colon cancer, but that there are also potential benefits with respect to a shorter length of hospital stay and decreased morbidity.^3,5

Surgical resection for curative intent remains the standard of care for colon cancer.^7–11 While surgeons across the world have begun to integrate robotic-assisted surgery into the care pathway for the treatment of left-sided colon cancer and rectal cancer, the benefits of the robotic approach for right-sided colon cancer remain relatively unknown.⁵ The purpose of this study was to compare the pathologic and 30-day morbidity and mortality outcomes after robotic-assisted right colon resection for cancer from a single institution with those of the targeted colectomy American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database.

Methods

All patients undergoing elective, robotic-assisted, right colon resection with primary anastomosis for stage I, II, or III colon cancer from years 2012 through 2014 were identified within the main ACS-NSQIP database using the current procedural terminology (CPT) code for laparoscopic right colon resection with primary anastomosis (CPT 44205). There is no specific CPT code for robotic-assisted right colon resection. Therefore, patients identified by this CPT code were then merged with the targeted colectomy ACS-NSQIP database, and those undergoing robotic-assisted right colon resection were identified using the “col-approach” variable. Within the targeted colectomy database is a “col-indication” variable that describes the primary indication for surgery. Only those patients with the primary indication for surgery of colon cancer were included in our analysis.

The option of robotic-assisted surgery as a surgical approach to the management of colon cancer began at our institution in 2009. Patients undergoing elective, robotic-assisted, right colon resection with primary extracorporeal anastomosis for stage I, II, or III colon cancer from years 2009 through 2015 were identified within a prospectively maintained institutional database performed by two surgeons.

Patients in both groups with disseminated/stage IV colon cancer, chemotherapy within 30 days of surgery, radiation within 90 days of surgery, nonelective cases, and those pregnant at the time of surgery were excluded from our analysis. Although our institution takes part in the main ACS-NSQIP database, we specifically do not participate in the targeted databases; thus, comparisons between our institution and the targeted colectomy database do not run a risk of self-comparison.

Preoperative patient variables investigated included age, gender, race, body mass index, current smoking status, chronic steroid use, albumin level, American Society of Anesthesiology class, hypertension, history of chronic obstructive pulmonary disease, end-stage renal disease, and diabetes mellitus as defined in the ACS-NSQIP participant user file.¹⁰ Intraoperative variables investigated included average operative time and number of lymph nodes retrieved.

Thirty-day morbidity and mortality outcome variables of interest included length of total hospital stay, bleeding occurrences requiring transfusion, return to the operating room, anastomotic leak, prolonged postoperative ileus (defined as >3 days without flatus or return of bowel function),^7,12,13 infection rates (defined as a composite outcome, including superficial wound infections, deep incisional infections, deep organ space infections, and wound dehiscence), total hospital stay >3 days, and 30-day mortality.

Preoperative, intraoperative, 30-day outcomes, and mortality were compared between groups using chi-square and between groups t-tests. All statistical analysis was done using SAS version 9.3 (SAS Institute, Cary, NC), and a P value <.05 was considered statistically significant.

Results

A total of 125 patients met inclusion criteria: 89 (71.2%) patients from the targeted colectomy ACS-NSQIP database (targeted colectomy group [TG]) and 36 (28.8%) patients from our institutional database (institutional group [IG]). With respect to preoperative patient variables, the only statistically significant difference between the two groups was that patients in the TG were more likely to be Caucasian, whereas those in the IG were more likely to be African American (P < .001) (Table 1). The average operative time for the TG was 187.2 minutes, whereas the average operative time for the IG was 197 minutes (P = .44) (Table 2).

Table 1.

Patient Demographics, Stratified by Targeted Colectomy Versus Institutional Group

	TG robotic	IG robotic	P
Total number (n)	89	36
Age, mean ± SD	68.9 ± 11.8	65.8 ± 9.8	.16
Gender, n (%)
Male	49 (55.1)	20 (55.6)
Female	40 (45.0)	16 (44.4)
Race, n (%)			<.05
White	68 (80.0)	13 (36.1)
Black/African American	12 (14.1)	21 (58.3)
Asian	5 (5.9)	2 (5.6)
BMI, kg/m², mean ± SD	29.3 ± 6.3	30.7 ± 9.1	.41
Diabetes, n (%)			.77
Yes	22 (24.3)	8 (22.2)
No	67 (75.3)	28 (77.8)
Smoker, n (%)			.07
Yes	7 (7.9)	7 (20.0)
No	82 (92.1)	28 (80.0)
Albumin level, g/dL, mean ± SD	3.9 ± 0.5	4.1 ± 0.5	.06
Severe COPD, n (%)	5 (5.6)	1 (2.8)	.67
Hypertension, n (%)	57 (64.0)	22 (61.1)	.76
On dialysis (preoperative), n (%)	0	1(2.9)	.29
ASA classification, n (%)			.89
1	0	0
2	32 (36.0)	14 (38.9)
3	52 (58.4)	21 (58.3)
4	5 (5.6)	1 (2.8)
Steroid use, n (%)	1 (1.1)	2 (5.6)	.20

P-value in bold is significant at <.05.

ASA, American Society of Anesthesiologists; BMI, body mass index; COPD, chronic obstructive pulmonary disease; IG, institutional group; TG, targeted colectomy group/NSQIP database.

Table 2.

Thirty-Day Outcomes, Stratified by Targeted Colectomy Versus Institutional Group ^a

	TG robotic	IG robotic	OR (CI)	P
Total (n)	89	36
Length of total hospital stay (days, SD)	4.4 ± 2.4	4.5 ± 2.1	—	.86
Length of total hospital stay >3 days, n (%)	51 (57.3)	22 (61.1)	1.2 (0.5–2.6)	.70
Total operation time (minutes, SD)	187.2 ± 81.4	196.9 ± 54.3	—	.44
Lymph nodes (n, SD)	20.1 ± 7.5	24.4 ± 11.1	—	<.05
Occurrences of bleeding transfusions, n (%)	10 (11.3)	2 (5.6)	0.46 (0.10–2.23)	.33
Return to operating room, n (%)	2 (2.3)	0	—	—
Anastomotic leak, n (%)	1 (1.1)	0	—	—
Prolonged postoperative ileus >3 days, n (%)	11 (12.4)	8 (22.2)	2.0 (0.7–5.6)	.16
Infection, n (%)	4 (4.5)	3 (8.3)	1.93 (0.4–9.10)	.41
Lymph nodes >12, n (%)	55 (61.8)	35 (97.2)	1.91 (0.2–19.1)	1.00
30-day mortality, n (%)	1 (1.12)	0 (0%)	—	—

P-value in bold is significant at <.05.

Definitions of 30-day morbidity as defined by the NSQIP database.¹⁰

IG, institutional group; TG, targeted colectomy group/NSQIP database; —, no answer.

With respect to pathologic and 30-day morbidity and mortality outcomes, the only statistically significant difference was that the IG had a higher average number of lymph nodes retrieved than the TG (P = .047) (Table 2). There was no statistically significant difference between the two groups with respect to 30-day morbidity outcomes. There were no 30-day mortalities recorded in the IG, and only one (1.1%) was recorded in the TG.

Discussion

To date, this has been the first study to directly compare the 30-day pathologic and morbidity and mortality outcomes from a single institution after robotic-assisted right colectomy for right colon cancer with a national dataset. While a majority of the literature has supported the use of robotic-assisted surgery predominantly in the realm of pelvic and gynecologic procedures, our study demonstrates the utility of robotic-assisted surgery for the treatment of right-sided colon cancer.^11,14 Specifically, our institutional outcomes were equivalent to those of a national database with respect to operative time, short-term pathology results, and 30-day morbidity outcomes. Furthermore, there were no mortalities in the IG within the perioperative period, and there was only one mortality reported in the TG within 30 days of the index operation. These findings support the safety and feasibility of performing robotic colectomy for the treatment of right-sided colon cancer.

While it has been increasingly shown in the literature that rectal and pelvic procedures using the robot have reported advantages over the traditional open and laparoscopic approaches, there continues to be a paucity of literature using national datasets with respect to the use of the robotic platform for right-sided colon cancer.^5,15 Currently, the standard approach to the surgical treatment of right-sided colon cancer is laparoscopy.^1,2,6,16,17 Nevertheless, with the introduction of the robotic platform for colorectal surgery cases in the early 2000s, it is important for the surgical community to determine the utility of the robotic approach in areas outside of the pelvis.

Studies have recently demonstrated advantages to the robotic approach for all types of colon resections when compared with laparoscopy. In a study by Benlice et al. in 2016 using the ACS-NSQIP database, they found that patients who underwent any type of elective, robotic-assisted colon resection were less likely to experience a prolonged intubation, bleeding requiring transfusion, or prolonged postoperative ileus, and that they had a shorter average length of hospital stay compared with those who underwent either open or laparoscopic colon resection.³

More recently, a study using the targeted colectomy ACS-NSQIP database compared robotic colon resection with anastomosis with standard laparoscopic approach, and found similar morbidity and mortality outcomes between groups with length of hospital stay actually being half a day shorter than laparoscopy.¹⁸ Smaller studies have shown similar benefits, specifically for robotic right colon resections. In 2013, Morpurgo et al. demonstrated fewer anastomotic leak rates and wound complications with robotic-assisted right colectomies compared with laparoscopy in a single institution, case–control study.¹⁹ Another case–control study across two institutions by Trastulli et al. in 2015 showed that the robotic approach to right colon cancer resection resulted in a significant decrease in total length of hospital stay and postoperative ileus compared with the standard laparoscopic approach using an extracorporeal anastomosis.²⁰

These preliminary results support the use of the robotic platform for elective, right-sided colon resection for colon cancer. Furthermore, our study, which compares the results of our institution with those of a national dataset, demonstrates that the robotic approach to right-sided colon cancer is not only safe and feasible, but suggests that the implementation of a robotic surgery program can produce results comparable with the national average over a relatively short duration.

Currently, national guidelines propose that at least 12 lymph nodes must be retrieved for adequate colon cancer staging, with a general consensus that increased lymph node retrieval would improve cancer staging.^21–25 When comparing laparoscopic colectomy lymph node retrieval rates with those of robotic-assisted colectomies, recent studies have observed no comparable difference thus far.²⁶ A single institution study in 2010 by D'Annibale et al. looked at early oncologic outcomes after a robotic right colectomy, which showed an average of 18 lymph nodes harvested with promising disease-free survival.²⁷

Another single institution study by Spinoglio in 2016 investigated the oncologic outcomes after robotic right colectomies, and showed promising disease-free survival rates and overall survival rates >90% at 4 years.²⁸ While we are limited to short-term outcomes in our study, our institution's data show a statistically significant increased lymph node retrieval rate compared with the national database, suggesting that there is a potential for improved oncologic outcomes at our institution with the robotic-assisted right colectomy (Table 2).

The performance of robotic surgery requires an additional skill set that is not currently integrated into all general surgery training programs. This is perhaps one reason that the robotic approach to right-sided colon resection for colon cancer has yet to become more prevalent. The improved visualization, articulating instruments, ambidexterity, and tremor filtration offered by the robotic platform over the laparoscopic approach have all been touted as some of the functional benefits of robotic surgery.^29–31 A study by Hassan et al. in 2015 demonstrated clear improvement in the speed of task completion using the robotic platform compared with the laparoscopy. When participants who were naïve to any robotic or laparoscopic experience were trialed with basic fundamental skill sets using robotic versus laparoscopic equipment, it was clear that robotic task completion was significantly faster than laparoscopy.³²

The learning curve for the adoption of robotic-assisted surgery has recently been shown to be shorter than that for the laparoscopic approach. Specifically, the learning curve for robotic-assisted right colectomies studied among surgeons has been anywhere from 20 to 30 cases, similar to the number of procedures generally accepted to learn robotic rectal technique.^33,34

A smaller study in 2016 by de'Angelis compared minimally invasive fellows who consecutively performed either laparoscopic or robotic right-sided colon resection for colon cancer, and showed that the number of cases required to safely perform these operations with efficiency in skill was 16 for the robotic group versus 25 for the laparoscopic group. Furthermore, the robotic-assisted procedures had significantly less blood loss and were associated with a decreased conversion to open when compared with the laparoscopic group. Total hospital costs did not differ between groups.³⁵

Thus far, there has been no standard training program provided for general surgeons to use the robotic platform, and training has largely been institution specific.^36,37 These findings, in addition to our program's equivalent performance to a national dataset, demonstrate that the establishment of robotic training as a component of general surgery training programs should be seriously considered.

Our study has limitations that must be noted. The ACS-NSQIP database is limited to 30-day outcomes, and therefore long-term oncologic results and disease-free survival could not be investigated in our study. Furthermore, cancer staging, oncologic margin status, and 30-day readmission rates are not consistently coded within the targeted colectomy ACS-NSQIP database, and therefore differences in outcomes based on stage, margin status, and unplanned 30-day hospital readmission rates could not be compared between the two groups. Additional studies are needed to assess the long-term outcomes regarding robotic-assisted right colectomies that are not captured in this study. Further stratification of cancer stage and margin status may help elucidate any differences in short- or long-term morbidity and mortality outcomes for robotic-assisted right colectomies that may be patient disease specific.

Conclusions

Our institutional experience with robotic right colon resection for the surgical treatment of colon cancer is equivalent to a national database with respect to short-term pathologic and morbidity outcomes. The shorter learning curve of the robotic platform and potential oncologic benefit for patients due to a higher average number of lymph nodes harvested suggest that the robotic surgical approach to right-sided colon cancer is a feasible alternative to the standard laparoscopic approach. Additional studies are needed to evaluate the long-term oncologic outcomes for single institution versus national datasets, as well as to the current standard-of-care laparoscopic approach.

Authors' Contributions

T.J. analyzed study concept, and performed data acquisition, data analysis, data interpretation, and article writing; I.N.H. also analyzed study concept, and performed data acquisition, data analysis, data interpretation, and article writing; X.K. performed data interpretation and data analysis. R.L.A. also performed data interpretation and data analysis; F.J.B. made final article review; V.O. performed data analysis, data interpretation, and final article review; S.A. analyzed study concept, and performed data interpretation and final article review.

Footnotes

Disclosure Statement

T.J., X.K., R.L.A., F.J.B., and S.A. have no conflicts of interest. I.N.H. has no conflict of interest relevant to this publication but has a Resident Research Grant from the American Hernia Society. V.O. is a consultant for Intuitive Surgical, Inc. and Medtronic, and receives personal fees but did not receive funds directly related to the development or production of this article.

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