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

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.

469 ASSESSMENT OF PERFUSION OF GASTRIC CONDUIT AND PROXIMAL ESOPHAGEAL STUMP BY INDOCYANINE GREEN FLUORESCENCE IMAGING IN PATIENTS UNDERGOING ESOPHAGECTOMY

Post esophagectomy anastomotic leakage and stricture are crucial factors in determining morbidity and mortality. Good vascularity of the gastric conduit is essential to avoid this complications. This prospective study assesses the utility of intraoperative indocyanine green (ICG) fluorescence imaging to determine gastric conduit vascularity in patients undergoing esophagectomy. Methods Thirteen consecutive patients who were undergoing esophagectomy for carcinoma middle, lower third esophagus or gastro-esophageal junction from August 2019 to September 2019, were included. Three patients underwent laparoscopic-assisted transhiatal esophagectomy, ten thoraco-laparoscopic assisted esophagectomy. Reconstruction was done by gastric pull up via posterior mediastinal route. Vascularity of gastric conduit was assessed by the near-infrared camera using ICG. Results On visual assessment of perfusion at the tip of gastric conduit, it was dusky in 11 patients, pink in two. Fuorescence imaging showed inadequate perfusion at the tip of conduit in 12 patients, needing revision. In one patient visual inspection showed adequate perfusion, but ICG disclosed poor vascularity requiring revision of the conduit’s tip. Resection of the devitalized portion of the proximal esophageal stump was needed in 5 patients both by visual and ICG assessment. The median time to appearance of blush from the time of injection of dye was 15 seconds (10 to 23 seconds). Conclusion Visual inspection of the gastric conduit vascularity can underestimate perfusion and hence can compromise resection of the devitalized part. ICG fluorescence imaging is more objective and promising means to ascertain the vascularity of gastric conduit during an esophagectomy. It could complement the visual inspection to decide the site of anastomosis.

490 COLONIC INTERPOSITION FOR ESOPHAGEAL REPLACEMENT AFTER ESOPHAGECTOMY FOR CANCER—A SINGLE CENTER EXPERIENCE

The standard esophageal replacement after esophagectomy for cancer treatment is a gastric conduit, as it is a simpler technique than the other options available, requiring only one anastomosis. However, when the stomach is not available, a left- or right colon graft interposition can be performed. The purpose of this study was to review our experience with colon interposition following esophagectomy for cancer and assess the surgical outcomes. Methods The clinical data and surgical outcomes form patients who underwent esophagectomy with colon interposition for cancer treatment, in a single institution, between January 1990 and December 2017. The results were compared with cases with gastric reconstruction. Results From January 1990 and December 2017, 25 cases of transhiatal esophagectomy with colon interposition were identified. In the same period, 97 cases of transhiatal esophagectomy with gastric pull-up were also performed. The patient’s clinical data and surgical outcomes are presented in Table 1. The indication for performing a colon interposition was positive distal margin in 87% of cases, gastric conduit ischemia in 8,7% and prior gastric surgery in 4,3%. The most common pull-up route was the posterior mediastinum (87%). Conclusion Our results are in line with the literature and demonstrate that colon interposition after esophagectomy is feasible and, despite having a significant morbimortality, appears to be a valuable alternative for the challenging situation where the stomach is not available.

851 TRANSHIATAL ESOPHAGECTOMY: A SELECTIVE ROLE IN THE CURATIVE APPROACH TO ESOPHAGEAL CANCER

Surgery remains central to the curative management of esophageal cancer. At this Center, based on evidence from the literature, transthoracic en bloc surgery (TTE) is standard, however transhiatal esophagectomy (THE) is considered for predicted early stage junctional (AEG) tumors, multifocal in situ cancer, or where age or respiratory co-morbidity suggests a high risk with TTE. This audit reports this experience over 19 years. Methods Data was acquired from our prospectively maintained database. Patients who underwent esophagectomy with curative intent and gastric tube reconstruction for mid/distal esophageal or esophagogastric junction cancer (cT1-4aN0-3 M0) from 2000 to 2018 were included. THE was compared with TTE for operative complications (ECCG-defined), and proxy markers of oncologic quality. Results 933 patients were included, 166 (18%) THE and 767 (82%) TTE. The median (range) age was 62(22–83) vs 67(36–86) in TTE and THE, with 43(6%) and 40(24%) over 75 respectively (p < 0.01). There were significantly (p < 0.01) more early tumors in the THE (58%) vs the TTE group(11%). 23% were > ASA 3 in THE vs 12% TTE (p < 0.01). Postoperative pulmonary complications (PPCs) were 11% and 18.3% in THE and TTE cohorts, respectively(p 0.03). In-hospital mortality was 1.2%vs3.4% in THE vs TTE (p = 0.21). Five-year survival was 67% and 40% in THE vs TTE, respectively. Conclusion These data are consistent with the safe and effective use of THE in selected cases. Notably, favourable major pulmonary morbidity and mortality rates for a higher risk cohort. We suggest that this approach may still be relevant in defined scenarios in an increasingly minimally invasive era.