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

Abstract

Background As 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. Methods Our 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. Results We 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. Conclusion Robotic 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.

National disparities in use of minimally invasive surgery for rectal cancer in older adults

“…This shows an opportunity to increase MIS utilization in this population. Our findings are consistent with a study by Richards et al, who found a 39% increase in robotic use for proctectomy with a 6% decrease in the open approach in older persons between 2006 and 2013 24 . While the data are dated, this study supports the growing use of robotics overall and in the older people.…”

“…Robotic surgery has also been described as safe in the older person, with comparable minimally invasive benefits, but little study on utilization in this population. 24,[31][32][33] Older persons specifically benefit from MIS through decreased postoperative pain, resulting in less use of opioids and incidence of delirium, and faster return to normal function, resulting in quicker discharge, decreased nosocomial infection risk, and less discharge to place other than home. 29,[34][35][36] With the known benefits in the expanding aging population, further study to address the disparities in use is warranted.…”

“…However, published reports estimate utilization in less than 50% of applicable rectal cancer cases overall 9,30 ; there is little study specifically on rectal cancer in persons 65 years and older. Robotic surgery has also been described as safe in the older person, with comparable minimally invasive benefits, but little study on utilization in this population 24,31–33 . Older persons specifically benefit from MIS through decreased postoperative pain, resulting in less use of opioids and incidence of delirium, and faster return to normal function, resulting in quicker discharge, decreased nosocomial infection risk, and less discharge to place other than home 29,34–36 .…”

“…Older persons are the most common demographic affected, yet there is little work to date on MIS in this population. 24,25 The safety and benefits of laparoscopy for rectal cancer have been specifically demonstrated in older persons. [26][27][28][29] However, published reports estimate utilization in less than 50% of applicable rectal cancer cases overall 9,30 ; there is little study specifically on rectal cancer in persons 65 years and older.…”

“…Despite increasing attention on the rising incidence of early onset rectal cancer, it remains a disease of persons 65 years and older. Older persons are the most common demographic affected, yet there is little work to date on MIS in this population 24,25 . The safety and benefits of laparoscopy for rectal cancer have been specifically demonstrated in older persons 26–29 .…”