Frailer Patients Undergoing Robotic Colectomies for Colon Cancer Experience Increased Complication Rates Compared With Open or Laparoscopic Approaches

BACKGROUND Minimally invasive surgical techniques are routinely promoted as alternatives to open surgery because of improved outcomes. However, the impact of robotic surgery on certain subsets of the population, such as frail patients, is poorly understood. OBJECTIVE The purpose of our study was to examine the association between frailty and minimally invasive surgical approaches with colon cancer surgery. DESIGN This is a retrospective study of prospectively collected outcomes data. Thirty-day surgical outcomes were compared by frailty and surgical approach using doubly robust multivariable logistic regression with propensity score weighting, and testing for interaction effects between frailty and surgical approach. SETTING Patients undergoing an open, laparoscopic, or robotic colectomy for primary colon cancer, 2012 to 2016, were identified from the American College of Surgeons National Surgical Quality Improvement Program database. PATIENTS Patients undergoing a colectomy with an operative indication for primary colon cancer were selected. MAIN OUTCOME MEASURES The primary outcomes measured were 30-day postoperative complications. RESULTS After propensity score weighting of patients undergoing colectomy, 33.8% (n = 27,649) underwent an open approach versus 34.3% (n = 28,058) underwent laparoscopic surgery versus 31.9% (n = 26,096) underwent robotic surgery. Robotic (OR, 0.53; 95% CI, 0.42-0.69, p < 0.001) and laparoscopic (OR, 0.58; 95% CI, 0.52-0.66, p < 0.001) surgeries were independently associated with decreased rates of major complications. Frailer patients had increased complication rates (OR, 1.56; 95% CI, 1.07-2.25, p = 0.018). When considering the interaction effects between surgical approach and frailty, frailer patients undergoing robotic surgery were more likely to develop a major complication (combined adjusted OR, 3.15; 95% CI, 1.34-7.45, p = 0.009) compared with patients undergoing open surgery. LIMITATIONS Use of the modified Frailty Index as an associative proxy for frailty was a limitation of this study. CONCLUSIONS Although minimally invasive surgical approaches have decreased postoperative complications, this effect may be reversed in frail patients. These findings challenge the belief that robotic surgery provides a favorable alternative to open surgery in frail patients. See Video Abstract at http://links.lww.com/DCR/B163. LOS PACIENTES MAS FRAGILES SOMETIDOS A COLECTOMIA ROBOTICA POR CANCER DE COLON EXPERIMENTAN MAYORES TASAS DE COMPLICACIONES EN COMPARACION CON ABORDAJES LAPAROSCOPICO O ABIERTO: Las tecnicas quirurgicas minimamente invasivas estan frecuentement promovidas como alternativas a la cirugia abierta debido a sus mejores resultados. Sin embargo, el impacto de la cirugia robotica en ciertos subgrupos de poblacion, como el caso de los pacientes endebles, es poco conocido.El proposito de nuestro estudio fue examinar la asociacion entre la fragilidad de los pacientes y el aborgaje quirurgico minimamente invasivo para la cirugia de cancer de colon.Estudio retrospectivo de datos de resultados recolectados prospectivamente. Los resultados quirurgicos a 30 dias se compararon entre fragilidad y abordaje quirurgico utilizando la regresion logistica multivariable doblemente robusta con ponderacion de puntaje de propension y pruebas de efectos de interaccion entre fragilidad y abordaje quirurgico.Los pacientes identificados en la base de datos del Programa Nacional de Mejora de la Calidad Quirurgica del Colegio Estadounidense de Cirujanos, que fueron sometidos a una colectomia abierta, laparoscopica o robotica por cancer de colon primario, de 2012 a 2016.Todos aquellos pacientes seleccionados con indicacion quirurgica de cancer primario de colon que fueron sometidos a una colectomia.Las complicaciones postoperatorias a 30 dias.Luego de ponderar el puntaje de propension de los pacientes colectomizados, el 33.8% (n = 27,649) fue sometido a laparotomia versus el 34.3% (n = 28,058) operados por laparoscopia versus el 31.9% (n = 26,096) operados con tecnica robotica. Las cirugias roboticas (OR 0.53, IC 95% 0.42-0.69, p < 0.001) y laparoscopicas (OR 0.58, IC 95% 0.52-0.66, p < 0.001) se asociaron de forma independiente con una disminucion de las tasas de complicaciones mayores. Los pacientes mas delicados tenian mayores tasas de complicaciones (OR 1.56, IC 95% 1.07-2.25, p = 0.018). Al considerar los efectos de interaccion entre el abordaje quirurgico y la fragilidad, los pacientes mas debiles sometidos a cirugia robotica tenian mas probabilidades de desarrollar una complicacion mayor (OR ajustado combinado 3.15, IC 95% 1.34-7.45, p = 0.009) en comparacion con los pacientes sometidos a cirugia abierta.El uso del indice de fragilidad modificado como apoderado asociativo de la fragilidad.Si bien los abordajes quirurgicos minimamente invasivos han disminuido las complicaciones postoperatorias, este efecto puede revertirse en pacientes labiles. Estos hallazgos desafian la creencia de que la cirugia robotica proporciona una alternativa favorable a la cirugia abierta en pacientes fragiles. Consulte Video Resumen en http://links.lww.com/DCR/B163. (Traduccion-Dr. Xavier Delgadillo).