EP384 - The Rise of Robotics: Surgical Approaches to Rectal Cancer over Time

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Purpose/Background: Multiple randomized controlled trials have been unable to demonstrate noninferiority of minimally invasive surgery (MIS) versus open approaches for rectal cancer. Despite these studies, laparoscopic and robotic approaches to rectal cancer remain popular. The aim of this study was to evaluate trends towards MIS approaches for rectal cancer over time.

Methods/Interventions: This is a multicenter cohort study utilizing deidentified data from the National Cancer Database from 2010 to 2021. Adult patients with clinical stage I-III rectal cancer undergoing definitive resection (low anterior or abdominoperineal resection) were included. Our primary outcome was a composite variable indicating successful oncologic resection: negative margins and at least 12 lymph nodes evaluated. Our secondary outcome was mortality. These outcomes were stratified over time divided evenly into tertiles (2010-2013, 2014-2017, 2018-2021) and by patient, hospital, and operative characteristics using multivariate logistic regression analyses.

Results/Outcomes: We included 87,611 patients with rectal cancer who underwent definitive resection from 2010 to 2021. Patients were more likely to be male, White, and receive treatment in a metropolitan location. Overall, 74.5% of patients received chemotherapy and 68.2% of patients received radiation.

Robotic surgery rates significantly increased over time (10.1% in 2010-2013, 27.0% in 2014-2017, 45.7% in 2018-2021, p< 0.001) while open surgery rates significantly decreased (58.9% in 2010-2013, 38.1% in 2014-2017, 25.4% in 2018-2021). The rate of successful oncologic resection significantly increased over time (65.4% in 2010-2013, 72.2% in 2014-2017, 75.3% in 2018-2021, p< 0.001).

With regards to our primary outcome, the odds of achieving successful oncologic resection statistically significantly increased over time (OR 1.28, p< 0.001 in 2014-2017 and OR 1.43, p< 0.001 in 2018-2021). Patients undergoing robotic approaches were 1.39 times more likely to achieve successful oncologic resection compared to those undergoing open approaches (p < 0.001). When evaluating MIS approaches over time, robotic approach was associated with increasing odds of successful oncologic resection (OR 1.70, p< 0.001 in 2014-2017 and OR 1.95, p< 0.001 in 2018-2021). Patients at a high-volume center were also 1.6 times more likely to achieve successful oncologic resection than those at a low-volume center (p < 0.001).

Mortality in this patient population decreased over time but this was not statistically significant (p=0.25). Robotic and laparoscopic approaches were statistically significantly associated with decreased odds of mortality compared to open approaches (OR 0.63, p< 0.001 and OR 0.72, p< 0.001 respectively). Being at a high-volume center was associated with decreased odds of mortality compared to those at a low-volume center (OR 0.66, p< 0.001). Age over 67 (OR 7.5, p< 0.001) and Charlson–Deyo Comorbidity Class 3 or higher (OR 2.67, p< 0.001) were also statistically significantly associated with increasing odds of mortality.

Conclusion/Discussion: MIS approaches to rectal cancer are increasing over time and are associated with decreased mortality compared to open approaches. Patients undergoing robotic approaches were more likely to achieve successful oncologic resection compared to laparoscopic or open approaches, and this effect increases over time suggesting an improvement in our skills with this platform.