256. OPERATIVE TIMES FOR MINIMALLY INVASIVE ESOPHAGECTOMY (MIE): IS THERE AN EFFECT ON OUTCOMES?
Authors: Tupper Haley , Banks Kian , Roybal Belia , Kwak Hyunjee , Jackson Riley , Alcasid Nathan , Hsu Diana , Velotta Jeffrey 
Published: August 2023

Abstract

Background
Esophagectomy, an esophageal cancer treatment mainstay, is associated with significant morbidity and mortality. Prolonged operative time, only partially predetermined by case complexity, is associated with worse outcomes (1,2). The impact of MIE duration is unknown. Extended operative and anesthesia time may be uniquely harmful to esophagectomy patients for numerous reasons, including tenuous conduit and protracted single-lung ventilation (3). This retrospective cohort study compares outcomes in MIE patients with operative times greater than and less than four hours.

Methods
Esophageal cancer patients who underwent MIE between 1/2010 and 12/2021 at one of our regionalized, standardized esophagectomy centers were extracted from our multi-center institutional cancer registry. Stage, treatment variables (neoadjuvant and adjuvant therapy), post-operative complications, and readmission were abstracted from electronic health records. Descriptive analyses included pre-treatment variables (age, gender, race, BMI, Charlson comorbidity index (CCI)) and key outcomes (length of stay (LOS), mortality). Multiple logistic regression was used to identify the impact of potential predictor variables on the aforementioned outcomes of interest.

Results
Of 325 MIE patients, 223 (68.6%) had operative times over four hours. Operative duration greater than four hours resulted in increased odds of a longer-than-average LOS (OR 4.7 (2.7–8.2), p &lt; 0.0001) and increased 1-year mortality (OR 2.3 (1.0–5.1), p = 0.0431)) after adjusting for age, gender, race, BMI and CCI. Of note, median MIE LOS was 3.2 days, largely due to standardized, enhanced post-esophagectomy recovery pathways. Extremes of BMI (&gt;30 or &lt; 19) were also associated with increased adjusted odds of 90-day and 1-year mortality, respectively, along with multi-morbidity (CCI 3–4).

Conclusion
Esophageal cancer is a devastating disease with a short-life expectancy for patients and their families. Beyond risk stratification, it is imperative that we improve post-operative outcomes. Prolonged operative time (&gt;4 hours) was associated with increased LOS and decreased 1-year survival for MIE patients. Although further analysis is ongoing to characterize the impact of pre-surgical therapy and stage on outcomes, these results preliminarily suggest improving operative efficiency, a modifiable procedural variable, may improve MIE outcomes.
Citations:
1. Cornellà N, Sancho J, Sitges-Serra A. Short and Long-Term Outcomes After Surgical Procedures Lasting for More Than Six Hours. Nat Sci Rep. 2017 Aug 23;7(1):9221.
2. Valsangkar N, Salfity HVN, Timsina L, Ceppa DP, Ceppa EP, Birdas TJ. Operative time in esophagectomy: Does it affect outcomes? Surgery. 2018 Oct;164(4):866–71.
3. Atkins BZ, Shah AS, Hutcheson KA, Mangum JH, Pappas TN, Harpole DH, et al. Reducing Hospital Morbidity and Mortality Following Esophagectomy. Ann Thorac Surg. 2004 Oct;78(4):1170–6.